Gastrointestinal Cryptococcosis Associated with Intestinal Lymphangiectasia

Intestinal lymphangiectasia is a pathological dilation of enteric lymphatic vessels resulting in lymph leakage to the intestinal lumen. This chronic lymph leakage leads to a state of immunosuppression secondary to the loss of humoral and cellular components of the immune system and represents a potential risk factor for opportunistic infections. We report a case of protein-losing enteropathy in a seemingly immunocompetent patient. An intestinal histopathological study revealed the unusual association of lymphangiectasia and intestinal cryptococcosis. Although cryptococcal infection is common in immunocompromised patients, intestinal involvement is rarely reported. We found no reports on the association of intestinal cryptococcosis in patients with lymphangiectasia. This case report is the first to describe intestinal cryptococcosis associated with intestinal lymphangiectasia.


Case
A 37-year-old man presents to the Emergency Department with abdominal pain exacerbation of 3 hours of evolution associated diarrhea with melena. e patient had a documented medical history of intermittent abdominal pain and diarrhea over the 6 months prior to the current admission. Upon admission, the patient presented febrile and in anasarca, with major edema in lower limbs. Initial blood work showed moderate microcytic anemia (Hb 10.3 g/dl, Hct. 23.7%, and MCV 75 fL), severe hypoalbuminemia (1.7 g/dL), inversion of albumin/globulin ratio, and CBC did not show signs of infection. e patient was started on protein replenishment with human albumin which resolved partially the edema.
An exhaustive workout was performed to identify the underlying cause of the edema and low protein levels. Liver disease was ruled out due to normal liver profile (total bilirubin 0.21 mg/dL, indirect bilirubin 0.11 mg/dL, direct bilirubin 0.10 mg/dL, AST 9 IU/L, and ALT 8 IU/L) and the negative liver ultrasound. Nephrotic syndrome was also ruled out as a possible diagnosis.
Due to the persistence of abdominal pain, structural damage or tumor processes were investigated; however, abdominal CT only showed edema in the small intestine wall suggesting chronic enteropathy.
An upper digestive endoscopy was performed showing a whitish lace pattern and erythematous walls in the second portion of the duodenum. In addition, a colonoscopy showed hemorrhoidal packages, multiple ulcerated lesions in sigma, and elevated, pseudopolypoid, infiltrative lesions in cecum and ileocecal valve.
Since our patient lived in a tuberculosis endemic area and that the lesions simulated intestinal tuberculosis, empirical antituberculosis therapy (isoniazid 75 mg, rifampicin 150 mg, ethambutol 275 mg, and pyrazinamide 400 mg) was started until biopsy results came back.
Multiple cryptococci were found in samples taken from the cecum, sigma, and ileocecal valve using the techniques of immunohistochemistry CD68, Grocott stain, PAS stain, and Alcian blue stain ( Figure 1). In addition, the presence of intestinal lymphangiectasia was confirmed with D240 staining (Figure 2).
After receiving the pathology report, antituberculosis therapy was suspended and a regimen consisting of fluconazole 800 mg/day IV for 2 weeks, and octreotide 1 ml subcutaneously every 8 hours was initiated. Due to the severity of the presentation octreotide was started along with dietary treatment. Octreotide and oral fluconazole 600 mg were maintained for 90 days after discharge with favorable symptomatic evolution, additionally, following laboratory controls shown that albumin levels went back to normal.

Discussion
Cryptococcosis is one of the most frequent opportunistic fungal diseases. Its incidence in Latin America has been  However, intestinal dissemination is rarely reported [1][2][3]. An exhaustive literature review in the Medline databases was performed using the terms "gastrointestinal cryptococcosis" and "intestinal lymphangiectasia." We identified a total of 10 case reports of intestinal cryptococcosis in the context of immunosuppressing conditions which are summarized in Table 1; however, we were unable to find reports similar to our case. e lack of literature on the coalescence of these conditions suggests that this work is the first description of intestinal cryptococcosis associated with intestinal lymphangiectasia. e countries with the highest incidence of common presentations of Cryptococcosis are Brazil, Colombia, and Venezuela. e infection occurs through contact with soil or eucalyptus trees contaminated with birds' feces. Most of these cases occur in young male patients diagnosed with HIV/AIDS, and in much lesser proportion in immunocompetent patients [2,3]. e infection involves the central nervous system (CNS) in almost 70% of cases, being the most common cause of meningitis in HIV/AIDS patients. Lung involvement is the second most common presentation and presents as infiltrations or granulomatous reactions [2,3,9]. e increasing prevalence of patients diagnosed with AIDS has been proportional to the increase in opportunistic infections such as Cryptococcosis. e use of antiretroviral therapy (ART) has modified its presentation, resulting in atypical locations. Intestinal cryptococcosis is believed to be through direct inoculation rather than hematogenous dissemination since blood cultures were always negative [2,9]. e apparent immunocompetence of our patient and his unspecific symptomatology made his diagnosis a real challenge, misguiding the diagnostic suspicion towards more common gastrointestinal tract infections such as tuberculosis. Similar situations happened in a large number of reported cases of intestinal cryptococcosis, in which diagnosis occurred incidentally.
Out of 11 case reports of gastrointestinal cryptococcosis, only Sciaudone G presented an immunocompetent patient while the rest reported immunologically compromised patients. e correlation between immunocompromised and intestinal cryptococcosis is well documented. Patients with advanced stages of HIV (CD4 < 200), with malignant processes (solid or hematological tumors), treatment with immunosuppressants [4,6], organ-transplanted [11], or cirrhotic [9,12] are considered as high-risk subjects.
Intestinal lymphangiectasia can produce a state of secondary immunodeficiency. e pathological dilation of lymphatic vessels in the intestinal wall, especially in the submucosa, causes chronic loss of lymph containing immunoglobulins and lymphocytes (predominantly naïve CD4 and CD8 T cells) and severe hypoalbuminemia. is state of secondary immunodeficiency is of difficult diagnosis and poses a high risk for opportunistic fungal infections such as cryptococcosis, as in our patient [13,14].
Our patient's age was accord with the average age of intestinal cryptococcosis presentation reported in the literature (37 years, ranging from 26 to 73 years) [3].
Abdominal pain was the most common initial symptom in patients infected with Cryptococcus. e onset of pain in reported cases ranged from 2 days to 6 months; however, the majority exceeded 3 weeks. In addition, 66% of patients had fever at some point in the course of the illness associated with vomiting and nausea sporadically. Despite being an invasive intestinal pathology, only half of the patients had diarrhea, and only 25% had bloody diarrhea or melena. Any gastrointestinal organ can be affected.
Although management varies depending on the localization of infection, fluconazole 400 to 800 mg once daily for 8 weeks followed by medium doses for 12 months can be used empirically. Intravenous amphotericin B is considered as the first line of treatment for disseminated Cryptococcus; however, its use in gastrointestinal cryptococcosis is not well studied (F. Cicora) (Rupashree Sundar). e cryptococcal infection had high mortality rates in immunocompromised patients; however, it is important to consider that in the majority of reports the patient's general condition was already severely compromised due to the advanced state of the underlying disease prior to infection.

Conflicts of Interest
e authors declare that they have no conflicts of interest.