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Year : 2017  |  Volume : 32  |  Issue : 4  |  Page : 377-379  

Fluorodeoxyglucose positron emission tomography–computed tomography in disseminated cryptococcosis


1 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication12-Oct-2017

Correspondence Address:
Shamim Ahmed Shamim
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_75_17

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   Abstract 


Disseminated cryptococcosis without pulmonary involvement is a very rare phenomenon. Patterns of organ involvement in cryptococcosis resemble various other infective conditions as well as malignant conditions on fluorodeoxyglucose positron emission tomography–computed tomography. We present a case of a 43-year-old male patient who had disseminated cryptococcosis. The rarity of the case being noninvolvement of lungs and meninges and resembling more like lymphoma due to the diffuse involvement of the lymph nodes on both sides of the diaphragm.

Keywords: Cryptococcosis, fluorodeoxyglucose positron emission tomography–computed tomography, lymphoma


How to cite this article:
Tripathy S, Parida GK, Roy SG, Singhal A, Mallick SR, Tripathi M, Shamim SA. Fluorodeoxyglucose positron emission tomography–computed tomography in disseminated cryptococcosis. Indian J Nucl Med 2017;32:377-9

How to cite this URL:
Tripathy S, Parida GK, Roy SG, Singhal A, Mallick SR, Tripathi M, Shamim SA. Fluorodeoxyglucose positron emission tomography–computed tomography in disseminated cryptococcosis. Indian J Nucl Med [serial online] 2017 [cited 2021 Mar 2];32:377-9. Available from: https://www.ijnm.in/text.asp?2017/32/4/377/216566



A 43-year-old male patient presented to the medicine OPD with the chief complaints of fever and headache for the past 3 months. He had lost weight of around 10 kg in 3 months and complained of anorexia and fatigue. On evaluation, he was found to be retroviral positive. Physical examination revealed generalized painless nonmatted lymphadenopathy and a palpable spleen (4 cm below the left costal margin). In suspicion of lymphoma, whole body 18-F-fluorodeoxyglucose positron emission tomography–computed tomography (18-F-FDG PET-CT) was done, which revealed bulky bilateral adrenal glands with increased FDG uptake [Figure 1]a and [Figure 1]b – white arrows]. Hypermetabolic multiple discrete enlarged bilateral cervical [Figure 1]c and [Figure 1]d, bilateral supraclavicular, bilateral axillary, multiple mediastinal, abdominal, retroperitoneal [Figure 1]e and [Figure 1]f, and pelvic lymph nodes. Splenomegaly (13 cm) was seen with increased FDG uptake [Figure 1]a and [Figure 1]b. Diffusely increased FDG uptake was also seen in both the kidneys [Figure 1]a, [Figure 1]b and [Figure 1]f. Lymph node biopsy from the cervical region was done which revealed sheets of Gram-positive budding encapsulated yeast cells [Figure 1]g and positive for methenamine silver stain [Figure 1]h.
Figure 1: FDG PET-CT shows hypermetabolic bulky bilateral adrenal glands (a and b – white arrows). Multiple FDG-avid discrete enlarged bilateral cervical (c and d), supraclavicular, axillary, mediastinal, abdomino-pelvic, retroperitoneal (e and f) lymph nodes. Splenomegaly is seen with increased FDG uptake (a and b). Diffusely increased FDG uptake is seen in both the kidneys with loss of cortico-medullary differentiation (a, b, and f). Biopsy from the cervical lymph node revealed sheets of gram positive budding encapsulated yeast cells (g) and positive for silver methenamine stain (h). FDG PET-CT: Fluorodeoxyglucose positron emission tomography–computed tomography

