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Prostatic cryptococcosis
PROSTATIC CRYPTOCOCCOSIS MINH THO HUYNH, M .D. CESAR V. REYES, M .D . From the Laboratory Service, Veterans Administration Hospital, Hines, and the Department of Pathology, University of Illinois Abraham Lincoln School of Medicine, Chicago, Illinois
ABSTRACT -A case is presented of recurrent dysuria and hernaturia due to cryptococcal prostatitis, followed up for eight years . There is an apparent rarity of histodiagnosis of this fungal infection of the prostate during life .
Cryptococcosis is a systemic fungal infection often seen in immunocompromised hosts .' It is caused by Cryptococcus neoformans which is considered ubiquitous in nature and commonly associated with pigeon nests and droppings .''' The initial pulmonary focus of infection is followed by hematogenous dissemination .' In its clinical evolution, the most frequent and lethal form of the disease is the involvement of the brain and meninges ;' and it may spread virtually to any organ, including the prostate .''" The prostatic lesion is usually an incidental postmortem finding and is rarely diagnosed with histologic confirmation during life ." The following report is added to the literature . Case Report A sixty-eight-year-old, white man entered the hospital because of dysuria and slowing of urinary stream of a few weeks' duration . Pertinent past medical history included adult-onset diabetes mellitus, left nephrectomy for lithiasis many years earlier, and acute cryptococcal meningitis two years earlier . In the latter, the fungus was identified and cultured from the cerebrospinal fluid . The patient was treated with amphotericin B for twenty-one days after which clinical evidence developed suggesting druginduced hepatitis . This was later supported by liver biopsy . Physical examination demonstrated an enlarged, nodular, and indurated left lobe of the prostate . Microscopic hematuria and pyuria were noted on routine urinalysis . Cystoscopy disclosed an obstruction of the urinary bladder 622
neck. The prostatic tissue from transurethral resection revealed hyperplastic glands and a granuloma with central necrosis (Fig . IA) . The latter was marginated by marked fibrosis, rare epithelioid cells, plasma cells, lymphocytes, and multinucleated Langhans giant cells . Focal calcification was also observed . The necrotic area contained numerous yeast-form organisms often surrounded by a clear halo (Fig . 1B). They were distinctly accentuated by periodic acid-Schiff and Grocott silver methenamine stains . With Mayer's procedure, a brightly mucicarminophilic thick capsule in many of the yeasts affirmed their identity as C . neoformans (Fig . 1C) .''' Because of the localized nature of the prostatic lesion, negative culture of prostatic secretion and multiple urine specimens, and failure in the clinical investigation to unravel other organ infection, no chemotherapy was administered to the patient . He had a good recovery after symptomatic treatment . Follow-up at eight years was marked by two recent hospitalizations because of gross hematuria. A prostatic biopsy disclosed only hyperplastic glands . The prostatic tissue from a subsequent, repeat transurethral resection, however, proved the diagnosis of a focal, necrotizing cryptococcal granuloma . The histology of the lesion was essentially similar to that described . Again, attempts to isolate the fungus from various clinical materials, serum indirect fluorescent antibody, and tube agglutination tests, spinal fluid, and serum latex agglutination tests for crvptococcosis were negative . The final interpretation was that the infection was localized UROLOGY / DECEMBER 1982 / VOLUME XX, NUMBER 6
FIGURE 1 . (A) Localized granuloma of prostate marginated by thick fibrous tissue ; central necrosis (arrow) is present, and inflammatory cellular reaction is sparse (hematoxylin and eosin stain, original magnification X 80) . (B) Necrotic area demonstrates numerous yeasts of Cryptococcus neoforrnans ; clear halo around each organism is striking (hematoxylin and eosin stain, original magnification x 320) . (C) Mucicarminophilic capsule is characteristic of C . neofonnans (Mayer mucicarrnine stain, original magnification X 320).
and that most of the prostatic tissue was removed . No therapy with amphotericin B was given . Six months after discharge, the patient was asymptomatic and had negative cultures . Comment Genitourinary mycosis usually represents a spread from a primary focus of infection elsewhere .'- " It affects the kidneys, prostate, epididymis, and testes in descending order of frequency .'-" Candida albicans and Blastomyces dermatitidis appear to be the more common offending organisms, along with Histoplasma capsulatum .s-11 Infections due to Cryptococcus, Actinomyces bovis, and Coccidioides immitis are relatively rare . -" Most cases of prostatic mycosis as previously reported are incidental findings at autopsy . 3-11 To our knowledge, only 7 cases of cryptococcal prostatitis, histologically diagnosed during life, have appeared in the literature .` The predominant complaints of patients are frequency, urgency, dysuria, urinary bladder outlet obstruction, perineal and suprapubic discomfort, and hematuria. 3-9 A high index of suspicion for this disorder is of utmost value in the clinical diagnosis, supplemented by a laboratory facility capable of isolating and defining the fimgus .s In the differential consideration, nodular prostatic hyperplasia, abscess, tuberculosis, syphilis, and cancer are included .'-" The usual treatment of choice is the administration of amphotericin B .
