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Puzzling mosaics in cerebrospinal fluid

2018; Elsevier BV; Volume: 24; Issue: 11 Linguagem: Inglês

10.1016/j.cmi.2018.06.019

1469-0691

Mathilde Pugès, Frédéric Gabriel, M. Carrer, S. Cedrés, H. Boijout, H. Dutronc, Charles Cazanave,

Cancer-related Molecular Pathways

A man in his 40s was admitted to Bordeaux University Hospital for febrile meningitis. He also had oral candidiasis and oral hairy leucoplakia. Lumbar puncture showed a meningitis with 13 cells/mm3 (60% lymphocytes, 30% neutrophils, 10% monocytes). Cerebrospinal fluid (CSF) analysis showed elevated protein and lactate (0.85 g/L and 4 mmol/L, respectively), and a low CSF glucose (ratio CSF-to-serum: 21%). Gram staining revealed structures that could not be identified by the microbiologist (Fig. 1). India ink showed encapsulated yeasts, highly suggestive of Cryptococcus sp. Human immunodeficiency virus infection was rapidly confirmed by serology (CD4 cell count of 1/mm3). Cryptococcal antigens were highly elevated in CSF and blood (titration using CALAS® kit; Meridian Bioscience, Cincinnati, OH, USA: 1/4096 and 1/16 384, respectively). Cryptococcus neoformans var. grubii was isolated from CSF culture and identified using matrix-assisted laser desorption/ionization time-of-flight, mass spectrometry (Bruker Daltonics, Bremen, Germany). Magnetic resonance images of the brain were normal. Computed tomography showed excavated lung nodules and interstitial pneumonia. Cryptococcus neoformans, Mycobacterium avium intracellulare and Pneumocytosis jirovecii were isolated in bronchoalveolar lavage. These geometric structures (Fig. 1), which were related to mucinous strands deriving from the mucopolysaccharidic capsule of Cryptococcus sp., interconnect yeasts. ‘Crystalloid’ structures could rarely be observed, but hexagons, octagons and even more complex structures, as in this case, are exceptional. Identifying Cryptococcus sp. on CSF by Gram staining can be confusing for cryptococcal meningitis diagnosis, and India ink negative staining remains the reference standard. This observation is of particular interest because Cryptococcus sp. infections are still frequent and have recently been diagnosed in patients with new types of immunosuppression [[1]Chamilos G. Lionakis M.S. Kontoyiannis D.P. Call for action: invasive fungal infections associated with ibrutinib and other small molecule kinase inhibitors targeting immune signaling pathways.Clin Infect Dis. 2018; 66: 140-148Crossref PubMed Scopus (157) Google Scholar]. There are no conflicts of interest to declare. No funding was received for this work.