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Case Reports and Small Case Series
October 2000

Conjunctival Cryptococcosis in the Acquired Immunodeficiency Syndrome

Arch Ophthalmol. 2000;118(10):1446-1449. doi:

Intraocular infection with Cryptococcus neoformans in people with the acquired immunodeficiency syndrome (AIDS) is very uncommon compared with meningeal and optic nerve involvement. When it does occur it is mostly in the posterior segment.1,2 For lesions in the anterior segment, a MEDLINE search revealed only 1 case of iris involvement3 and 2 of small conjunctival granulomas.4,5 We describe a patient with a larger conjunctival lesion mimicking a carcinoma.

Report of a Case

A 28-year-old Ugandan man had a 6 × 10-mm lesion of the temporal interpalpebral conjunctiva of the right eye, encroaching 1 mm onto the cornea (Figure 1). There was marked surrounding hyperemia. In site and appearance it resembled a conjunctival carcinoma except that the surface was less rough and opaque than usual. Visual acuity in the eye was 6/18 + 2 and the fundus was normal. The left eye was normal with an acuity of 6/6. Aside from having oral candidiasis, he was well and had not lost weight. The lesion was excised with a lamellar sclerokeratectomy as it was firmly fixed to the underlying coats. Alcohol was applied to the corneal edge after resection. The defect was closed with a pedicle graft from the upper bulbar conjunctiva. It healed well and postoperative acuity was 6/9. After pretest counseling, results from human immunodeficiency virus (HIV) testing with 3 different tests were positive (1 agglutination test and 2 enzyme immunoassay tests). He received posttest counseling and was referred to the nearby AIDS Support Organization for management of his general condition. Findings from a cryptococcal antigen test done retrospectively on stored serum were 1+.

Figure 1.
A 6 × 10-mm lesion of the temporal interpalpebral conjunctiva encroaching onto the cornea, found to be a cryptococcal infection.

A 6 × 10-mm lesion of the temporal interpalpebral conjunctiva encroaching onto the cornea, found to be a cryptococcal infection.

One month later he developed a wasting syndrome with recurrent fever, diarrhea, and stomatitis. He did not complain of headache, and meningitis was not suspected. His condition deteriorated rapidly and he died 2 months postoperatively.

Histopathologic Findings

Histopathologic findings (Figure 2) showed that beneath the conjunctival epithelium there were numerous giant cells arranged in a loose granulomatous pattern. The pseudocystic spaces containing the fungus were evident. A Grocott stain (Figure 3) showed abundant C neoformans yeasts, some within mucoid pseudocystic spaces.

Figure 2.
Histopathologic finding showing giant cells and pseudocystic spaces containing fungi beneath a normal epithelium (hematoxylin-eosin, original magnification ×1000).

Histopathologic finding showing giant cells and pseudocystic spaces containing fungi beneath a normal epithelium (hematoxylin-eosin, original magnification ×1000).

Figure 3.
Abundant cryptococci are shown, some with mucoid pseudocystic spaces seen (Grocott, original magnification ×1000).

Abundant cryptococci are shown, some with mucoid pseudocystic spaces seen (Grocott, original magnification ×1000).

Comment

The preoperative diagnosis was squamous cell carcinoma since so many of these are now being seen in Uganda6 (more than 150 a year were seen by our team alone). Histologic study showed this preoperative diagnsosis to be incorrect. In retrospect, the smoother surface and total fixation to the sclera were unusual for a moderately sized carcinoma. Excision appeared curative for the amount of time he survived thereafter. T-lymphocyte subsets were not measured, but the course of the disease makes it very likely he was severely immunosuppressed. The possibility of meningeal or pulmonary cryptococcosis was not considered during his terminal illness, but it might have been obscured by the other features. It is therefore uncertain whether the eye lesion was isolated or associated with cryptococcal infection elsewhere. It is known that cutaneous lesions can appear before dissemination.7 In one of the previously reported conjunctival cases,5 systemic disease in the form of multifocal choroiditis was present. In another case4 disease was isolated and preceded seroconversion to HIV. These cases (one from Brazil and the other from Germany) had inconspicuous nodules (largest, 5 × 5 mm) of uncertain nature until biopsy was performed. This raises the possibility that such lesions are being overlooked in ill patients and yet would provide a useful pointer to the diagnosis of cryptococcosis. In Uganda this is unlikely to be true because this case is the only cryptococcal infection found in our current study of more than 400 conjunctival biopsy specimens, most of which (65%) were from people who are HIV positive.

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Article Information

Corresponding author: Keith M. Waddell, FRCP, Box 4008, Kampala, Uganda (e-mail: AIM-UGANDA@maf.org).

References
1.
Kestelyn  PTaelman  HBogaerts  JKagame  AAbdel Aziz  MBatungwanayo  J Ophthalmic manifestations of infections with Cryptococcus neoformans in patients with the acquired immunodeficiency syndrome. Am J Ophthalmol. 1993;116721- 727
2.
Verma  SGraham  E Cryptococcus presenting as cloudy choroiditis in an AIDS patient [letter]. Br J Ophthalmol. 1995;79618- 619Article
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Charles  NBoxrud  CSmall  E Cryptococcosis of the anterior segment in acquired immune deficiency syndrome. Ophthalmology. 1992;99813- 816Article
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Balmes  RBialasiewicz  MBusse  H Conjunctival cryptococcosis preceding human immunodeficiency virus seroconversion. Am J Ophthalmol. 1992;113719- 721
5.
Muccioli  CBelfort  RNeves  RRao  N Limbal and choroidal Cryptococcus infection in the acquired immunodeficiency syndrome. Am J Ophthalmol. 1995;120539- 50
6.
Waddell  KLewallen  SLucas  SAtenyi Agaba  CHerrington  CLiomba  G Conjunctival carcinoma and HIV infection in Uganda and Malawi. Br J Ophthalmol. 1996;80503- 508Article
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Coccia  LCalista  DBoschini  A Eyelid nodule: a sentinel lesion of disseminated cryptococcosis in a patient with acquired immunodeficiency syndrome. Arch Ophthalmol. 1999;117271- 272
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