DEPARTMENT OF PATHOLOGY
The Johns Hopkins Medical Institutions
 

Vol. 18, No. 11
THE JOHNS HOPKINS MICROBIOLOGY NEWSLETTER
Monday, March 22, 1999
 

  1. Provided by Leslie Edwards Reger, Division of Outbreak Investigation, Maryland Department of Health and Mental Hygiene.  Outbreaks reported to DHMH for week 11 (3/15/99 - 3/21/99):
12 total: 1 MRSA outbreak in a nursing home, 3 foodborne gastroenteritis outbreaks associated with food-service facilities, 1 hepatitis A outbreak in an institution, 1 hepatitis A outbreak in a day care setting, 5 influenza-like illness outbreaks reported in nursing homes, and 1 gastroenteritis outbreak at a nursing home.
  1. The Johns Hopkins Hospital. Information provided by Joseph D Kronz, M.D., Department of Pathology.
Clinical Presentation: A 42-year-old African-American male with a history of intravenous drug abuse, hepatitis B and C infections, PPD-positive treated with INH, HIV (CD4 count <200, viral load >400,000 copies) and splenectomy was experiencing pyuria after bowel movements. He stated that he was treated for a kidney infection about one month ago at another hospital. The pyuria was associated with pain on urination of a scalding nature. He also describes poor urinary stream, voiding small amounts of urine particularly at night, and he was having difficulty initiating urination. Three urine cytologies were negative for malignancy. An ultrasound of the kidneys and bladder demonstrated a 3.7 x 3.3 exophytic heterogenous mass at the lower pole of the right kidney. A CT scan revealed a 3.5 cm complex cyst on the right kidney compatible with renal cell carcinoma as well as a prostatic versus seminal vesicle abscess. On physical exam the patient was afebrile and had an enlarged prostate without fluctuance. He underwent an ultrasound-guided aspiration of the abscess. Cryptococcus neoformans was recovered in the microbiology laboratory and a cryptococcal antigen was positive in serum but negative in CSF. The patient was treated with fluconazole 400 mg every day for six weeks followed by 200 mg every day for life.
Cryptococcal infection within the prostate
Background: Cryptococcus spp. are basidiomycetous yeast. It grows well in nitrogen rich soil and is therefore found in the highest concentrations in soil contaminated by bird droppings. The majority of Cryptococcal infections are found in the HIV infected population. In fact, there were 1264 reported cases of Cryptococosis in the entire United States from 1965 to 1977; however, in 1991 there were 1277 reported cases in New York city alone.

Clinical Presentation: This fungus is acquired through inhalation where it frequently causes an asymptomatic pulmonary infection which allows hematogenous spread to the central nervous system. The resulting meningoencephalitis causes headache, nausea, abnormal gait and confusion. Fever and meningeal signs can be absent. After appropriate therapy and resolution of symptoms some male patients appear to sequester the organism within the prostate. This can act as a site for reactivation and dissemination of the disease. The infection is frequently described as a chronic granulomatous prostatitis and usually does not present as an abscess as in this patient.

Diagnosis: The identification of Cryptococcus spp. in the laboratory is made by identifying irregular sized yeast cells measuring 4-10 um with a prominent capsule. These yeast are urease positive, produce pigment under certain circumstances, do not ferment sugars or grow hyphal forms. The diagnosis of cryptococcal sequestration within the prostate can be made by culturing Cryptococcus from the prostate, seminal fluid, or from a midstream voided specimen after prostatic massage. The prostate must be the only focus of infection.

Therapy: Currently infection is treated with amphotericin B and/or fluconazole. Patients may need to be on lifelong therapy to prevent relapse of the disease.

 References:
    1. Koneman EW, Allen SD, Janda WM, Schreckenberger PC and Winn, Jr. WC (eds). Color Atlas and Textbook of Diagnostic Microbiology. pp 598 and 620, 5th ed. Lippincott, New York 1997.
    2. Ndimbie OK, Dekker A, Martinez AJ, Dixon B. Prostatic sequestration of Cryptococcus neoformans in immunocompromised persons treated for cryptococcal meningoencephalitis. Histol Histopathol 1994 Oct;9(4):643-8.
    3. Staib F, Seibold M, L'age M, Heise W, Skorde J, Grosse G, Nurnberger F, Bauer G. Cryptococcus neoformans in the seminal fluid of an AIDS patient. A contribution to the clinical course of cryptococcosis. Mycoses 1989 Apr;32(4):171-80.
    4. Larsen RA, Bozzette S, McCutchan JA, Chiu J, Leal MA, Richman DD. Persistent Cryptococcus neoformans infection of the prostate after successful treatment of meningitis. California Collaborative Treatment Group. Ann Intern Med 1989 Jul 15;111(2):125-8.

Specimen from prostatic abscess. Note numerous
organisms (arrow heads). In other fields, the
background material acts like India-ink and
demonstrates the organisms capsule.


Urine cytology from patient revealed cryptococcal
organisms within histiocytes. The urine cytology
findings in Cryptococcus infections have not been

  • reported in the literature.

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