Skip to main content

An AIDS patient with urine retention

Abstract

Background

Cryptococcal prostatitis is a rare clinical disease and has never been reported in China.

Case presentation

We report on a male HIV-infected patient with pulmonary and prostate cryptococcosis that was misdiagnosed (as tuberculosis) and delayed diagnosed. Although the patients accepted anti-fungal treatment and anti-retroviral treatment finally, the physician’s mistakes reflect the rarity of this condition in China.

Conclusion

Cryptococcal prostatitis is a rare disease that unusually presents in immunodeficient patients. Physicians should have a heightened awareness of this particular infection in the immunodeficient population.

Peer Review reports

Background

Cryptococcosis is a common opportunistic infection in HIV-infected patients, causing up to 70% mortality at 3 months in some areas [1]. Patients with HIV tend to have more extraneural involvement and cryptococcemia than those without HIV [2]. Therefore, being aware of atypical Cryptococcus infection sites is critical when caring for HIV patients.

Cryptococcal prostatitis is rare. It usually presents in immunocompromised patients, such as those with diabetes, liver cirrhosis or organ transplantation [3,4,5,6]. Cryptococcus-infected prostates are occasionally reported in patients with AIDS [7, 8]. However, cryptococcal prostatitis has never been reported in China. Here, we report the first Chinese case of a patient with AIDS and urinary retention, in which the infection was misdiagnosed as tuberculosis before being correctly diagnosed as cryptococcal prostatitis.

Case presentation

In October 2017, a 47-year-old man had presented to a local hospital with cough and weight loss. He tested positive for HIV and a chest CT scan indicated a cavity in the right upper pulmonary lobe (Additional file 1). His CD4+ T cell count was 78 cells/μl and his sputum smear was negative for tuberculosis. He was diagnosed as HIV positive with tuberculosis infection (smear negative) and started antiviral therapy with tenofovir, lamivudine and efavirenz after 2 weeks of anti-tuberculosis treatment with isoniazid, rifampin, ethambutol and pyrazinamide.

In December 2017, the patient presented to the same hospital after having urinary retention for 2 weeks. He had no other symptoms such as headache, fever or cough. His prostate was found to be enlarged, and the doctor suggested continuing anti-tuberculosis treatment and inserted a urinary catheter to relieve the patient’s urinary retention. Given that the urinary retention had deteriorated for two weeks before this visiting, the doctor suggested the patient attend the First Affiliated Hospital of Zhejiang University for better solution. After admission, physical examination revealed no significant clinical findings except for the presence of the urinary catheter. The sputum culture, smear and interferon-γ release assay were all negative for Mycobacterium tuberculosis. Lumbar puncture indicated a nearly normal cerebrospinal fluid (CSF) profile and the CSF was negative for cryptococcal antigen, so urinary retention as a result of central nervous system infection seemed unlikely. A CT scan indicated a cavity with effusion in the upper right lung (Fig. 1.a). Bronchoscopy was performed, and a lateral flow immunoassay and culture of the bronchoalveolar lavage fluid (BALF) were both positive for Cryptococcus neoformans. Enhanced MRI of the prostate revealed an abnormal patchy signal in the central gland of the prostate that was isointense on T1-weighted imaging (WI), high intensity on T2WI, and no signal on diffusion-weighted imaging. The signal of T2 W1 was reduced in the seminal vesicles and peripheral zone of the prostate, and T1 W1 in the peripheral zone was enhanced (Fig. 1. b). An haematoxylin and eosin (H&E) stain of the ultrasound-guided prostatic biopsy showed granulomatous inflammation; periodic acid–Schiff staining of the biopsied tissue was positive, Mayer’s Mucicarmine stain was negative, Gomori-methenamine silver staining was positive, and Ziehl-Neelsen staining was negative (Fig. 2). Culture of the prostatic tissue grew Cryptococcus neoformans. The patient was diagnosed with AIDS with pulmonary cryptococcosis and cryptococcal prostatitis. Oral voriconazole (200 mg bid) combined with oral flucytosine (100 mg/kg/d) for 2 months and then oral fluconazole (600 mg/d) for maintenance treatment for 4 months that relieved the cryptococcal prostatitis and urinary retention (Additional file 2).

