0022-534 7/92/1483-0889~03.00/0
VoL
THE ,JOURNAL OF UROLOGY
Copyright© 1992 by AMERICAN UROLOGICAL ASSOC!t.T!ON, INC.
889-890, ~;epternber 1992
Pririted in U.S. A.
CRYPTOCOCCAL PROSTATIC ABSCESS ASSOCIATED WITH THE ACQUIRED IMMUNODEFICIENCY SYNDROME GEORGE J. MAMO, MANUEL A. RIVERO
AND
STEPHEN C. JACOBS
From the Division of Urology and Department of Pathology, The University of Maryland School of Medicine, Baltimore, Maryland
ABSTRACT
A case of cryptococcal prostatic abscess in a 28-year old man with the acquired immunodeficiency syndrome is presented. This is a unique presentation of a cryptococcal prostatic infection and of a prostatic abscess. The diagnosis and management are discussed, and the literature is reviewed. KEY WORDS: prostatic diseases, abscess, acquired immunodeficiency syndrome, cryptococcus
Prostatic abscesses occur infrequently and are usually caused by bacterial organisms. Before the antibiotic era, the most common organisms were Staphylococcus aureus and Neisseria gonorrhoeae. 1 Presently, gram-negative enteric bacteria, such as Escherichia coli, are the most common infecting organisms. 2 Anaerobic prostatic abscesses are rare. Prostatic fungal infections are usually found incidentally at autopsy or in surgically removed specimens. The majority are due to blastomycosis. 3 Other mycotic infections that can invade the prostate include coccidioidomycosis, actinomycosis, histoplasmosis, moniliasis and, rarely, cryptococcosis. Cryptococcus neofonnans has been reported rarely to infect the prostate in patients on immunosuppressants, and in patients with hematological malignancies, cirrhosis, diabetes, sarcoidosis 4 and more recently the acquired immunodeficiency syndrome (AIDS). 5• 6 Fungal prostatic infections are usually infiltrative and granulomatous. Fungal prostatic abscesses are extremely rare. Single case reports of prostatic abscesses caused by Candida albicans, 7 Blastomyces dermatitides 8 and Histoplasma capsulatum 9 have been reported. A review of the literature did not reveal any cases of prostatic cryptococcosis presenting as an abscess. CASE REPORT
A 28-year-old white male homosexual with AIDS presented with a temperature of 39.lC, malaise, rectal discomfort and obstructive voiding symptoms. He was voiding in small amounts every 2 hours with a weak stream and mild dysuria. Medical history was significant for AIDS, and for cryptococcal and Pneumocystis carinii pneumonia. He was on chronic suppression with intravenous amphotericin B (35 mg. every 21 days) for persistent cryptococcal fungemia. Other medications included azidothymidine and cephalexin. On physical examination the bladder was palpable, and the prostate was tender and fluctuant. Post-void residual was 600 cc. Urinalysis yielded 10 to 20 white and O to 3 red blood cells per high power field and no bacteria. White blood count was 1,100/mm. 3• Blood urea nitrogen was 11.0 mg. % and serum creatinine was 1.1 mg. %. A urine culture using Sabouraud's dextrose agar was positive for C. neoformans. Blood and cerebral spinal fluid cultures were negative. Serologic testing for cryptococcal antigen using latex agglutination was negative in the cerebrospinal fluid but elevated in the serum (greater than 1 :8090). An abdominal and pelvic computerized tomogram (CT) demonstrated multiple small iliac and mesenteric lymph nodes, and an enlarged prostate with a fluid collection consistent with an abscess (fig. 1). Chest x-ray was normal. Cystoscopy revealed a moderately obstructing prostate and a normal bladder. Transperineal prostate biopsies were obtained and the abscess was aspirated. Approximately 4 cc purulent fluid were drained. The biopsies showed fibromuscular prostatic Accepted for publication March 20, 1992.
