British Journal of Radiology (2005) 78, 353-354
© 2005 British Institute of Radiology
doi: 10.1259/bjr/13082711
MRI and CT findings of cryptococcal vaginitis
S Ranganathan, MBBS, MRAD1,
F Moosa, MBBS, FRCR1,
A Kamarulzaman, MBBS, FRACP2 and
L M Looi, MBBS, MPath, FRCPath3
Departments of 1 Radiology, 2 Medicine and 3 Pathology, University Malaya Medical Centre, Lembah Pantai, 59100 Kuala Lumpar, Malaysia
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Abstract
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Cryptococcus neoformans is a yeast like fungus, which is commonly found in bird droppings, especially pigeons. Most cases of cryptococcal infections occur in immunocompromised patients or in those who are on long term immunosuppressant therapies. Cryptococcal infection usually presents as a meningoencephalitis or a pulmonary infection. Skin, bone and genital infections are very rare. We report the second case of vaginal cryptococcossis to be reported in English literature and the first to be imaged with CT and MRI.
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Case report
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A 20-year-old Chinese female was referred with a history of vaginal pain and intermittent per vaginal bleeding for 5 months. Vaginal examination revealed nodularity all over the vagina which resembled adenocarcinoma and a punch biopsy and vaginal smear was taken for analysis. Biopsy revealed cryptococcal vaginitis. The vaginal smear had scanty growth of Cryptococcus neoformans, while serology for Cryptococcus neoformans antigen was positive at 1:256 dilution.
The patient was treated with oral Flucanozole for 2 months and a single course of vaginal Flucanozole. However, symptoms recurred 3 weeks after completion of treatment. Significant past history was that she had unprotected intercourse with only one partner and underwent a termination of pregnancy at 6 weeks of amenorrhoea a year prior to onset of symptoms. She was not immunocompromised.
The cerebrospinal fluid and blood investigations were negative for detection of Human Immunodeficiency Virus, Hepatitis B and C antigens, and sexually transmitted diseases. CT and MRI were performed to exclude involvement of other sites and to note the extent of the lesion. CT of the brain, chest and abdomen were normal. CT pelvis revealed a mixed attenuation necrotic soft tissue mass arising from the right lateral wall of the vagina involving the right fornix with pockets of air extending up to the lower cervical canal with no involvement of the endocervical canal. The lesion measured 6 cm x 5 cm x 3.5 cm and showed no significant enhancement (Figure 1
). There was no apparent involvement of the parametrium. No free fluid was seen in the pelvis and no pelvic lymphadenopathy was present. MRI of the pelvis at 1.5 Tesla showed a high signal intensity lobulated mass within the upper right vaginal wall on the T2 weighted sequences (Figures 2 and 3) which returned a low signal on T1 weighted images. The lesion extended into the right lateral fornix, with extension into the lower cervix but without involvement of the endocervical canal. The uterus was normal in size with normal ovaries. The margins of this lesion were clearly demarcated. Following intravenous gadolinium, minimal enhancement of the lesion was noted. A punch biopsy of the vagina showed tissue pieces lined by stratified squamous epithelium. The underlying stroma was oedematous and lined by foamy histiocytes within which were numerous round encapsulated organisms which stained positive with periodic acid Schiff stain (PAS). Mucocarmine stain showed the mucinous capsule outlined by pink stain (Figure 4). Budding forms were noted. The findings were compatible with cryptococcal vaginitis.
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Figure 1. Axial enhanced CT image of the pelvis showing a mixed attenuation necrotic soft tissue mass measuring 6 cm x 5 cm x 3.5 cm arising from the right lateral wall of the vagina involving the right fornix (arrow) with pockets of air extending up to the lower cervical canal with no involvement of the endocervical canal and showing no significant enhancement.
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Figure 2. Sagittal T2 MR image showing high signal intensity lobulated mass within the upper right vaginal wall (arrow) extending to the lower cervical region.
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Figure 3. Coronal T2 MR image showing high signal intensity lesion in the right side of the vaginal wall (arrow).