Fig. 1
figure1

Radiology images of patient. a. Chest CT in Dec 2017 indicated a cavity with effusion in the upper right lung; b. Enhanced MRI of the prostate in Dec 2017 revealed an abnormal patchy signal in the central gland of the prostate

Fig. 2
figure2

Pathological finding in Prostate biopsy. Cryptococcal capsules were shown in histiocytes. a. Gomori-methenamine silver (GSM) staining (50×); b. GSM staining (200×);c. GSM staining (400×):d. Hematoxylin-Eosin (HE) staining (200×); d. Periodic Acid–Schiff (PAS) staining (200×); f. PAS staining (400×)

Discussion and conclusions

China has a high prevalence of tuberculosis infection, and tuberculosis is a common opportunistic infection in Chinese HIV-infected patients. Smear-negative tuberculosis is more common in patients with HIV infection than in those without [9, 10]. However, there have been reports of Cryptococcus infection in immunocompromised patients with atypical presentations being misdiagnosed as tuberculosis [11, 12].

Our patient was misdiagnosed as having smear-negative pulmonary tuberculosis. Cryptococcus infection was hinted at by the lung cavity and the prostate hypertrophy; this was then confirmed by the presence of Cryptococcus in the BALF and prostatic biopsy specimen.

Although the correct diagnosis was reached eventually, this case provides some valuable lessons. First, a detailed pathogen screen should be done in HIV patients, especially in those with pneumonia; it is sometimes difficult to make accurate diagnoses based only on radiology. A lateral flow immunoassay for cryptococcal antigen is a rapid and reliable diagnosis method for suspected Cryptococcus infection [13]. Second, prostate infections should be a ‘red flag’ for urologists and pathologists in general hospitals in China. There are two types of hospitals in China responsible for HIV treatment; specialized and general hospitals. Doctors in some general hospitals, especially in those without HIV/AIDS wards, are less aware of atypical infections in HIV patients. Strengthening and highlighting AIDS-associated medical knowledge in these practitioners is important. Third, cryptococcal prostatitis is an uncommon disease in clinical practice, which may influence some doctors’ correctly diagnosis and treatment decisions in some circumstances.

In summary, cryptococcal prostatitis is a rare disease that unusually presents in immunodeficient patients. Physicians should have a heightened awareness of this particular infection in the immunodeficient population.

Availability of data and materials

Some original images were provided as supplements.

Abbreviations

AIDS:

Acquired immune deficient syndrome

BLAF:

Bronchoalveolar lavage fluid

CSF:

Cerebrospinal fluid

CT:

Computed tomography

HIV:

Human immunodeficiency virus

MRI:

Magnetic Resonance Imaging

References

  1. 1.

    Limper AH, Adenis A, Le T, Harrison TS. Fungal infections in HIV/AIDS. Lancet Infect Dis. 2017;17(11):e334–e43. https://doi.org/10.1016/s1473-3099(17)30303-1.

    Article  PubMed  Google Scholar 

  2. 2.

    Lee YC, Wang JT, Sun HY, Chen YC. Comparisons of clinical features and mortality of cryptococcal meningitis between patients with and without human immunodeficiency virus infection. J Microbiol Immunol Infect. 2011;44(5):338–45. https://doi.org/10.1016/j.jmii.2010.08.011.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Brooks MH, Scheerer PP, Linman JW. CRYPTOCOCCAL PROSTATITIS. Jama. 1965;192:639–41.

    CAS  Article  Google Scholar 

  4. 4.

    Hinchey WW, Someren A. Cryptococcal prostatitis. Am J Clin Pathol. 1981;75(2):257–60.

    CAS  Article  Google Scholar 

  5. 5.

    Siddiqui TJ, Zamani T, Parada JP. Primary cryptococcal prostatitis and correlation with serum prostate specific antigen in a renal transplant recipient. J Inf Secur. 2005;51(3):e153–7. https://doi.org/10.1016/j.jinf.2004.12.005.

    Article  Google Scholar 

  6. 6.

