Abstract Herein, we present a case of extensive lymph node involvement by disseminated Cryptococcus infection developing in the immediate period after liver transplantation and initiation of immunosuppressive therapy. The patient, a 56 year old ethnicity unknown man, received a liver transplant for acute decompensated liver. Beginning 24 days after transplantation, he was found to have Cryptococcus neoformans infection, involving the pleural fluid, blood, cerebrospinal fluid (CSF), liver, and lymph nodes. He received treatment with amphotericin B and flucytosine; he was transitioned to fluconazole, and his response was good. This relatively rapid development of disease raises the possibility of donor-derived Cryptococcus infection. immunosuppressive therapy, biopsy, infection, lymph node, Cryptococcus, liver transplant Clinical History A 56 year old man presented with acute decompensated hepatic cirrhosis. One month previously, the patient had had liver function testing as part of his evaluation for fatigue and muscle cramping while taking a statin medication; his results showed mild elevation of alanine transaminase and aspartate transaminase. He had no reported history of alcohol use, hepatitis, or autoimmune conditions. Liver biopsy at the time of acute decompensation showed cirrhosis and steatohepatitis suggestive of nonalcoholic steatohepatitis (NASH). The results of a further workup, including testing for viral hepatitis and human immunodeficiency virus (HIV), were negative. The patient received an orthotopic liver transplant from a deceased donor. The early postoperative course for the patient was complicated by mild acute cellular rejection, which was successfully treated with corticosteroids; the patient was discharged on postoperative day 14. Maintenance immunosuppression included mycophenolate and tacrolimus; prophylaxis for opportunistic infection included trimethoprim/sulfamethoxazole, valganciclovir, and clotrimazole. The patient was readmitted on postoperative day 17 for bilirubin levels that had risen to 20.7 mg per dL due to biliary obstruction requiring multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures. At 24 days after transplantation, while hospitalized, he underwent thoracentesis for a pleural effusion, which yielded growth of yeast in 5 days of incubation, subsequently identified as Cryptococcus neoformans. Blood and cerebrospinal fluid (CSF) cryptococcal antigen testing results were positive (titers: CSF, 1:1280; blood, 1:327,680). The patient was treated with amphotericin B and flucytosine; we noted that his condition showed improvement with cryptococcal antigen titers decreased to 1:20,480 in the blood after 15 days of therapy. Laboratory Identification of Fungus in Tissue The patient underwent excisional biopsy for localized left axillary lymph-node enlargement 52 days after transplantation. Prior to biopsy, Physical examination had revealed mobile, nontender lymph nodes in the axilla, and computed tomography (CT) scans obtained to assess the pleural effusion noted stable left axillary lymphadenopathy. Gross examination of the excisional biopsy specimen revealed an enlarged lymph node (2.2 × 1.1 × 1.1 cm). Hematoxylin and eosin (H&E)–stained sections showed extensive replacement of the normal lymph-node architecture by numerous fungal forms, with a histiocytic response but no granulomas (Image 1A), consistent with extensive involvement by Cryptococcus. Fungal forms are highlighted by Grocott methenamine silver (GMS) staining. None of the 3 follow-up liver biopsies performed during the readmission of the patient showed evidence of rejection. However, we observed scattered fungal organisms consistent with Cryptococcus, in the absence of granulomatous inflammation, mainly within sinusoids and portal-tract blood vessels (Image 1B). The patient was discharged 59 days after transplantation, with instructions to undergo outpatient fluconazole therapy. Image 1 View largeDownload slide Histologic findings from lymph node and liver specimens in our patient, a 56 year old ethnicity unknown man. A, Lymph node specimen showing diffuse replacement by histiocytic reaction with intracellular yeasts but no granulomas (hematoxylin-eosin [H&E] staining, original magnification 2x/50x; Grocott methenamine silver [GMS], original magnification 50x). B, Liver specimen containing budding yeasts predominantly located within sinusoids and around portal vessels without conspicuous granulomatous response (H&E, original magnification 2x/100x; GMS, original magnification 50x). Image 1 View largeDownload slide Histologic findings from lymph node and liver specimens in our patient, a 56 year old ethnicity unknown man. A, Lymph node specimen showing diffuse replacement by histiocytic reaction with intracellular yeasts but no granulomas (hematoxylin-eosin [H&E] staining, original magnification 2x/50x; Grocott methenamine silver [GMS], original magnification 50x). B, Liver specimen containing