A 2-year-old previously healthy boy presented with a 6-day history of intermittent fever documented up to 39°C without shivering and dry cough. Physical examination disclosed multiple swollen lymph nodes in the neck and axilla were mobile, non-stony and tender. Apart from cryptococcal antigen, serological tests were negative for viral, bacterial, mycoplasma, chlamydial infections, and normal for immunological evaluations. Computed tomography (CT) revealed multiple swollen lymph nodes (Fig. 1A–C). Subsequent cervical lymph nodes histopathology confirmed cryptococcal infection (Fig. 1F). On further questioning, his parents confirmed his recent exposure to pigeon droppings. Then cryptococcal lymphadenitis was diagnosed. He was treated with liposomal amphotericin B, flucytosine and fluconazole. After 6 months, a repeated thoracic CT revealed lymph nodes reduction to non-pathological range (Fig. 1D and E).
Volume-rendered CT (A) and axial unenhanced images (B) showed multiple swollen and partially fused lymph nodes in the hilar (white arrows) and mediastinal (red arrowheads) areas, with the largest one measuring 5cm×3cm, causing the compression of right and left main bronchus (blue arrows). Axial CT contrast-enhanced image (C) demonstrated slight enhancement of the swollen lymph nodes. At six-month follow-up, chest CT (D and E) showed the shrinkage of lymph nodes and the relief of main bronchus compression. H&E staining (F) demonstrated numerous spherical yeast cells of variable size surrounded by a clear halo (400×), suggesting the diagnosis of cryptococcosis.
Cryptococcosis is usually involved lung or brain, typically in immunocompromised hosts.1 Despite its rarity, cryptococcosis may affect immunocompetent individuals, just like this case. The correct diagnosis of cryptococcal lymphadenitis is challengeable as its clinical symptoms and imaging findings are nonspecific. A history of exposure to pigeon droppings and a positive cryptococcal antigen test may assist in diagnosis, but the definite diagnosis was made by histopathology.2 In conclusion, cryptococcal lymphadenitis should be suspected in children with generalized lymphadenopathy.
FundingNo funding was received for this study.
Conflict of InterestThe authors report no competing interests.
