Cryptococcosis differential diagnosis: Difference between revisions
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==Differentiating Cryptococcosis from other Diseases== | ==Differentiating Cryptococcosis from other Diseases== | ||
Cryptococcosis is more common among [[Immunocompromised|immunocompromised patients]] who are at high risk for other [[fungal]], [[bacterial]], and [[viral infections]]. It should be differentiated from the following | Cryptococcosis is more common among [[Immunocompromised|immunocompromised patients]] who are at high risk for other [[fungal]], [[bacterial]], and [[viral infections]]. It should be differentiated from the following diseases: | ||
{| class="wikitable" | {| class="wikitable" | ||
!Disease | !Disease | ||
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|[[Lymphoma|CNS lymphoma]] | |[[Lymphoma|CNS lymphoma]] | ||
| | | | ||
* [[ | * Patient is [[immunocompetent]] | ||
* Focal symptoms indicative of a mass lesion | * Focal symptoms indicative of a mass [[lesion]] | ||
* [[Seizure]] | * [[Seizure]] | ||
| | | | ||
*Single solitary ring | *Single solitary ring enhancing [[lesion]] on [[CT]] or [[MRI]] | ||
|- | |- | ||
|[[Disseminated tuberculosis]] | |[[Disseminated tuberculosis]] | ||
| | | | ||
* Prior history of residence in an [[Endemic (epidemiology)|endemic]] area | * Prior history of residence in an [[Endemic (epidemiology)|endemic]] area | ||
* Chronic [[cough]], [[weight loss]], [[hemoptysis]] | * Chronic [[cough]], [[weight loss]], [[hemoptysis]] | ||
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* [[Brain]] biopsy for [[acid-fast bacilli]] staining | * [[Brain]] biopsy for [[acid-fast bacilli]] staining | ||
* Culture and acid stain positive for [[acid-fast bacilli]] | * Culture and acid stain positive for [[acid-fast bacilli]] | ||
* CXR shows [[Cavitation|cavitations]] | * CXR shows [[Cavitation|cavitations]] | ||
|- | |- | ||
|[[Aspergillosis]] | |[[Aspergillosis]] | ||
| | | | ||
* [[Pulmonary]] lesions in addition to [[CNS]] lesions | * [[Pulmonary]] [[lesions]] in addition to [[CNS]] [[lesions]] | ||
* Symptoms may include [[cough]], [[chest pain]], and [[hemoptysis]] | * Symptoms may include [[cough]], [[chest pain]], and [[hemoptysis]] | ||
| | | | ||
*[[CSF]] fungal culture, [[galactomannan]] | *[[CSF]] fungal culture, [[galactomannan]] | ||
|- | |- | ||
|[[Cryptococcosis]] | |[[Cryptococcosis]] | ||
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|[[Chagas disease]] | |[[Chagas disease]] | ||
| | | | ||
*History of residence in Central | *History of residence in Central or South America | ||
*Acute infection is rarely symptomatic | *Acute infection is rarely symptomatic | ||
*[[Encephalitis]] or focal [[brain]] lesions | *[[Encephalitis]] or focal [[brain]] [[lesions]] | ||
*[[Myocarditis]] | *[[Myocarditis]] | ||
*Chronic infections in [[immunocompromised]] patients | *[[Chronic]] [[infections]] in [[immunocompromised]] patients develop into [[encephalitis]] with [[necrotic]] [[brain]] lesions causing a [[mass effect]] | ||
| | | | ||
*[[Trypanosoma cruzi]] in [[blood]], [[Tissue (biology)|tissue]] or [[CSF]] | *[[Trypanosoma cruzi]] in [[blood]], [[Tissue (biology)|tissue]], or [[CSF]], [[PCR]] of [[Tissue (biology)|tissue]] or [[body fluids]], and [[Serological testing|serologic tests]] | ||
|- | |- | ||
|[[Cytomegalovirus infection|CMV infection]] | |[[Cytomegalovirus infection|CMV infection]] | ||
| | | | ||
*Most common [[CNS]] [[opportunistic infection]] in [[AIDS]] patients | *Most common [[CNS]] [[opportunistic infection]] in [[AIDS]] patients | ||
*Presents with [[encephalitis]], [[retinitis]], progressive [[myelitis]] or [[polyradiculitis]] | *Presents with [[encephalitis]], [[retinitis]], progressive [[myelitis]], or [[polyradiculitis]] | ||
*In [[disseminated disease]], it involves both [[liver]] and | *In [[disseminated disease]], it involves both the [[liver]] and kidneys | ||
