Using endoscopic ultrasound-guided fine needle aspiration to diagnose mediastinal cryptococcosis.

with AIDS and a CD4 count of 6 cells/mm3, non-compliant with antiretroviral therapy, presented with severe headaches, vomiting, fevers, and a productive cough. Physical examination revealed tachycardia, a temperature of 39.4°C, clear lungs, and an absence of meningeal signs. Laboratory studies showed a white blood cell count of 4.8 and hemoglobin of 10.1 g/dL. A lumbar puncture was consistent with cryptococcal meningitis (cryptococcal antigen titer 1 :32768), and the patient had positive blood cultures growing Cryptococcus neoformans. The admitting chest radiograph was unremarkable. Amphotericin B and flucytosine were given. Her repeat lumbar puncture 2 weeks later showed an unchanged cryptococcal antigen titer, and she continued to have high fevers (39.4–40°C) and cough. Tuberculosis was ruled out. A computed tomography scan of the chest, abdomen, and pelvis revealed bilateral multiple moderately enlarged mediastinal and hilar lymphadenopathy, patchy infiltrate in the right lung, and mild hepatomegaly (●" Fig. 1). Endoscopic ultrasound (EUS) was performed to evaluate the mediastinal lymphadenopathy. Images showed a large heterogeneous hypoechoic mass extending from the subcarinal space to the distal peri-esophageal space (●" Fig. 2). The mass was sampled by fine-needle aspiration (FNA) biopsy, revealing cryptococcosis and aspergillosis (●" Fig. 3). The patient then asked to leave the hospital and was placed on oral voriconazole. EUS-guided FNA has emerged as an important diagnostic imaging modality. It is a non-surgical method to obtain tissue sampling from mediastinal lesions, with the advantage of real-time ultrasound guidance [1]. EUS can identify lymph nodes as small as 3mm, particularly in the celiac, subcarinal, and aorto–pulmonary areas [2]. Pulmonary cryptococcus has rarely been diagnosed via EUS-guided FNA. Concurrent diagnoses of patients with pulmonary cryptococcal isolates are common, especially in patients with HIV infection [3]. Here, aspergillus was concomitantly found. It has been shown that EUS with FNA has a 97% accuracy rate for tissue confirmation, and should be the test of choice especially for evaluating posterior mediastinal lymphadenopathy [4,5]. In conclusion, we report a non-traditional modality to diagnose pulmonary cryptococcus using EUSwith FNA.