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==Cryptococcus neoformans==


Keywords (immunodeficiency): HIV, antiretroviral therapy, oropharyngeal thrush, hepatosplenomegaly, central umbilication, central necrosis, hemorrhagic crust.
*Cryptococcus neoformans is an encapsulated yeast
*Occurs in patients with advanced HIV (CD4<100/mm3)
*The most common manifestation is meningoencephalitis
*Pulmonary and/or disseminated disease may occur
*Cutaneous cryptococcosis considered as a marker of disseminated disease
*Rapid onset (2 weeks) of multiple widespread papular lesions with central umbilication
*Diagnostic clue is the presence of a small area of central hemorrhage or necrosis
*Resembles molluscum contagiosum
*Most common areas affected are head and neck
*Disseminated infections can affect liver, lymph nodes, peritoneum, adrenal gland, and eyes
*Diagnosis
**Biopsy of the lesion
**Histopathological examination after staining (periodic acid-Schiff, Gomori methenamine silver nitrate)
**Hyperplasia of the overlying dermis with underlying granulomas surrounding encapsulated yeasts
**Fungal blood culture is often positive in severe disseminated cryptococcal disease but a biopsy is more sensitive and specific than blood culture (because untreated HIV patients have multiple ongoing opportunistic infections)
**Serum antigen testing can be useful for the diagnosis
**The most common wrong answer is skin scrapings with a microscopic evaluation which is used for the diagnosis of fungal infections as tinea or candidiasis.
*Treatment:
**>/= 2 weeks of IV amphotericin B plus oral flucytosine
**Followed by a year of oral fluconazole (higher dose for 8 weeks, then maintenance)
DD:
*Kaposi Sarcoma:
**Primarily presents in homosexual men(men with HIV who are sexually active with other men)
**Red or purple papules with no necrosis
*Disseminated Mycobacterium avium complex:
**Common opportunistic infection
**Affects patients with advanced AIDS
**Presents as fever, night sweats, abdominal pain, diarrhea, weight loss
**Cutaneous lesions are uncommon and are usually nodular and ulcerating
*Pyoderma gangrenosum:
**Rare neutrophilic dermatitis
**Associated with inflammatory bowel disease and inflammatory arthritides
**Presents as a tender papule that degrades into a bluish, violaceous ulcer
*Basal cell carcinoma
**Single, pink, flesh-colored papules
**Arise slowly
==Tuberculosis==
*Active pulmonary tuberculosis
**Due to reactivation of the latent disease
**Epidemiologic risk factors
***Substance abuse
***Homelessness
***Birth in a TB-endemic region
**Clinical manifestations
***Fever, cough >2 weeks, weight loss
Diagnosis:
*Chest x-ray
**signs of active disease (upper lobe cavitation 970-80%), hilar lymphadenopathy, or pleural effusion.
**Definitive diagnosis of suspicious x-ray finding by isolation of Mycobacterium tuberculosis in body fluid or tissues (lung, pleura)
**Sputum sampling (acid-fast bacilli smear and culture)
***Least invasive and costly route for microbial confirmation
***Three single sputum samples (spontaneous or induced) are submitted in 8- to 24-hour intervals with at least 1 early-morning sample
***Sputum should be sent for acid-fast bacillus smear, mycobacterial culture, and nucleic acid amplification testing.
**Tuberculin skin test and interferon-gamma release assay
***both can only support the diagnosis and if positive suggest exposure
***Can't distinguish between active and latent disease
**Bronchoscopy with bronchoalveolar lavage
***More invasive and expensive than sputum sampling
***Reserved for patients who are
****Unable to produce adequate expectorated or induced sputum
****Have negative sputum studies with a high suspicion for active TB
****Have possible alternate diagnosis that requires bronchoscopy for evaluation

Latest revision as of 16:27, 15 October 2019