UROLOGY
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DECEMBER 1982
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VOLUME XX, NUMBER 6
Flucytosine (5-fluorocytosine, 5-FC) is also widely accepted as an alternative drug or in combination with low doses of amphotericin B . 1-" This case is unique in the sense of histodiagnosis of the prostatic lesion during life and the negative results of the subsequent clinical followup to uncover other organ involvement for eight years . Veterans Administration Hospital (113) Hines, Illinois 60141 (DR . REYES) References 1 . Editorial : Cryptococcal infections, Br Med j 1 : 1008 (1978) . 2 . Rippon JW : Medical Mycology. The pathogenic fungi and pathogenic actinnmycetes, Philadelphia, WB Saunders Co ., 1974, p . 205. 3 . Bowman HE, and Ritchey JO : Cryptococcosis (Torulosis) involving the brain, adrenal and prostate, J Urol 71 : 373 (1954). 4 . Dreyhrss ML, and Sommer RI : Granulomatous prostatitis due to Cryptococcus neoformans (Torula) with disseminated cryptococcosis and meningitis, New York J Med 61 : 1589 (1961) . 5. Brooks MH, Scheere PP, and Linman JW : Cryptococcal prostatitis, JAMA 192 : 639 (1965) . 6 . O'Connor FJ, Foushee JHS Jr, and Cox CE : Prostatic cryptococcosis : a case report . J Urol 94 : 160 (1965) . 7 . Tillotson JR, and Lerner AM : Prostatism in an eighteen-yearold boy due to infection with Cryptococcus neoformans, N Engl J Med 273 : 1150 (1965) . 8 . Orr WA, Mulholland SG, and Walzak MP ; Genitourinary tract involvement with systemic mycosis, j Urol 107 : 1047 (1972) . 9. Salyer WR, and Salver DC : Involvement of the kidney and prostate in crvptococcosis,ibid 109 :695 (1973) . 10. Michigan S : Genitourinary fungal infection, ibid 118: 390 (1976) . 11 . Bissada NK, Finkbeiner AE, and Redman JF : Prostatic mycosis . Nonsurgical diagnosis and management, Urology 9 : 104 (1917) .
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ABSTRACT -A case is presented of recurrent dysuria and hernaturia due to cryptococcal prostatitis, followed up for eight years . There is an apparent rarity of histodiagnosis of this fungal infection of the prostate during life .
Cryptococcosis is a systemic fungal infection often seen in immunocompromised hosts .' It is caused by Cryptococcus neoformans which is considered ubiquitous in nature and commonly associated with pigeon nests and droppings .''' The initial pulmonary focus of infection is followed by hematogenous dissemination .' In its clinical evolution, the most frequent and lethal form of the disease is the involvement of the brain and meninges ;' and it may spread virtually to any organ, including the prostate .''" The prostatic lesion is usually an incidental postmortem finding and is rarely diagnosed with histologic confirmation during life ." The following report is added to the literature . Case Report A sixty-eight-year-old, white man entered the hospital because of dysuria and slowing of urinary stream of a few weeks' duration . Pertinent past medical history included adult-onset diabetes mellitus, left nephrectomy for lithiasis many years earlier, and acute cryptococcal meningitis two years earlier . In the latter, the fungus was identified and cultured from the cerebrospinal fluid . The patient was treated with amphotericin B for twenty-one days after which clinical evidence developed suggesting druginduced hepatitis . This was later supported by liver biopsy . Physical examination demonstrated an enlarged, nodular, and indurated left lobe of the prostate . Microscopic hematuria and pyuria were noted on routine urinalysis . Cystoscopy disclosed an obstruction of the urinary bladder 622
neck. The prostatic tissue from transurethral resection revealed hyperplastic glands and a granuloma with central necrosis (Fig . IA) . The latter was marginated by marked fibrosis, rare epithelioid cells, plasma cells, lymphocytes, and multinucleated Langhans giant cells . Focal calcification was also observed . The necrotic area contained numerous yeast-form organisms often surrounded by a clear halo (Fig . 1B). They were distinctly accentuated by periodic acid-Schiff and Grocott silver methenamine stains . With Mayer's procedure, a brightly mucicarminophilic thick capsule in many of the yeasts affirmed their identity as C . neoformans (Fig . 1C) .''' Because of the localized nature of the prostatic lesion, negative culture of prostatic secretion and multiple urine specimens, and failure in the clinical investigation to unravel other organ infection, no chemotherapy was administered to the patient . He had a good recovery after symptomatic treatment . Follow-up at eight years was marked by two recent hospitalizations because of gross hematuria. A prostatic biopsy disclosed only hyperplastic glands . The prostatic tissue from a subsequent, repeat transurethral resection, however, proved the diagnosis of a focal, necrotizing cryptococcal granuloma . The histology of the lesion was essentially similar to that described . Again, attempts to isolate the fungus from various clinical materials, serum indirect fluorescent antibody, and tube agglutination tests, spinal fluid, and serum latex agglutination tests for crvptococcosis were negative . The final interpretation was that the infection was localized UROLOGY / DECEMBER 1982 / VOLUME XX, NUMBER 6
FIGURE 1 . (A) Localized granuloma of prostate marginated by thick fibrous tissue ; central necrosis (arrow) is present, and inflammatory cellular reaction is sparse (hematoxylin and eosin stain, original magnification X 80) . (B) Necrotic area demonstrates numerous yeasts of Cryptococcus neoforrnans ; clear halo around each organism is striking (hematoxylin and eosin stain, original magnification x 320) . (C) Mucicarminophilic capsule is characteristic of C . neofonnans (Mayer mucicarrnine stain, original magnification X 320).