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Figure 4. Histopathology of the vagina showing foamy histiocytes within which were numerous round encapsulated cryptococcal organisms the capsules of which are outlined in pink by Mucocarmine stain.
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The patient was discharged on long term treatment with oral Flucanozole 400 mg daily for 6 months.
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Discussion
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Cryptococcus neoformans is an encapsulated basidiomycetous yeast like fungus found commonly throughout the world in bird excreta, mainly pigeon droppings [1]. In humans, most cases of cryptococcal infection are thought to be due to airborne particles. However, the vector is unknown [1]. Immunocompromised people are more susceptible to being infected with cryptococcosis. Skin and genital infections with Cryptococcus neoformans are rare. There has been only one reported case of vulval lesion, which was seen in a patient who had been on immunosuppressant therapy [2]. Only one case of cryptococcal vaginitis has been reported in the English literature. Chen et al [3] noted a suspicious vaginal lesion diagnosed histologically to be a cryptococcal infection of the vagina in a 72-year-old patient who had undergone resection of the colon for cancer [3]. However, unlike previous reported vaginal cryptococcal infection, our patient was not immunocompromised and had no exposure to pigeons. There have been no previous reports of imaging of these lesions. CT and MRI were performed after the biopsy of the lesion, which showed no specific findings except for a nodular mass in the right lateral wall of the vagina.
Differential diagnosis would include an infective process or malignant lesions such as carcinoma of the vagina, adenoma malignum or malignant melanoma.
Carcinomas of the vagina generally are ill-defined lesions that appear hypodense on CT images and usually show significant enhancement with contrast. Primary vaginal carcinoma usually returns low signal on T1 weighted MRI, high signal on T2 weighted sequences and demonstrates contrast enhancement. Infections too may show similar findings, however they may show more adjacent inflammatory changes compared with malignant tumour. Adenoma malignum is a special subtype of adenocarcinoma which may appear benign on histology. This lesion appears as multicystic lesions with solid components. The solid components appear isointense with muscle on T1 weighted sequence and enhance with gadolinium [4].
Malignant melanoma of the genitalia usually presents in post menopausal women appearing as a well defined nodule which is easily diagnosed on clinical examination. On CT, malignant melanoma may appear as high attenuation mass which enhances moderately with contrast. On MRI, it may be of high signal on both T1 weighted and T2 weighted sequences and shows intense enhancement following contrast [5].
Although our patient was not immunocompromised, in a younger patient, a differential diagnosis of an infective process has to be considered. However biopsy is necessary to make the diagnosis.
Cryptococcus neoformans infection can be treated effectively with Flucanozole which is better tolerated than Amphotericin B, the previous mainstay of treatment [6].
Relapse may occur when treatment is discontinued and long term therapy may be needed.
Received for publication August 19, 2003.
Revision received November 27, 2004.
Accepted for publication December 16, 2004.
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References
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- Ellis DH, Pfeiffer TJ. Ecology, life cycle, and infectious propagule of Cryptococcus neoformans. Lancet 1990;336:923–5.[CrossRef][Medline]
- Blocher KS, Weeks JA, Noble RC. Cutaneous cryptococcal infection presenting as vulvar lesion. Genitourin Med 1987;63:341–3.[Medline]
- Chen CK, Chang DY, Chang SC, Lee EF, Huang SC, Chow SN. Cryptococcal infection of the vagina. Obstet Gynecol 1993;81:867–9.[Abstract/Free Full Text]
- Okamoto Y, Tanaka YO, Nishida M, Tsunoda H, Yoshikawa H, Itai Y. MR imaging of the uterine cervix: imaging-pathologic correlation. Radiographics 2003;23:425–45; quiz 534–5.
- Moon WK, Kim SH, Han MC. MR findings of malignant melanoma of the vagina. Clin Radiol 1993;48:326–8.[CrossRef][Medline]
- Sugar AM, Saunders C. Oral fluconazole as suppressive therapy of disseminated cryptococcosis in patients with acquired immunodeficiency syndrome. Am J Med 1988;85:481–9.[Medline]
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Abstract
Case report
