Using endoscopic ultrasound-guided fine needle aspiration to diagnose mediastinal cryptococcosis

A 33-year-old woman from Zimbabwe with AIDS and a CD4 count of 6 cells/mm³, non-compliant with antiretroviral therapy, presented with severe headaches, vomiting, fevers, and a productive cough. Physical examination revealed tachycardia, a temperature of 39.4 °C, clear lungs, and an absence of meningeal signs. Laboratory studies showed a white blood cell count of 4.8 and hemoglobin of 10.1 g/dL. A lumbar puncture was consistent with cryptococcal meningitis (cryptococcal antigen titer 1 : 32 768), and the patient had positive blood cultures growing Cryptococcus neoformans. The admitting chest radiograph was unremarkable.

Amphotericin B and flucytosine were given. Her repeat lumbar puncture 2 weeks later showed an unchanged cryptococcal antigen titer, and she continued to have high fevers (39.4 – 40 °C) and cough. Tuberculosis was ruled out. A computed tomography scan of the chest, abdomen, and pelvis revealed bilateral multiple moderately enlarged mediastinal and hilar lymphadenopathy, patchy infiltrate in the right lung, and mild hepatomegaly ([Fig. 1]).

Fig. 1 Computed tomography (CT) scan of the chest, showing hilar adenopathy.

Endoscopic ultrasound (EUS) was performed to evaluate the mediastinal lymphadenopathy. Images showed a large heterogeneous hypoechoic mass extending from the subcarinal space to the distal peri-esophageal space ([Fig. 2]). The mass was sampled by fine-needle aspiration (FNA) biopsy, revealing cryptococcosis and aspergillosis ([Fig. 3]). The patient then asked to leave the hospital and was placed on oral voriconazole.

Fig. 2 Endoscopic ultrasound (EUS) revealing lymphadenopathy (arrows).

Fig. 3 Cryptococcus on histopathological staining using: a Grocott’s methenamine silver (40 ×); b hematoxylin and eosin (40 ×). (Aspergillus not shown.)

EUS-guided FNA has emerged as an important diagnostic imaging modality. It is a non-surgical method to obtain tissue sampling from mediastinal lesions, with the advantage of real-time ultrasound guidance [1]. EUS can identify lymph nodes as small as 3 mm, particularly in the celiac, subcarinal, and aorto–pulmonary areas [2]. Pulmonary cryptococcus has rarely been diagnosed via EUS-guided FNA. Concurrent diagnoses of patients with pulmonary cryptococcal isolates are common, especially in patients with HIV infection [3]. Here, aspergillus was concomitantly found. It has been shown that EUS with FNA has a 97 % accuracy rate for tissue confirmation, and should be the test of choice especially for evaluating posterior mediastinal lymphadenopathy [4] [5].

In conclusion, we report a non-traditional modality to diagnose pulmonary cryptococcus using EUS with FNA.

Endoscopy_UCTN_Code_CCL_1AF_2AC

References

• 1 Puri R, Vilmann P, Sud R, Kumar M et al. Endoscopic ultrasound-guided fine-needle aspiration cytology in the evaluation of suspected tuberculosis in patients with isolated mediastinal lymphadenopathy.  Endoscopy. 2010;  42 462-467
• 2 Prasad P, Wittmann J, Pereira S. Endoscopic ultrasound of the upper gastrointestinal tract and mediastinum: diagnosis and therapy.  Cardiovasc Intervent Radiol. 2006;  29 947-957
• 3 Lanjewar D N, Duggal R. Pulmonary pathology in patients with AIDS: an autopsy study from Mumbai.  HIV Med. 2001;  2 266-271
• 4 Puli S R, Batapati Krishna Reddy J, Bechtold M L et al. Endoscopic ultrasound: its accuracy in evaluating mediastinal lymphadenopathy? A meta-analysis and systematic review.  World J Gastroenterol. 2008;  14 3028-3037
• 5 Eloubeidi M A, Cerfolio R J, Chen V K et al. Endoscopic ultrasound-guided fine needle aspiration of mediastinal lymph node in patients with suspected lung cancer after positron emission tomography and computed tomography scans.  Ann Thorac Surg. 2005;  79 263-268