and that most of the prostatic tissue was removed . No therapy with amphotericin B was given . Six months after discharge, the patient was asymptomatic and had negative cultures . Comment Genitourinary mycosis usually represents a spread from a primary focus of infection elsewhere .'- " It affects the kidneys, prostate, epididymis, and testes in descending order of frequency .'-" Candida albicans and Blastomyces dermatitidis appear to be the more common offending organisms, along with Histoplasma capsulatum .s-11 Infections due to Cryptococcus, Actinomyces bovis, and Coccidioides immitis are relatively rare . -" Most cases of prostatic mycosis as previously reported are incidental findings at autopsy . 3-11 To our knowledge, only 7 cases of cryptococcal prostatitis, histologically diagnosed during life, have appeared in the literature .` The predominant complaints of patients are frequency, urgency, dysuria, urinary bladder outlet obstruction, perineal and suprapubic discomfort, and hematuria. 3-9 A high index of suspicion for this disorder is of utmost value in the clinical diagnosis, supplemented by a laboratory facility capable of isolating and defining the fimgus .s In the differential consideration, nodular prostatic hyperplasia, abscess, tuberculosis, syphilis, and cancer are included .'-" The usual treatment of choice is the administration of amphotericin B .
UROLOGY
/
DECEMBER 1982
/
VOLUME XX, NUMBER 6
Flucytosine (5-fluorocytosine, 5-FC) is also widely accepted as an alternative drug or in combination with low doses of amphotericin B . 1-" This case is unique in the sense of histodiagnosis of the prostatic lesion during life and the negative results of the subsequent clinical followup to uncover other organ involvement for eight years . Veterans Administration Hospital (113) Hines, Illinois 60141 (DR . REYES) References 1 . Editorial : Cryptococcal infections, Br Med j 1 : 1008 (1978) . 2 . Rippon JW : Medical Mycology. The pathogenic fungi and pathogenic actinnmycetes, Philadelphia, WB Saunders Co ., 1974, p . 205. 3 . Bowman HE, and Ritchey JO : Cryptococcosis (Torulosis) involving the brain, adrenal and prostate, J Urol 71 : 373 (1954). 4 . Dreyhrss ML, and Sommer RI : Granulomatous prostatitis due to Cryptococcus neoformans (Torula) with disseminated cryptococcosis and meningitis, New York J Med 61 : 1589 (1961) . 5. Brooks MH, Scheere PP, and Linman JW : Cryptococcal prostatitis, JAMA 192 : 639 (1965) . 6 . O'Connor FJ, Foushee JHS Jr, and Cox CE : Prostatic cryptococcosis : a case report . J Urol 94 : 160 (1965) . 7 . Tillotson JR, and Lerner AM : Prostatism in an eighteen-yearold boy due to infection with Cryptococcus neoformans, N Engl J Med 273 : 1150 (1965) . 8 . Orr WA, Mulholland SG, and Walzak MP ; Genitourinary tract involvement with systemic mycosis, j Urol 107 : 1047 (1972) . 9. Salyer WR, and Salver DC : Involvement of the kidney and prostate in crvptococcosis,ibid 109 :695 (1973) . 10. Michigan S : Genitourinary fungal infection, ibid 118: 390 (1976) . 11 . Bissada NK, Finkbeiner AE, and Redman JF : Prostatic mycosis . Nonsurgical diagnosis and management, Urology 9 : 104 (1917) .
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