PMC5491828_01
Computed tomography image of the adrenal mass from the patient. Bilateral adrenal enlargement is seen in the contrast-enhanced computed tomography (arrows). An enhancing effect is seen at the margin and inside the adrenal mass. No calcification is seen in the mass.
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No calcification was seen on either adrenal gland (Fig. 1).
Computed tomography image of the lung nodules from the patient. The right S1, left S1+2, and left S6 nodules were 9, 3, and 8 mm in diameter, respectively.
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However, the CT scan showed nodular shadows around both lungs (right S1, left S1+2, left S6) (Fig. 2).
Histologic studies of the right adrenal gland by a fine-needle aspiration biopsy (periodic acid-Schiff stain x100). Cryptococcosis is stained with the periodic acid-Schiff stain.
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CT-guided biopsy of the right adrenal gland was performed to obtain tissue for culture and a histologic evaluation. Cryptococcus spp. were identified within the necrotic adrenal tissue (Fig. 3).
A cytological analysis of the cerebrospinal fluid (Grocott's stain x800). Yeast-like fungi are seen in the histological analysis of the cerebrospinal fluid.
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These findings suggested meningitis; Cryptococcus spp. were seen in the CSF on a smear culture (Fig. 4).
Gross appearance of the adrenal glands. (A) Left side (approximately 7.5x4.5x4.5 cm). (B) Right side (approximately 6.5x4.0x4.0 cm)
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The glands were approximately 7.5x4.5x4.5 cm (left side) and 6.5x4.0x4.0 cm (right side) (Fig. 5).
Adrenal histopathology. (A) Hematoxylin and Eosin (H&E) staining x40. (B) H&E staining x200. (C) Grocott's staining x800. (D) Alcian blue staining x800. Widespread necrotizing granulomatous inflammation is seen. Epithelioid granuloma is seen along with lymphocytes, plasma cells, and multinucleated giant cells. The epithelioid granuloma is covered with fibrous connective tissue (A, B). In the necrotic tissue, a large number of class round fungal growths are seen that are stained positive with Grocott's and Alcian blue staining (C, D).
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A histological analysis of the resected adrenal glands showed massive noncaseating necrosis containing yeast-like particles, which was diagnostic for a Cryptococcus spp. infection (Fig. 6).
Time course of the serum cryptococcal titer and CRP.
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At 10 months after adrenalectomy, the serum cryptococcal antigen titer had decreased to 1:128 (Fig. 7).