Endoscopy 2021; 53(04): E150-E152
DOI: 10.1055/a-1216-1048
E-Videos

Small-bowel cryptococcosis diagnosed by double-balloon endoscopy in patient without human immunodeficiency virus

Túlio Riguetti Prazeres
1  Endoscopy Unit, Coloproctology Surgical Division, Department of Gastroenterology, University of São Paulo Medical School
,
Marcela Almeida Menezes de Vasconcellos
1  Endoscopy Unit, Coloproctology Surgical Division, Department of Gastroenterology, University of São Paulo Medical School
,
Marcella Salazar Sousa
1  Endoscopy Unit, Coloproctology Surgical Division, Department of Gastroenterology, University of São Paulo Medical School
,
Evelin Sánchez Ortiz
2  Department of Pathology, University of São Paulo Medical School, São Paulo, Brazil
,
Ulysses Ribeiro Junior
3  Coloproctology Surgical Division, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
,
Sérgio Carlos Nahas
3  Coloproctology Surgical Division, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
,
Adriana Vaz Safatle-Ribeiro
1  Endoscopy Unit, Coloproctology Surgical Division, Department of Gastroenterology, University of São Paulo Medical School
› Author Affiliations
 

A 45-year-old man presented with a 2-year history of diarrhea and anasarca. His work involved opening tunnels and exploding rocks. He had no cardiovascular abnormalities or proteinuria. Celiac disease and human immunodeficiency virus (HIV) serologies were negative. Total protein (2.6 g/dL), albumin (1.5 g/dL), ionized calcium (3.09 mg/dL), vitamin D (6.7 ng/mL), and immunoglobulin (IgM 29 mg/dL, IgG 357 mg/dL, IgA 60 mg/dL) levels were low. Sodium and potassium were normal.

Upper gastrointestinal endoscopy demonstrated erosions and patchy, whitish lesions in the second portion of the duodenum, suggestive of lymphangiectasia. Biopsies showed unspecific duodenitis. Colonoscopy was normal.

Computed tomography (CT) demonstrated thickness and lymphatic cystic lesions involving the duodenum, jejunum, pancreas, and retroperitoneum ([Fig. 1]). Owing to suspicion of protein-losing enteropathy, anterograde double-balloon endoscopy (DBE) was indicated. DBE showed whitish spots and nodularity in the second and third portions of the duodenum, and multiple subepithelial cystic lesions with lymphatic fluid extravasation at biopsy in the fourth portion of the duodenum and up to 150 cm of the jejunum ([Video 1]). Histopathology revealed lymphomononuclear infiltrate, granuloma ( [Fig.2]), and spores on mucicarmine and Grocott stains ([Fig. 3]), compatible with Cryptococcus neoformans.

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Fig. 1 Computed tomography demonstrated thickness and lymphatic cystic lesions (arrow) involving the duodenum, proximal jejunum, pancreas, and retroperitoneum.

Video 1 Computed tomography showed lymphatic cystic lesions involving the small bowel, confirmed by double-balloon endoscopy. Subepithelial duodenal and jejunal lesions with lymphatic fluid extravasation were observed, with great improvement after treatment.


Quality:
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Fig. 2 Hematoxylin and eosin staining showed lymphomononuclear infiltrate, with traces of granuloma and round organisms.
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Fig. 3 Staining was suggestive of Cryptococcus neoformans. a Mucicarmine staining revealed the presence of the organism’s mucopolysaccharide capsule (in pink). b Grocott staining highlighted the fungal cell wall (in black).

The patient was hospitalized with intense headache, reduced visual acuity, and convulsions. He was diagnosed with systemic Cryptococcus infection, affecting central nervous system, gastrointestinal tract, and lymphatic system. Amphotericin B was given for 21 days with significant clinical improvement, followed by fluconazole 800 mg/day for 1 year. CT and laboratory tests returned to normal. DBE showed significant improvement ([Fig. 4]), with negative fungal histology.

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Fig. 4 Double-balloon endoscopy demonstrated reduction of the lymphatic cystic lesions after 1 year of treatment.

The few reports of disseminated cryptococcosis mostly involve HIV/acquired immunodeficiency syndrome [1] [2]. Gastrointestinal tract symptoms on presentation are seldom described [3] [4]. In this case of disseminated cryptococcosis in an immunocompetent, non-HIV patient, DBE was valuable in diagnosing and managing the small-bowel involvement [5].

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Adriana Vaz Safatle-Ribeiro, MD, PhD
Endoscopy Unit
Department of Gastroenterology
University of São Paulo Medical School
Av. Dr. Enéas Carvalho de Aguiar
255 Cerqueira Cesar
05403-000 São Paulo
SP, Brazil   
Fax: +55-11-32849885   

Publication History

Publication Date:
20 August 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Computed tomography demonstrated thickness and lymphatic cystic lesions (arrow) involving the duodenum, proximal jejunum, pancreas, and retroperitoneum.
Zoom Image
Fig. 2 Hematoxylin and eosin staining showed lymphomononuclear infiltrate, with traces of granuloma and round organisms.
Zoom Image
Fig. 3 Staining was suggestive of Cryptococcus neoformans. a Mucicarmine staining revealed the presence of the organism’s mucopolysaccharide capsule (in pink). b Grocott staining highlighted the fungal cell wall (in black).
Zoom Image
Fig. 4 Double-balloon endoscopy demonstrated reduction of the lymphatic cystic lesions after 1 year of treatment.