| | | | ||
*[[Brain]] CT/MRI/biopsy: location of lesions | *[[Brain]] [[CT]]/[[MRI]]/[[biopsy]]: location of [[lesions]] is usually near the [[brain stem]] or periventricular areas | ||
*[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic | *[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic | ||
*[[Brain biopsy]] with + [[staining]] for [[CMV]] or evidence of owl's eyes is also diagnostic, but it is rarely performed | *[[Brain biopsy]] with + [[staining]] for [[CMV]] or evidence of owl's eyes is also diagnostic, but it is rarely performed because of the location of [[brain]] lesions | ||
|- | |- | ||
|[[HSV|HSV infection]] | |[[HSV|HSV infection]] | ||
| | | | ||
*[[Seizures]], [[headache]], [[confusion]] and/or [[urinary retention]] can be seen in [[disseminated disease]], which usually affects only [[immunocompromised]] or acute infections | *[[Seizures]], [[headache]], [[confusion]] and/or [[urinary retention]] can be seen in [[disseminated disease]], which usually affects only the [[immunocompromised]] or acute [[infections]] | ||
*In [[pregnant]] women it may be associated with concurrent [[genital]]/[[oral]] lesions; can be spread to the [[neonate]] during acute infection in the mother, or via [[viral shedding]] in the [[birth canal]] | *In [[pregnant]] women, it may be associated with concurrent [[genital]]/[[oral]] [[lesions]]; can be spread to the [[neonate]] during acute infection in the mother, or via [[viral shedding]] in the [[birth canal]] | ||
*[[Neonatal]] [[Herpes simplex virus|HSV]] can range from localized [[Skin and soft-tissue infections|skin infections]] to [[encephalitis]], [[pneumonitis]], and [[disseminated disease]] | *[[Neonatal]] [[Herpes simplex virus|HSV]] can range from localized [[Skin and soft-tissue infections|skin infections]] to [[encephalitis]], [[pneumonitis]], and [[disseminated disease]] | ||
| | | | ||
*[[Brain]] CT/MRI/biopsy: location of lesions is usually the [[medial]] [[temporal lobe]] or the [[Orbital cavity|orbital]] surface of the [[frontal lobe]]. | *[[Brain]] [[CT]]/[[MRI]]/[[biopsy]]: location of [[lesions]] is usually the [[medial]] [[temporal lobe]] or the [[Orbital cavity|orbital]] surface of the [[frontal lobe]]. | ||
*[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic | *[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic | ||
|- | |- | ||
|[[Chickenpox|Varicella Zoster infection]] | |[[Chickenpox|Varicella Zoster infection]] | ||
| | | | ||
*Multifocal involvement has subacute course, usually only in [[immunosuppressed]], with [[headache]], [[fever]], focal deficits and [[seizures]]. | *Multifocal involvement has subacute course, usually only in [[immunosuppressed]], with [[headache]], [[fever]], focal deficits, and [[seizures]]. | ||
*Unifocal involvement is more typically seen in [[immunocompetent]] hosts, occurring after [[contralateral]] [[cranial nerve]] [[herpes zoster]], with [[Altered mental status|mental status changes]], [[TIA|TIAs]] and [[stroke]] | *Unifocal involvement is more typically seen in [[immunocompetent]] hosts, occurring after [[contralateral]] [[cranial nerve]] [[herpes zoster]], with [[Altered mental status|mental status changes]], [[TIA|TIAs]], and [[stroke]] | ||
*[[Disseminated disease|Disseminated]] [[varicella zoster virus]] can occur in adults during primary [[infection]], presenting with [[pneumonitis]] and/or [[hepatitis]] | *[[Disseminated disease|Disseminated]] [[varicella zoster virus]] can occur in adults during primary [[infection]], presenting with [[pneumonitis]] and/or [[hepatitis]] | ||
*Disease is a [[Vasculitis|vasculopathy]] | *Disease is a [[Vasculitis|vasculopathy]] with [[hemorrhage]] and [[stroke]] | ||
| | | | ||
*[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic | *[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic | ||
|- | |- | ||
|[[Brain abscess]] | |[[Brain abscess]] | ||
| | | | ||