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Cryptococcal infections mostly affect the immunocompromised hosts such as those with acquired immune deficiency syndrome, organ transplant recipients or patients with hematologic malignancy and long-standing diabetes mellitus.[1] It occurs most commonly by the inhalation of the organism with the pulmonary system being affected earliest and subsequent dissemination to the other systems.[2] Usually, inhalation of Cryptococcus causes focal pneumonitis and the infection is generally detected as single or multiple pulmonary nodules.[3] Disseminated cryptococcosis most commonly affects the lung, central nervous system, followed by skin, adrenal glands, prostate, and bones. Involvement of lymph nodes is very rare although it has been previously reported in the literature.[4],[5],[6] FDG PET-CT has slowly but steadily established itself as an infection imaging agent and has been used to delineate the extent of the disease on many occasions. FDG accumulation in infectious tissue can be attributed to migratory inflammatory cells, microorganisms, and granulation tissues.[7],[8],[9],[10] Hot et al. emphasized on the use of FDG PET in initial diagnosis and staging of fungal infections.[11] Hence, cryptococcosis can very well mimic lymphoma on 18-F-FDG PET-CT and treatment algorithm should be started only after biopsy from the concerned lesion. This case reiterates the fact that FDG PET-CT has been unreliable in differentiating inflammation/infection from malignancy based on the standardized uptake value values and such cases warrants histopathological correlation. However, it can very well describe the extent of the disease and organ involvement.

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Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Warnock DW. Trends in the epidemiology of invasive fungal infections. Nihon Ishinkin Gakkai Zasshi 2007;48:1-12.  Back to cited text no. 1
    
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Sarosi GA. Cryptococcal pneumonia. Semin Respir Infect 1997;12:50-3.  Back to cited text no. 2
    
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Kishi K, Homma S, Kurosaki A, Kohno T, Motoi N, Yoshimura K, et al. Clinical features and high-resolution CT findings of pulmonary cryptococcosis in non-AIDS patients. Respir Med 2006;100:807-12.  Back to cited text no. 3
    
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Ghosh A, Tilak R, Bhushan R, Dhameja N, Chakravarty J. Lymphnodal co-infection of Cryptococcus and histoplasma in a HIV-infected patient and review of published reports. Mycopathologia 2015;180:105-10.  Back to cited text no. 4
    
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Bhuyan P, Pattnaik K, Kar A, Brahma RC, Mahapatra S. Cryptococcal lymphadenitis in HIV: A chance diagnosis by FNAC. Diagn Cytopathol 2013;41:456-8.  Back to cited text no. 5
    
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Shravanakumar BR, Iyengar KR, Parasappa Y, Ramprakash R. Cryptococcal lymphadenitis diagnosed by FNAC in a HIV positive individual. J Postgrad Med 2003;49:370.  Back to cited text no. 6
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7.
West J, Morton DJ, Esmann V, Stjernholm RL. Carbohydrate metabolism in leukocytes 8. Metabolic activities of the macrophage. Arch Biochem Biophys 1968;124:85-90.  Back to cited text no. 7
    
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Weisdorf DJ, Craddock PR, Jacob HS. Glycogenolysis versus glucose transport in human granulocytes: Differential activation in phagocytosis and chemotaxis. Blood 1982;60:888-93.  Back to cited text no. 8
    
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Anderson RL, Wood WA. Carbohydrate metabolism in microorganisms. Annu Rev Microbiol 1969;23:539-78.  Back to cited text no. 9
    
10.
Kubota R, Yamada S, Kubota K, Ishiwata K, Tamahashi N, Ido T, et al. Intratumoral distribution of fluorine-18-fluorodeoxyglucose in vivo: High accumulation in macrophages and granulation tissues studied by microautoradiography. J Nucl Med 1992;33:1972-80.  Back to cited text no. 10
    
11.
Hot A, Maunoury C, Poiree S, Lanternier F, Viard JP, Loulergue P, et al. Diagnostic contribution of positron emission tomography with [18F]fluorodeoxyglucose for invasive fungal infections. Clin Microbiol Infect 2011;17:409-17.  Back to cited text no. 11
    


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