Cryptococcosis, a globally relevant mycosis, primarily affects immunocompromised individuals, especially those with HIV/AIDS.1 The most common clinical signs involve the central nervous system and lungs, and spread to other sites, such as the gastrointestinal tract, is infrequent and often overlooked. Gastrointestinal involvement is rare, with anecdotal cases reported in the liver, pancreas, and digestive tract, some of which are confirmed only through autopsy.2 The clinical case presented here is unique, adding to the literature by describing rectal ulcers caused by Cryptococcus neoformans as the source of lower gastrointestinal bleeding, an atypical manifestation with significant diagnostic importance.
A 42-year-old man with a history of advanced HIV/AIDS sought medical care at the emergency service due to proctalgia, tenesmus, and intermittent rectal bleeding of 5-month progression. Symptoms had worsened 2 weeks earlier, with bloody diarrhea and mucus. Cardiopulmonary examination was normal, but a painful ulcer in the anal region was found upon rectal examination. The patient had no neurologic symptoms at the time of consultation. Initial laboratory tests demonstrated anemia, lymphopenia, and hypoalbuminemia. The CD4+ T-cell count was 22 cells/mm³ and HIV viral load was 293,382 copies/mL, confirming advanced infection. Tests for other opportunistic infections, including Cryptococcus neoformans in cerebrospinal fluid, Pneumocystis jirovecii, pulmonary tuberculosis, and latent syphilis, were also positive.
Colonoscopy revealed friable rectal mucosa, erosions, and an ulcer in the anal canal, suggestive of infectious proctitis (Fig. 1). Infectious origins, including bacterial infections (Treponema pallidum, Haemophilus ducreyi, Chlamydia trachomatis, mycobacteria), viral infections (cytomegalovirus or herpes simplex), and fungal infections (C. neoformans) were initially considered. Histopathologic study of the rectal biopsies identified the presence of Cryptococcus neoformans yeasts, confirming the diagnosis (Fig. 2).
A) Photomicrograph with hematoxylin and eosin staining, showing numerous rounded yeasts with a clear, peripheral halo, consistent with Cryptococcus spp., distributed in the rectal tissue. The characteristic narrow-based budding and a sparsely inflammatory background are identified. B) Grocott-Gomori Methenamine Silver stain highlights multiple fungal yeasts stained in black, with narrow-based budding, confirming the presence of Cryptococcus spp. in the rectal tissue.
The patient received comprehensive, multidisciplinary management. The initial treatment for the disseminated cryptococcosis was antifungal therapy, based on amphotericin B and fluconazole, followed by a consolidation and maintenance phase with oral fluconazole. Specific treatment for opportunistic coinfections (such as antibiotics and anti-tuberculosis agents) was also administered, and antiretroviral therapy was restarted.
The patient had marked clinical improvement after treatment. His digestive symptoms remitted, and he was discharged from the hospital with a strict follow-up plan for the phases of antifungal treatment maintenance and HIV infection control.
Gastrointestinal cryptococcosis is an uncommon clinical entity; most reported cases are anecdotal, with some cases identified only at autopsy. Bonacini et al. described 3 AIDS patients with cryptococcal invasion of the stomach, duodenum, colon, pancreas, and liver, but none of them exhibited gastrointestinal symptoms directly attributable to Cryptococcus neoformans.2 In contrast, our patient presented with prominent gastrointestinal symptoms and was diagnosed through endoscopic biopsy, underlining the importance of considering this opportunistic mycosis in the differential diagnosis of gastrointestinal manifestations in patients with advanced HIV infection.
With the advent of highly effective antiretroviral therapy, disseminated opportunistic infections have significantly decreased. However, gastrointestinal cryptococcosis has also been documented in other immunosuppressive settings. Chavapradit and Angkasekwinai3 and Osawa and Singh4 reported cases in patients with Crohn’s disease in treatment with biologic therapies, reinforcing the need to consider this etiology in subgroups different from HIV. Even though disseminated cryptococcosis is predominantly seen in immunocompromised patients, there are isolated reports on immunocompetent individuals, albeit far less frequently.5 This observation broadens the spectrum of patients in whom the infection should be suspected.
The present case emphasizes the importance of including cryptococcosis in the differential diagnosis of gastrointestinal symptoms in patients with advanced HIV and other immunosuppressive conditions. Early identification and timely treatment are determinants for improving clinical outcomes.
Ethical considerationsThe authors declare that the procedures they followed are in accordance with and conform to the norms of the World Medical Association Declaration of Helsinki.
The authors declare that this work is a clinical case report and not a formal research protocol, and so approval by an institutional Ethics and Research Committee was not required. They also state it meets the current ethics regulations.
Informed consent was obtained from the patient for clinical treatment and management, following the customary hospital protocols for medical care.
The authors declare they obtained a written statement of informed consent from the patient for the publication of this clinical case, including relevant imaging and medical data. All necessary measures were taken to preserve patient anonymity and data confidentiality.
Financial disclosureNo financial support was received in relation to this article.
The authors declare that there is no conflict of interest.