889
tissue with an inflammatory reaction containing multiple fun gal organisms (fig. 2). Alcian blue and mucicarmine stains were positive for C. neoformans. Prostatic tissue cultures using Sabouraud's dextrose agar yielded C. neoformans. All bacterial cultures were negative. Fluconazole (400 mg. per day) was begun and the amphotericin B was increased to 40 mg. per day. The overall condition of the patient improved during the next 10 days. He was able to void with minimal difficulty and was discharged from the hospital on fluconazole. A pelvic CT scan 1 month later demonstrated a prostatic abscess that was unchanged from the original CT scan. Transurethral resection of the prostate to drain the abscess was recommended to the patient but he refused treatment. The patient had 2 subsequent minor hospitalizations: 1 for gastroenteritis and 1 for biopsy of an enlarged posterior cervical lymph node, which was infiltrated with cryptococcus. The patient was rehospitalized 1 month later with Kaposi's sarcoma of the nasopharynx. He also had staphylococcal bacteremia and cryptococcal pneumoni?.. The condition deteriorated during the next 2 weeks until he died of sepsis, respiratory failure and disseminated cryptococcosis. Postmortem examination revealed a firm prostate with patchy areas of yellowish, round lesions containing small abscess cavities. DISCUSSION
C. neoformans is an encapsulated yeast-like soil organism commonly associated with excreta of pigeons. 10 The lung is usually the primary focus of infection. The puimonary infection can develop into a progressive cryptococcosis with ,,,,,,uacv,," nous spread to other organ systems, ·-··--·--··J the central nervous system. Involvement of the tract is un-
FIG. 1. CT scan demonstrates abscess cavity (arrow) within left lobe of prostate gland.
890
MAMO, RIVERO AND JACOBS
Fm. 2. Multiple budding yeast forms of cryptococcus seen in center of granuloma. Thick capsule typically seen around organism is clearly demonstrated (arrows). Mucicarmine, reduced from X450.
usual. The kidney, prostate, epididymis and testes are involved in descending order of frequency. Prostatic cryptococcosis is usually asymptomatic but it may present with irritative voiding symptoms or even obstruction. 11 Positive urine cultures, as found in our patient, are common in patients with cryptococcosis, even in the absence of demonstrable genitourinary tract involvement. Recent experiences with cryptococcal disease in AIDS patients has demonstrated that the prostate is a common site of persistent infection after apparently effective systemic treatment for other organ involvement, such as meningitis. 5 This finding may explain the 50% relapse of cryptococcal meningitis following therapy. 6 In 1 report urine cultures in such patients were positive in 29% of the cases after prostatic massage despite the lack of urinary symptoms. 5 C. neoformans can be isolated and cultured from the prostate by needle biopsy, aspiration or transurethral resection. Microscopic examination of the specimen usually reveals an acute and chronic inflammatory cell infiltrate separated by fibromuscular bundles and normal prostatic tissue. Necrotic debris, neutrophils, foreign body giant cells and fungi are seen mixed within the granulomatous reaction. The organisms can be identified easily by the surrounding capsule, which appears as a halo when stained with periodic acid, Schiff and mucicarmine. Urine cultures are usually positive for the organism. Systemic cryptococcosis can be diagnosed by serologic tests for the cryptococcal antigen. Patients with prostatic abscesses are generally symptomatic and can present with obstructive voiding symptoms, urinary retention, pyrexia, epididymitis, rectal discomfort, backache or hematuria. The pathogenesis of abscess formation involves 1 of 2 distinct mechanisms: 1) underlying lower genitourinary tract disease or 2) metastatic seeding from a septic focus elsewhere. The latter mechanism is involved in most fungal infections in the prostate. Diagnosing a prostatic abscess is straightforward if one has a high index of suspicion. CT is the best modality; however, transrectal ultrasound is also useful especially when biopsy or aspiration is considered. The optimal treatment of prostatic cryptococcosis is with antifungal agents. Surgical drainage is required when an abscess is present. Amphotericin B is the drug of choice for severe cases, while 5-fluorocytosine can be used alone in less severe cases or synergistically with amphotericin B in advanced cases. Fluconazole, a synthetic broad-spectrum bis-triazole antifungal agent that selectively inhibits fungal cytochrome P-450 sterol