*Associated with [[sinusitis]] (abutting the sinuses) or with [[bacteremia]] | *Associated with [[sinusitis]] (abutting the sinuses) or with [[bacteremia]] | ||
*Signs and symptoms includes [[fever]] and [[necrotizing]] [[brain]] lesions with mass effect | *Signs and symptoms includes [[fever]] and [[necrotizing]] [[brain]] [[lesions]] with [[mass effect]] | ||
| | | | ||
*[[CSF]] culture or culture of [[brain abscess]] | *[[CSF]] culture or culture of [[brain abscess]] | ||
|- | |- | ||
|[[Progressive multifocal leukoencephalopathy]] | |[[Progressive multifocal leukoencephalopathy]] | ||
| | | | ||
*Symptoms are often more insidious in onset and progress over months. Symptoms include progressive [[weakness]], poor [[coordination]], with gradual slowing of [[mental]] function. Only seen in the [[immunosuppressed]]. Rarely associated with [[fever]] or other systemic symptoms | *Symptoms are often more insidious in onset and progress over months. Symptoms include progressive [[weakness]], poor [[coordination]], with gradual slowing of [[mental]] function. Only seen in the [[immunosuppressed]]. Rarely associated with [[fever]] or other systemic symptoms | ||
| | | | ||
*[[Polymerase chain reaction|PCR]] of [[CSF]] for [[JC virus]] | *[[Polymerase chain reaction|PCR]] of [[CSF]] for [[JC virus]] | ||
*[[Biopsy]] reveals [[white matter]] lesions and not well-circumscribed lesions. | *[[Biopsy]] reveals [[white matter]] [[lesions]] and not well-circumscribed [[lesions]]. | ||
|} | |} | ||
'''Cutaneous Cryptococcosis must be differentiated from the following diseases:''' | '''Cutaneous Cryptococcosis must be differentiated from the following diseases:''' | ||
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*'''[[Blastomycosis]]'''<ref name="pmid1404541">Boyars MC, Zwischenberger JB, Cox Jr CS. Clinical manifestations of pulmonary fungal infections. Journal of thoracic imaging. 1992 Sep 1;7(4):12-22.</ref> | *'''[[Blastomycosis]]'''<ref name="pmid1404541">Boyars MC, Zwischenberger JB, Cox Jr CS. Clinical manifestations of pulmonary fungal infections. Journal of thoracic imaging. 1992 Sep 1;7(4):12-22.</ref> | ||
**[[CNS]] involvement is much less common with [[blastomyces]]. | **[[CNS]] involvement is much less common with [[blastomyces]]. | ||
**[[Cutaneous]] manifestations may resemble [[cutaneous]] [[cryptococcosis]] | **[[Cutaneous]] manifestations may resemble [[cutaneous]] [[cryptococcosis]]. | ||
**Not ubiquitous, more common | **Not ubiquitous, more common in [[endemic]] areas in North America. | ||
===Differentiating cryptococcal meningitis from other causes of meningitis=== | ===Differentiating cryptococcal meningitis from other causes of meningitis=== | ||
[[Cryptococcal Meningitis|Cryptococcal meningitis]] may be differentiated from other causes of [[meningitis]] by [[cerebrospinal fluid]] examination as shown below:<ref name="pmid23717798">{{cite journal| author=Le Rhun E, Taillibert S, Chamberlain MC| title=Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. | journal=Surg Neurol Int | year= 2013 | volume= 4 | issue= Suppl 4 | pages= S265-88 | pmid=23717798 | doi=10.4103/2152-7806.111304 | pmc=3656567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23717798 }} </ref><ref name="pmid24326618">{{cite journal| author=Chow E, Troy SB| title=The differential diagnosis of hypoglycorrhachia in adult patients. | journal=Am J Med Sci | year= 2014 | volume= 348 | issue= 3 | pages= 186-90 | pmid=24326618 | doi=10.1097/MAJ.0000000000000217 | pmc=4065645 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24326618 }} </ref><ref name="pmid22880096">{{cite journal| author=Leen WG, Willemsen MA, Wevers RA, Verbeek MM| title=Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice. | journal=PLoS One | year= 2012 | volume= 7 | issue= 8 | pages= e42745 | pmid=22880096 | doi=10.1371/journal.pone.0042745 | pmc=3412827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22880096 }} </ref><ref name="pmid10654948">{{cite journal| author=Negrini B, Kelleher KJ, Wald ER| title=Cerebrospinal fluid findings in aseptic versus bacterial meningitis. | journal=Pediatrics | year= 2000 | volume= 105 | issue= 2 | pages= 316-9 | pmid=10654948 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10654948 }} </ref><ref name="pmid20610819">{{cite journal| author=Brouwer MC, Tunkel AR, van de Beek D| title=Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis. | journal=Clin Microbiol Rev | year= 2010 | volume= 23 | issue= 3 | pages= 467-92 | pmid=20610819 | doi=10.1128/CMR.00070-09 | pmc=2901656 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610819 }} </ref> | [[Cryptococcal Meningitis|Cryptococcal meningitis]] may be differentiated from other causes of [[meningitis]] by [[cerebrospinal fluid]] examination as shown below:<ref name="pmid23717798">{{cite journal| author=Le Rhun E, Taillibert S, Chamberlain MC| title=Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. | journal=Surg Neurol Int | year= 2013 | volume= 4 | issue= Suppl 4 | pages= S265-88 | pmid=23717798 | doi=10.4103/2152-7806.111304 | pmc=3656567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23717798 }} </ref><ref name="pmid24326618">{{cite journal| author=Chow E, Troy SB| title=The differential diagnosis of hypoglycorrhachia in adult patients. | journal=Am J Med Sci | year= 2014 | volume= 348 | issue= 3 | pages= 186-90 | pmid=24326618 | doi=10.1097/MAJ.0000000000000217 | pmc=4065645 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24326618 }} </ref><ref name="pmid22880096">{{cite journal| author=Leen WG, Willemsen MA, Wevers RA, Verbeek MM| title=Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice. | journal=PLoS One | year= 2012 | volume= 7 | issue= 8 | pages= e42745 | pmid=22880096 | doi=10.1371/journal.pone.0042745 | pmc=3412827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22880096 }} </ref><ref name="pmid10654948">{{cite journal| author=Negrini B, Kelleher KJ, Wald ER| title=Cerebrospinal fluid findings in aseptic versus bacterial meningitis. | journal=Pediatrics | year= 2000 | volume= 105 | issue= 2 | pages= 316-9 | pmid=10654948 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10654948 }} </ref><ref name="pmid20610819">{{cite journal| author=Brouwer MC, Tunkel AR, van de Beek D| title=Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis. | journal=Clin Microbiol Rev | year= 2010 | volume= 23 | issue= 3 | pages= 467-92 | pmid=20610819 | doi=10.1128/CMR.00070-09 | pmc=2901656 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610819 }} </ref> | ||
Revision as of 20:15, 3 August 2017
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Cryptococcosis Microchapters |
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Case Studies |
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Cryptococcosis differential diagnosis On the Web |
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American Roentgen Ray Society Images of Cryptococcosis differential diagnosis |
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Risk calculators and risk factors for Cryptococcosis differential diagnosis |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Serge Korjian M.D.; Yazan Daaboul, M.D.
Overview
Cryptococcosis is more common among immunocompromised patients who are at high risk for other fungal, bacterial, and viral infections. Cryptococcal meningitis can be indistinguishable from bacterial or viral meningitis. Cryptococcosis must be differentiated from diseases that cause symptoms of lower respiratory tract infection (fever, dyspnea, cough) and meningitis (fever, headache, neck stiffness, focal neurological deficits) such as coccidioidomycosis, histoplasmosis, tuberculosis, and community/hospital-acquired pneumonia. Cutaneous cryptococcosis in HIV/AIDS patients must be differentiated from molluscum contagiosum and Kaposi's sarcoma.
