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Fungal Prostatitis Caused by Coccidioides
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Fungal Prostatitis Caused by Coccidioides A 54-year-old man had been treated with steroids. Hematoxylin and eosin-stained sections of the prostate revealed a granulomatous inflammatory response, with necrosis, giant cells and large, rounded spherules, especially within the giant cells ½F1 (fig. 1). Gomori methenamine silver stain highlighted the spherules, some empty and others containing ½F2 endospores (fig. 2). These findings are diagnostic of coccidioidomycosis of the prostate, or granulomatous prostatitis due to Coccidioides infection. Fungal granulomatous prostatitis is rare. Predisposing conditions for prostatic fungal infection include immunosuppression, prolonged antibiotic use, diabetes mellitus, malignancy and an indwelling bladder catheter.1e3 Fungi detected in the prostate include Cryptoccocus, Paracoccidioides, Coccidioides, Histoplasma, Blastomyces, Candida and Aspergillus. In patients with predisposing conditions, and granulomatous prostatitis or necrotizing granulomas in the absence of bacillus Calmette-Guerin therapy, special histochemical stains for fungal organisms and acid-fast bacilli should be employed. Coccidioidomycosis of the male genital tract is rare but should be considered in the differential diagnosis of granulomatous prostatitis, particularly
Figure 1. Granulomatous prostatitis with several giant cells
0022-5347/13/1911-0001/0 THE JOURNAL OF UROLOGY® © 2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
Figure 2. Coccidioides spherules, one containing endospores
in desert regions of the southwestern United States, northern Mexico, and limited areas of Central and South America where Coccidioides is endemic.4,5 Most patients with primary coccidioidal infection of the lungs are asymptomatic or manifest selflimited respiratory symptoms. Extrapulmonary spread is infrequent and for the genitourinary tract the spread is thought to occur mainly via a hematogenous route. In 1 autopsy study of disseminated coccidiodomycosis the prostate was involved in only about 2% of cases.5 Most patients with genital coccidioidomycosis were older than 50 years (range 27 to 84) and had a history of primary pulmonary infection. In most cases of coccidioidal infection of the prostate the diagnosis was incidental and established by histological examination of needle biopsy tissue sections or prostatic chips from transurethral resection. Patients with symptomatic coccidioidomycosis require immediate antifungal therapy.4,5 The treatment for isolated male genital tract disease has not been well-defined,5 and many but not all immunocompetent patients with isolated genital tract (including prostate) involvement have been cured with surgical resection. For asymptomatic patients http://dx.doi.org/10.1016/j.juro.2013.10.045 Vol. 191, 1-2, January 2014 Printed in U.S.A.
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with coccidioidomycosis of the prostate diagnosed as an incidental finding, management depends on the type of tissue sampling. For patients with Coccidioides in prostate needle biopsy tissue observation is an option, whereas for patients with Coccidioides identified in prostatectomy tissue antifungal therapy is recommended.4 Peter A. Humphrey Department of Pathology and Immunology Washington University School of Medicine St. Louis, Missouri
Dochead: Pathology Page
1. Haas CA, Bodner DR, Hampel N et al: Systemic candidiasis presenting with prostatic abscess. Br J Urol 1998; 82: 450. 2. Abbas F, Kamal MK and Talati J: Prostatic aspergillosis. J Urol 1995; 153: 748. 3. Campbell TB, Kaufman L and Cook JL: Aspergillosis of the prostate associated with an indwelling bladder catheter: case report and review. Clin Infect Dis 1992; 14: 942. 4. Yurkanin JP, Ahmann F and Dalkin BL: Coccidioidomycosis of the prostate: a determination of incidence, report of 4 cases, and treatment recommendations. J Infect 2006; 52: e19. 5. Sohail MR, Andrews PE and Blair JE: Coccidioidomycosis of the male genital tract. J Urol 2005; 173: 1978.
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Fungal Prostatitis Caused by Coccidioides A 54-year-old man had been treated with steroids. Hematoxylin and eosin-stained sections of the prostate revealed a granulomatous inflammatory response, with necrosis, giant cells and large, rounded spherules, especially within the giant cells ½F1 (fig. 1). Gomori methenamine silver stain highlighted the spherules, some empty and others containing ½F2 endospores (fig. 2). These findings are diagnostic of coccidioidomycosis of the prostate, or granulomatous prostatitis due to Coccidioides infection. Fungal granulomatous prostatitis is rare. Predisposing conditions for prostatic fungal infection include immunosuppression, prolonged antibiotic use, diabetes mellitus, malignancy and an indwelling bladder catheter.1e3 Fungi detected in the prostate include Cryptoccocus, Paracoccidioides, Coccidioides, Histoplasma, Blastomyces, Candida and Aspergillus. In patients with predisposing conditions, and granulomatous prostatitis or necrotizing granulomas in the absence of bacillus Calmette-Guerin therapy, special histochemical stains for fungal organisms and acid-fast bacilli should be employed. Coccidioidomycosis of the male genital tract is rare but should be considered in the differential diagnosis of granulomatous prostatitis, particularly
Figure 1. Granulomatous prostatitis with several giant cells
0022-5347/13/1911-0001/0 THE JOURNAL OF UROLOGY® © 2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
Figure 2. Coccidioides spherules, one containing endospores
in desert regions of the southwestern United States, northern Mexico, and limited areas of Central and South America where Coccidioides is endemic.4,5 Most patients with primary coccidioidal infection of the lungs are asymptomatic or manifest selflimited respiratory symptoms. Extrapulmonary spread is infrequent and for the genitourinary tract the spread is thought to occur mainly via a hematogenous route. In 1 autopsy study of disseminated coccidiodomycosis the prostate was involved in only about 2% of cases.5 Most patients with genital coccidioidomycosis were older than 50 years (range 27 to 84) and had a history of primary pulmonary infection. In most cases of coccidioidal infection of the prostate the diagnosis was incidental and established by histological examination of needle biopsy tissue sections or prostatic chips from transurethral resection. Patients with symptomatic coccidioidomycosis require immediate antifungal therapy.4,5 The treatment for isolated male genital tract disease has not been well-defined,5 and many but not all immunocompetent patients with isolated genital tract (including prostate) involvement have been cured with surgical resection. For asymptomatic patients http://dx.doi.org/10.1016/j.juro.2013.10.045 Vol. 191, 1-2, January 2014 Printed in U.S.A.
www.jurology.com Dochead: Pathology Page
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with coccidioidomycosis of the prostate diagnosed as an incidental finding, management depends on the type of tissue sampling. For patients with Coccidioides in prostate needle biopsy tissue observation is an option, whereas for patients with Coccidioides identified in prostatectomy tissue antifungal therapy is recommended.4 Peter A. Humphrey Department of Pathology and Immunology Washington University School of Medicine St. Louis, Missouri
Dochead: Pathology Page
1. Haas CA, Bodner DR, Hampel N et al: Systemic candidiasis presenting with prostatic abscess. Br J Urol 1998; 82: 450. 2. Abbas F, Kamal MK and Talati J: Prostatic aspergillosis. J Urol 1995; 153: 748. 3. Campbell TB, Kaufman L and Cook JL: Aspergillosis of the prostate associated with an indwelling bladder catheter: case report and review. Clin Infect Dis 1992; 14: 942. 4. Yurkanin JP, Ahmann F and Dalkin BL: Coccidioidomycosis of the prostate: a determination of incidence, report of 4 cases, and treatment recommendations. J Infect 2006; 52: e19. 5. Sohail MR, Andrews PE and Blair JE: Coccidioidomycosis of the male genital tract. J Urol 2005; 173: 1978.
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