C-14 a-demethylation, is a relatively new drug that can also be used to treat such patients. The absorption of fluconazole by prostatic tissue has not been tested in humans. However, preliminary unpublished data in New Zealand rabbits indicate that penetration of fluconazole into prostate tissue is approximately a third of the penetration into the serum at doses of 80 mg./ kg. Surgical drainage is the treatment of choice for all types of prostatic abscesses. Transurethral resection is generally the preferred method because it is the most effective. Other modalities that have been described include transurethral incision and drainage of the prostate, transrectal or perinea! aspiration, perinea! incision and drainage, and blind digital rupture transrectally. Transperineal aspiration was insufficient treatment in our patient even though the symptoms improved after the procedure. A repeat CT or transrectal ultrasound study immediately after the aspiration might have been helpful in evaluating for a residual abscess. Successful transrectal ultrasoundguided needle aspiration also is a method that has been reported12• 13 and appears to be effective. Another consideration in the treatment of prostatic abscesses is to insert antibiotics into the cavity following aspiration. However, this is not well substantiated in the literature. C. neoformans currently is number 4 on the list of opportunistic life-threatening infections in patients with AIDS (after pneumocystis, cytomegalovirus and mycobacterial infections). The current consensus is that in AIDS patients, unlike other patients with cryptococcosis, the infection should rarely be considered cured following diagnosis. This is certainly illustrated in our patient. Furthermore, cryptococcosis should be considered as a potential cause of prostatic abscess in patients with AIDS. REFERENCES
1. Pai, M. G. and Bhat, H. S.: Prostatic abscess. J. Urol., 108: 599, 1972. 2. Brawer, M. K. and Stamey, T. A.: Prostatic abscess owing to anaerobic bacteria. J. Urol., 138: 1254, 1987. 3. Bissada, N. K., Finkbeiner, A. E. and Redman, J. F.: Prostatic mycosis: nonsurgical diagnosis and management. Urology, 9: 327, 1977. 4. Brooks, M. H., Scheerer, P. P. and Linman, J. W.: Cryptococcal prostatitis. J.A.M.A., 192: 639, 1965. 5. Larsen, R. A., Bozzette, S., McCutchan, J. A., Chiu, J., Leal, M.A. and Richman, D. D.: Persistent Cryptococcus neoformans infection of the prostate after successful treatment of meningitis. Ann. Intern. Med., 111: 125, 1989. 6. Kovacs, J. A., Kovacs, A. A., Polis, M., Wright, W. C., Gill, V. J., Tuazon, C. U., Gelmann, E. P., Lane, H. C., Longfield, R., Overturf, G., Macher, A. M., Fanci, A. S., Parrillo, J.E., Bennett, J. E. and Masur, H.: Cryptococcosis in acquired immunodeficiency syndrome. Ann. Intern. Med., 103: 533, 1985. 7. Lentino, J. R., Zielinski, A., Stachowski, M., Cummings, J. E., Maliwan, N. and Reid, R. W.: Prostatic abscess due to Candida albicans. J. Infect. Dis., 149: 282, 1984. 8. Bergner, D. M., Krause, S. D., Duck, G. B. and Lewis, R.: Systemic blastomycosis presenting with acute prostatic abscess. J. Urol., 126: 132, 1981. 9. Marans, H. Y., Mandell, W., Kislak, J. W., Starrett, B. and Moussouris, H.F.: Prostatic abscess due to Histoplasma capsulatum in the acquired immunodeficiency syndrome. J. Urol., 145: 1275, 1991. 10. Lief, M. and Sarfarazi, F.: Prostatic cryptococcosis in acquired immune deficiency syndrome. Urology, 28: 318, 1986. 11. Huynh, M. T. and Reyes, C. V.: Prostatic cryptococcosis. Urology, 20: 622, 1982. 12. Rf/lrvik, J. and Daehlin, L.: Prostatic abscess: imaging with transrectal ultrasound. Case report. Scand. J. Urol. Nephrol., 23: 307, 1989. 13. Cytron, S., Weinberger, M., Pitlik, S. D. and Servadio, C.: Value of transrectal ultrasonography for diagnosis and treatment of prostatic abscess. Urology, 32: 454, 1988.