    Shah SI, Bui H, Velasco N, Rungta S. Incidental finding of Cryptococcus on prostate biopsy for prostate adenocarcinoma following cardiac transplant: case report and review of the literature. Am J Case Rep. 2017;18:1171–80.

    Article  Google Scholar 

  7. 7.

    de Lima MA, dos Santos JA, Lazo J, Silva-Vergara ML, dos Santos LA, dos Santos VM. Cryptococcus infection limited to the prostate in an AIDS patient with disseminated mycobacteriosis. A necropsy report. Rev Soc Bras Med Trop. 1997;30(6):501–5.

    Article  Google Scholar 

  8. 8.

    Staib F, Seibold M, L'Age M, Heise W, Skorde J, Grosse G, et al. Cryptococcus neoformans in the seminal fluid of an AIDS patient. A contribution to the clinical course of cryptococcosis. Mycoses. 1989;32(4):171–80.

    CAS  Article  Google Scholar 

  9. 9.

    Floyd K, Glaziou P, Zumla A, Raviglione M. The global tuberculosis epidemic and progress in care, prevention, and research: an overview in year 3 of the end TB era. Lancet Respir Med. 2018;6(4):299–314. https://doi.org/10.1016/s2213-2600(18)30057-2.

    Article  PubMed  Google Scholar 

  10. 10.

    Maimaiti R, Zhang Y, Pan K, Mijiti P, Wubili M, Musa M, et al. High prevalence and low cure rate of tuberculosis among patients with HIV in Xinjiang, China. BMC Infect Dis. 2017;17(1):15. https://doi.org/10.1186/s12879-016-2152-4.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Jarvis JN, Wainwright H, Harrison TS, Rebe K, Meintjes G. Pulmonary cryptococcosis misdiagnosed as smear-negative pulmonary tuberculosis with fatal consequences. Int J Infect Dis. 2010;14(Suppl 3):e310–2. https://doi.org/10.1016/j.ijid.2010.02.2255.

    Article  PubMed  Google Scholar 

  12. 12.

    Ismail J, Chidambaram M, Sankar J, Agarwal S, Lodha R. Disseminated Cryptococcosis presenting as Miliary lung shadows in an Immunocompetent child. J Trop Pediatr. 2018;64(5):434–7. https://doi.org/10.1093/tropej/fmx083.

    Article  PubMed  Google Scholar 

  13. 13.

    Escandon P, Lizarazo J, Agudelo CI, Chiller T, Castaneda E. Evaluation of a rapid lateral flow immunoassay for the detection of cryptococcal antigen for the early diagnosis of cryptococcosis in HIV patients in Colombia. Med Mycol. 2013;51(7):765–8. https://doi.org/10.3109/13693786.2013.781692.

    CAS  Article  PubMed  Google Scholar 

Download references

Acknowledgements

Many thanks for works by the staffs in HIV/AIDS ward from the First Affiliated Hospital, College of Medicine, Zhejiang University.

Funding

1) The national science and technology major project of China during the 13th Five-year plan period (2018ZX10302104); 2) Independent Research Foundation of the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University [491010*A61703]. The funding had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author information

Affiliations

Authors

Contributions

LJX drafted the manuscript and revised all versions; RT contributed to the care of the patient, QYZ contributed to prostatic biopsy, JLC provided pathological images and BZ revised the manuscript for publication. All authors read and approved the Manuscript.

Corresponding authors

Correspondence to Lijun Xu or Biao Zhu.

Ethics declarations

Ethics approval and consent to participate

Ethics approval or consent to participate was not applicable.

Consent for publication

Written consent to publish is obtained from study participant, and written consent is available for review by the Editor-in-Chief of journal.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Additional file 1.

Chest CT in Oct 2017.

Additional file 2.

Prostate CT after 6 month of anti-fungal treatment.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Xu, L., Tao, R., Zhao, Q. et al. An AIDS patient with urine retention. BMC Infect Dis 19, 1051 (2019). https://doi.org/10.1186/s12879-019-4641-8

Download citation

Keywords

  • Cryptococcal prostatitis
  • HIV
  • Tuberculosis