budding yeasts predominantly located within sinusoids and around portal vessels without conspicuous granulomatous response (H&E, original magnification 2x/100x; GMS, original magnification 50x). Discussion Disseminated cryptococcal disease results in substantial morbidity and mortality, most notably among individuals with HIV infection but also in patients with immunosuppression and HIV negativity and, rarely, in individuals with immunocompetance. This disease is caused by the organisms C. neoformans and C. gattii, which are encapsulated saprophytic yeasts. C. gattii constitutes a much smaller proportion of disease and is traditionally associated with illness in individuals with immunocompetance who reside in tropical and subtropical regions, as well as the Pacific Northwest. HIV infection accounts for 95% of cases of cryptococcal disease in middle- and low-income countries and 80% of cases in high-income countries. Transplant patients receiving immunosuppressive drugs constitute most of the remaining caseload, although hosts with immunocompetance are susceptible in some settings. In the small subset of patients in whom Cryptococcus infection occurs outside the setting of HIV or transplant and excluding C. gattii epidemics in endemic regions, most patients have immune dysfunction related to other comorbidities, including autoimmune disease, malignancy, or primary immune dysfunction. The incidence of cryptococcal disease in solid-organ transplant recipients is approximately 3%,1 with a lower incidence in patients receiving liver transplantation.2 In the organ-transplant setting, Cryptococcus infections typically occur beyond the earliest post-transplant period.3–5 In this case individual, the relatively rapid development of disease after transplantation and initiation of immunosuppressive therapy is unusual and raises the possibility of donor-derived Cryptococcus infection.6–8 Histologic documentation of lymph-node involvement by Cryptococcus is described in the literature as case reports, predominantly in individuals who test HIV positive.9 To our knowledge, this is the first report of histologic documentation of lymph-node involvement in a patient who has received a liver transplant, in the immediate post-transplantation period. Laboratory Role in Diagnosis The Cryptococcal antigen test has proven useful in the clinical laboratory (Image 2A). It can be used as a diagnostic test for meningitis when performed on a CSF specimen. Also, it can be used as a screening test when performed on serum for early detection of disseminated Cryptococcal infection because it has been demonstrated to yield positive results for as many as 234 days before symptoms of meningitis. Additionally, it is useful in the HIV-positive cohort because it can identify untreated systemic Cryptococcal infection and predict the development of immune reconstitution inflammatory syndrome with the initiation of antiretroviral therapy. As a result, the treatment team has the opportunity for prevention by treating the patient with Cryptococcal targeted antifungal therapy. Image 2 View largeDownload slide Results of testing and laboratory staining in cerebrospinal fluid (CSF) specimens from our patient, a 56 year old ethnicity unknown man. A, Rapid cryptococcal antigen testing showing negative test result (left) and positive test result (right). The top line shows the control reaction; the bottom line shows the patient result, with a positive result denoted by the presence of a line. B, India ink wet prep. C, Gram stain of CSF specimen (original magnification, 100x). Note narrow-based budding yeast organisms. Image 2 View largeDownload slide Results of testing and laboratory staining in cerebrospinal fluid (CSF) specimens from our patient, a 56 year old ethnicity unknown man. A, Rapid cryptococcal antigen testing showing negative test result (left) and positive test result (right). The top line shows the control reaction; the bottom line shows the patient result, with a positive result denoted by the presence of a line. B, India ink wet prep. C, Gram stain of CSF specimen (original magnification, 100x). Note narrow-based budding yeast organisms. Along with the Cryptococcal antigen test, direct morphologic examination can be carried out on wet mount India ink CSF preparations (Image 2B), Gram stained material (Image 2C), or formalin-fixed paraffin-embedded tissue sections, the last of which offers the advantage of also being able to assess host response to the organisms. Tissue sections may be stained with standard H&E or any number of histological stains enhanced for fungi, including GMS stain and Periodic acid–Schiff (PAS), in addition to mucicarmine that specifically stains the yeast capsule or Fontana-Masson that stains the contained melanin.10 Regardless of preparation, the morphologic characteristics of fungal organisms in and of themselves lack the degree of specificity needed for precise identification and can only be interpreted