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Meningitis and pulmonary infections are common manifestations of cryptococcosis but gastrointestinal involvement is rare.
A woman aged 39 was admitted with cryptococcal meningitis. Her CD4 count was low at 30 × 106/L but she responded to intravenous amphotericin (0.7 mg/kg per day), flucytosine (25 mg/kg per day) for 2 weeks and oral fluconazole (800 mg per day) thereafter. Four weeks after admission, however, she developed progressive abdominal distension with pain and vomiting. CT demonstrated features consistent with small-bowel obstruction but no cause was identified radiologically. Despite a trial of conservative management with nil orally, nasogastric tube aspiration and fluid and electrolyte replacement, her symptoms persisted. At exploratory laparotomy a 3 cm stricture of the distal ileum was seen to be causing small-bowel obstruction (Figure 1). It was resected and bowel continuity was restored by end-to-end hand-sewn anastomosis. Histological examination of the stricture showed infiltration of the intestinal wall by cryptococci with a florid inflammatory response (Figure 2). Postoperative recovery was uneventful.
Fungal infection is a common affliction of HIV-positive patients because of their immunocompromised state and poor general health. Systemic infection with Cryptococcus neoformans, an encapsulated yeast, is the most lethal of all AIDS-related fungal infections.1 The organism is primarily transmitted via the respiratory route but can infect any organ of the body by haematogenous spread. It has a predilection for the central nervous and respiratory systems.2 Clinically, gastrointestinal cryptococcosis is rare even in the context of HIV infection; however, in one necropsy series, gastrointestinal involvement was seen in 8 of 24 patients with disseminated cryptococcal infection.3
Small-bowel obstruction due to cryptococcosis has been reported in an HIV-negative patient treated for cryptococcal meningitis. A jejunal stricture developed where cryptococcal peritoneal granulomas had caused extrinsic compression of the bowel.4 Other reports have described cryptococcal peritonitis, but without histological confirmation.5 By contrast, in the present HIV-positive patient, the ileal stricture was proven histologically to be the result of cryptococcal infection within the bowel wall, without evidence of peritonitis.