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J R Soc Med. 2005 November; 98(11): 513–514.
PMCID: PMC1276000

Cryptococcal small-bowel obstruction in an HIV-positive patient

Meningitis and pulmonary infections are common manifestations of cryptococcosis but gastrointestinal involvement is rare.

CASE HISTORY

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.

Figure 1
Resected small bowel segment with stricture Figure 2 Section through stricture showing florid infiltrate of foamy histiocytes and numerous DPAS (diastase-resistant periodic acid–Schiff) positive cryptococci (mucicarmine positive)

COMMENT

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.

References

1. Perfect JR, Casadevall A. Cryptococcosis. Infect Dis Clin North Am 2002;16: 837–74 [PubMed]
2. Lewis JL, Rabinovich S. The wide spectrum of cryptococcal infections. Am J Med 1972;53: 315–22 [PubMed]
3. Washington K, Gottfried MR, Wilson ML. Gastrointestinal cryptococcosis. Mod Pathol 1991;4: 707–11 [PubMed]
4. Gordon SM, Gal AA, Amerson JR. Granulomatous peritoneal cryptococcomas. An unusual sequela of disseminated cryptococcosis. Arch Pathol Lab Med 1994;118: 194–5 [PubMed]
5. Poblete RB, Kirby DB. Cryptococcal peritonitis: report of a case and review of the literature. Am J Med 1987;82: 665–7 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press