within the context of other laboratory results (eg, polymerase chain reaction [PCR] and serology). Morphologic features suggestive of Cryptococcus include heterogenous size ranging from 5 µm to 10 µm, budding on a narrow base, and a thick polysaccharide capsule.10 The host response is epitomized by histiocytes and/or fibrosis, the degree of both of which is highly variable and can range from extracellular organisms in the absence of macrophages to well-formed granulomas with multinucleated giant cells.10 Following the ongoing trend of the microbiology laboratory, laboratory technicians are beginning to perform identification of Cryptococcus, like that of other yeasts, by advanced methodology such as matrix-assisted laser desorption ionization–time of flight (MALDI-TOF) mass spectrometry, PCR, and molecular sequencing analyses. These methods allow for more rapid identification and eliminate the need to maintain many genus- and species-specific tests in the laboratory, while providing superior accuracy compared with traditional phenotypic methods.11 Patient Follow-up Herein, we present a case involving a 56 year old man who developed disseminated cryptococcal disease as an early complication of liver transplantation. For immunosuppression, the patient had received mycophenolic acid, prednisone, and tacrolimus. Shortly thereafter, he was found to have disseminated Cryptococcus (proven on day 24). Seven months later, he continued to take antifungal drugs. At that time, he had discontinued taking amphotericin B for the past 2 months but continued taking fluconazole maintenance therapy, with cryptococcal antigen titers continuing to trend down (1:1280 at 4 months after discharge). CSF results became negative by culture on day 18 of therapy. Disseminated cryptococcosis is known to occur in the liver-transplantation setting. Nevertheless, the relatively rapid development of disease after transplantation and initiation of immunosuppressive therapy, in the patient whose case is presented herein, is unusual and raises the possibility of reactivation or donor-derived Cryptococcus infection.6,7 This case offers an example of histologic documentation of extensive lymph node involvement by cryptococcal disease. Abbreviations NASH nonalcoholic steatohepatitis HIV human immunodeficiency virus ERCP endoscopic retrograde cholangiopancreatography CSF cerebrospinal fluid CT computed tomography H&E hematoxylin and eosin GMS Grocott methenamine silver PAS periodic acid–Schiff PCR polymerase chain reaction MALDI-TOF matrix-assisted laser desorption ionization–time of flight References 1. Singh N . How I treat cryptococcosis in organ transplant recipients . Transplantation . 2012 ; 93 ( 1 ): 17 – 21 . 2. Pacholczyk M , Lagiewska B , Lisik W , Wasiak D , Chmura A . Invasive fungal infections following liver transplantation - risk factors, incidence and outcome . Ann Transplant . 2011 ; 16 ( 3 ): 14 – 16 . 3. Pappas PG , Alexander BD , Andes DR , et al. Invasive fungal infections among organ transplant recipients: results of the Transplant-Associated Infection Surveillance Network (TRANSNET) . Clin Infect Dis . 2010 ; 50 ( 8 ): 1101 – 1111 . 4. Singh N , Alexander BD , Lortholary O , et al. ; Cryptococcal Collaborative Transplant Study Group . Cryptococcus neoformans in organ transplant recipients: impact of calcineurin-inhibitor agents on mortality . J Infect Dis . 2007 ; 195 ( 5 ): 756 – 764 . 5. Husain S , Wagener MM , Singh N . Cryptococcus neoformans infection in organ transplant recipients: variables influencing clinical characteristics and outcome . Emerg Infect Dis . 2001 ; 7 ( 3 ): 375 – 381 . 6. Chang CM , Tsai CC , Tseng CE , et al. Donor-derived Cryptococcus infection in liver transplant: case report and literature review . Exp Clin Transplant . 2014 ; 12 ( 1 ): 74 – 77 . 7. Baddley JW , Schain DC , Gupte AA , et al. Transmission of Cryptococcus neoformans by organ transplantation . Clin Infect Dis . 2011 ; 52 ( 4 ): e94 – e98 . 8. MacEwen CR , Ryan A , Winearls CG . Donor transmission of Cryptococcus neoformans presenting late after renal transplantation . Clin Kidney J . 2013 ; 6 ( 2 ): 224 – 227 . 9. Natukunda E , Musiime V , Ssali F , Kizito H , Kityo C , Mugyenyi P . A case of Cryptococcal lymphadenitis in an HIV-infected child . AIDS Res Hum Retroviruses . 2011 ; 27 ( 4 ): 373 – 376 . 10. Guarner J , Brandt ME . Histopathologic diagnosis of fungal infections in the 21st century . Clin Microbiol Rev . 2011 ; 24 ( 2 ): 247 – 280 . 11. Posteraro B , Efremov L , Leoncini E , et al. Are the conventional commercial yeast identification methods still helpful in the era of new clinical microbiology diagnostics? A meta-analysis of their accuracy . J Clin Microbiol . 2015 ; 53 ( 8 ): 2439 – 2450 . © American Society for Clinical Pathology 2018. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Laboratory Medicine – Oxford University Press
Published: May 11, 2018
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