Differentiating Cryptococcosis from other Diseases
Cryptococcosis is more common among immunocompromised patients who are at high risk for other fungal, bacterial, and viral infections. It should be differentiated from the following diseases:
| Disease | Differentiating signs and symptoms | Differentiating tests |
|---|---|---|
| CNS lymphoma |
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| Disseminated tuberculosis |
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| Aspergillosis |
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| Cryptococcosis |
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| Chagas disease |
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| CMV infection |
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| HSV infection |
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| Varicella Zoster infection |
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| Brain abscess |
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| Progressive multifocal leukoencephalopathy |
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Cutaneous Cryptococcosis must be differentiated from the following diseases:
- Molluscum contagiosum[1]
- Is very similar in appearance to disseminated cryptococcosis manifesting on the skin (umbilicated lesions).
- Patients are usually less sick, as molluscum is restricted to the skin.
- Kaposi's Sarcoma[2][3]
- Cutaneous cryptococcosis may also present with violaceous papules.
- It can only be differentiated by biopsy.
- Blastomycosis[4]
- CNS involvement is much less common with blastomyces.
- Cutaneous manifestations may resemble cutaneous cryptococcosis.
- Not ubiquitous, more common in endemic areas in North America.
Differentiating cryptococcal meningitis from other causes of meningitis
Cryptococcal meningitis may be differentiated from other causes of meningitis by cerebrospinal fluid examination as shown below:[5][6][7][8][9]
| Cerebrospinal fluid level | Normal level | Bacterial meningitis[8] | Viral meningitis[8] | Cryptococcal meningitis | Tuberculous meningitis[10] | Malignant meningitis[5] |
|---|---|---|---|---|---|---|
| Cells/ul | < 5 | >300 | 10-1000 | 10-500 | 50-500 | >4 |
| Cells | Lymphocyte:Monocyte 7:3 | Granulocyte > Lymphocyte | Lymphocyte > Granulocyte | Lympho.>Granulocyte | Lymphocytes | Lymphocytes |
| Total protein (mg/dl) | 45-60 | Typically 100-500 | Normal or slightly high | High | Typically 100-200 | >50 |
| Glucose ratio (CSF/plasma)[6] | > 0.5 | < 0.3 | > 0.6 | <0.3 | < 0.5 | <0.5 |
| Lactate (mmols/l)[7] | < 2.1 | > 2.1 | < 2.1 | >3.2 | > 2.1 | >2.1 |
| Others | ICP:6-12 (cm H2O) | CSF gram stain, CSF culture, CSF bacterial antigen | PCR of HSV-DNA, VZV | CSF gram stain, CSF india ink | PCR of TBC-DNA | CSF tumor markers such as alpha fetoproteins, CEA |
References
- ↑ Penneys NS, Hicks B (1985). "Unusual cutaneous lesions associated with acquired immunodeficiency syndrome". J Am Acad Dermatol. 13 (5 Pt 1): 845–52. PMID 3001157.
- ↑ Jones C, Orengo I, Rosen T, Ellner K (1990). "Cutaneous cryptococcosis simulating Kaposi's sarcoma in the acquired immunodeficiency syndrome". Cutis. 45 (3): 163–7. PMID 2311432.
- ↑ Blauvelt A, Kerdel FA (1992). "Cutaneous cryptococcosis mimicking Kaposi's sarcoma as the initial manifestation of disseminated disease". Int J Dermatol. 31 (4): 279–80. PMID 1634295.
- ↑ Boyars MC, Zwischenberger JB, Cox Jr CS. Clinical manifestations of pulmonary fungal infections. Journal of thoracic imaging. 1992 Sep 1;7(4):12-22.
- ↑ 5.0 5.1 Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.
- ↑ 6.0 6.1 Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
- ↑ 7.0 7.1 Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.
- ↑ 8.0 8.1 8.2 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.
- ↑ Brouwer MC, Tunkel AR, van de Beek D (2010). "Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis". Clin Microbiol Rev. 23 (3): 467–92. doi:10.1128/CMR.00070-09. PMC 2901656. PMID 20610819.
- ↑ Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.