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Case Reports
. 2019 Mar 4;19(1):220.
doi: 10.1186/s12879-019-3831-8.

Invasive fungal infection by Cryptococcus neoformans var. grubii with bone marrow and meningeal involvement in a HIV-infected patient: a case report

Hareton Teixeira Vechi  1 , Raquel Cordeiro Theodoro  2 , Andrea Lima de Oliveira  2 , Ronald Muryellison Oliveira da Silva Gomes  2 , Rodolfo Daniel de Almeida Soares  3 , Munya Gandour Freire  4 , Mônica Baumgardt Bay  5
Affiliations
Case Reports

Invasive fungal infection by Cryptococcus neoformans var. grubii with bone marrow and meningeal involvement in a HIV-infected patient: a case report

Hareton Teixeira Vechi et al. BMC Infect Dis. .

Abstract

Background: Cryptococcosis is a common opportunistic infection in patients infected by Human Immunodeficiency Virus (HIV) and is the second leading cause of mortality in Acquired Immunodeficiency Syndrome (AIDS) patients worldwide. The most frequent presentation of cryptococcal infection is subacute meningitis, especially in patients with a CD4+ T Lymphocytes count below 100 cells/μL. However, in severely immunosuppressed individuals Cryptococcus neoformans can infect virtually any human organ, including the bone marrow, which is a rare presentation of cryptococcosis.

Case presentation: A 45-year-old HIV-infected male patient with a CD4+ T lymphocyte count of 26 cells/μL who presented to the emergency department with fever and pancytopenia. Throughout the diagnostic evaluation, the bone marrow aspirate culture yielded encapsulated yeasts in budding, identified as Cryptococcus sp. The bone marrow biopsy revealed a hypocellularity for age and absence of fibrosis. It was observed presence of loosely formed granuloma composed of multinucleated giant cells encompassing rounded yeast like organisms stained with mucicarmine, compatible with Cryptococcus sp. Then, the patient underwent a lumbar puncture to investigate meningitis, although he had no neurological symptoms and neurological examination was normal. The cerebrospinal fluid culture yielded Cryptococcus sp. The species and genotype identification step showed the infection was caused by Cryptococcus neoformans var. grubii (genotype VNI). The patient was initially treated with amphotericin B deoxycholate plus fluconazole for disseminated cryptococcosis, according to guideline recommendations. However, the patient developed acute kidney injury and the treatment was switched for fluconazole monotherapy. The symptoms disappeared completely with recovery of white blood cells and platelets counts. Cerebrospinal fluid cultures for fungi at one and two-weeks of treatment were negative.

Conclusions: Bone marrow infection caused by Cryptococcus neoformans is a rare presentation of cryptococcosis. The cryptococcal infection should be included for differential diagnosis in HIV-infected patients with fever and cytopenias, especially when CD4+ T lymphocytes count is below 100 cells/μL.

Keywords: AIDS; Bone marrow; Cryptococcosis; Cryptococcus neorformans; HIV.

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Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

A written informed consent was obtained from the patient for publication of this case report and any accompanying images. Available on request.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1
Fig. 1
Photomicrography of the patient’s bone marrow biopsy. Effacement of normal bone marrow architecture at 40x and 100x magnification (a and b, respectively), with replacement of normal adipose tissue by an inflammatory infiltrate consisting of xanthomatous histiocytes and multinucleated giant cells, constituting a loosely formed granuloma, better visualized at 400x magnification (c). At this magnification, the multinucleated giant cells exhibit clear areas inside their cytoplasm. At 1000x magnification, such clear areas revealed to be rounded yeast like organisms (arrows), located inside multinucleated giant cells and histocytes, stained with mucicarmine in their capsule, compatible with Cryptococcus sp. (d and e)
Fig. 2
Fig. 2
Genotyping by PCR-RFLP of URA5 gene of Cryptococcus neoformans isolated from patient’s bone marrow culture. Lane 1: 100pb DNA ladder. Lane 2: fragments obtained after double digestion of URA5 PCR products
See this image and copyright information in PMC

References

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