CASE OF THE MONTH: ABSTRACT
July 2004. A 40‐year‐old man had a 6‐week history of severe frontal headaches and dry cough. Chest x‐ray showed hilar adenopathy with bilateral parenchymal infiltrates. A diagnosis of atypical pneumonia was made. Four weeks later he was admitted with persistent headache. Infectious screen was negative. Brain MR post contrast, revealed cerebellar enhancement and swelling with moderate tonsillar herniation; findings which precluded the performance of a lumbar puncture. High resolution CT thorax confirmed hilar abnormalities; shown by microscopy to represent non caseating granulomata. A presumptive diagnosis of sarcoidosis was reached. Despite an initial symptomatic improvement his headache persisted. Repeat MRI, eleven days after admission, showed reduced cerebellar enhancement and swelling with no change in the degree of tonsillar herniation. He deteriorated acutely and died two weeks after admission. Autopsy revealed cerebral oedema with tonsillar herniation secondary to cryptococcal meningitis variety neoformans. There was no evidence of neurosarcoid. Active and inactive sarcoid was identified in the lungs and hilar nodes with no evidence of systemic sarcoid. Focal evidence of cryptococcal pneumonitis was present in the lung as a necrotic focus. A strong index of clinical suspicion is necessary to diagnose the rare association of cryptococcus complicating sarcoidosis.
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REFERENCES
- 1. Arnder L, Castilla M, Heinz ER, Scatliff JH, Enterline D (1996) Unusual pattern of enhancement in cryptococcal meningitis: in vivo findings with post mortem correlation. J Comput Assist Tomogr 20:1023–1026. [DOI] [PubMed] [Google Scholar]
- 2. Botha RJP, Wessels E (1999) Cryptococcal meningitis in an HIV negative patient with systemic sarcoidosis. J Clin Pathol 52:928–930. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Lukacs NW, Hogaboam C, Chensue SW, Blease K, Kunkel SL (2001) Type 1, type 2 cytokine paradigm and the progression of pulmonary fibrosis. Chest 120 (Suppl)5S–8S. [DOI] [PubMed] [Google Scholar]
- 4. Menefee McDonnell J, Hutchins GH (1985) Pulmonary cryptococcosis. Hum Pathol 16:121–128. [DOI] [PubMed] [Google Scholar]
- 5. Mitchell DH, Sorrell TC, Allworth AM, Heath CH, McGregor, AR , Papanaoum K, Richards MJ, Gottleib T (1995) Cryptococcal disease of the CNS in immunocompetent hosts: Influence of cryptococcal variety on clinical manifestations and outcome. Clin Infect Dis 20:611–616. [DOI] [PubMed] [Google Scholar]
- 6. Newman LS, Rose CS, Maier LA. (1999) Sarcoidosis. New Eng J Med 336:1224–1234. [DOI] [PubMed] [Google Scholar]
- 7. Shijubo N, Fujishima T, Ooashi K, Morita S, Shigehara K, Nakata H, Abe S (1995) Pulmonary cryptococcal infection in an untreated patient with sarcoidosis. Sarcoidosis 12:71–74. [PubMed] [Google Scholar]
- 8. Thomas G, Murphy S, Staunton H, O'Neill S, Farrell MA, Brett FM (1998) Pathogen‐free granulomatous diseases of the central nervous system. Hum Pathol 29:110–115. [DOI] [PubMed] [Google Scholar]