VoL
THE ,JOURNAL OF UROLOGY
Copyright© 1992 by AMERICAN UROLOGICAL ASSOC!t.T!ON, INC.
889-890, ~;epternber 1992
Pririted in U.S. A.
CRYPTOCOCCAL PROSTATIC ABSCESS ASSOCIATED WITH THE ACQUIRED IMMUNODEFICIENCY SYNDROME GEORGE J. MAMO, MANUEL A. RIVERO
AND
STEPHEN C. JACOBS
From the Division of Urology and Department of Pathology, The University of Maryland School of Medicine, Baltimore, Maryland
ABSTRACT
A case of cryptococcal prostatic abscess in a 28-year old man with the acquired immunodeficiency syndrome is presented. This is a unique presentation of a cryptococcal prostatic infection and of a prostatic abscess. The diagnosis and management are discussed, and the literature is reviewed. KEY WORDS: prostatic diseases, abscess, acquired immunodeficiency syndrome, cryptococcus
Prostatic abscesses occur infrequently and are usually caused by bacterial organisms. Before the antibiotic era, the most common organisms were Staphylococcus aureus and Neisseria gonorrhoeae. 1 Presently, gram-negative enteric bacteria, such as Escherichia coli, are the most common infecting organisms. 2 Anaerobic prostatic abscesses are rare. Prostatic fungal infections are usually found incidentally at autopsy or in surgically removed specimens. The majority are due to blastomycosis. 3 Other mycotic infections that can invade the prostate include coccidioidomycosis, actinomycosis, histoplasmosis, moniliasis and, rarely, cryptococcosis. Cryptococcus neofonnans has been reported rarely to infect the prostate in patients on immunosuppressants, and in patients with hematological malignancies, cirrhosis, diabetes, sarcoidosis 4 and more recently the acquired immunodeficiency syndrome (AIDS). 5• 6 Fungal prostatic infections are usually infiltrative and granulomatous. Fungal prostatic abscesses are extremely rare. Single case reports of prostatic abscesses caused by Candida albicans, 7 Blastomyces dermatitides 8 and Histoplasma capsulatum 9 have been reported. A review of the literature did not reveal any cases of prostatic cryptococcosis presenting as an abscess. CASE REPORT
A 28-year-old white male homosexual with AIDS presented with a temperature of 39.lC, malaise, rectal discomfort and obstructive voiding symptoms. He was voiding in small amounts every 2 hours with a weak stream and mild dysuria. Medical history was significant for AIDS, and for cryptococcal and Pneumocystis carinii pneumonia. He was on chronic suppression with intravenous amphotericin B (35 mg. every 21 days) for persistent cryptococcal fungemia. Other medications included azidothymidine and cephalexin. On physical examination the bladder was palpable, and the prostate was tender and fluctuant. Post-void residual was 600 cc. Urinalysis yielded 10 to 20 white and O to 3 red blood cells per high power field and no bacteria. White blood count was 1,100/mm. 3• Blood urea nitrogen was 11.0 mg. % and serum creatinine was 1.1 mg. %. A urine culture using Sabouraud's dextrose agar was positive for C. neoformans. Blood and cerebral spinal fluid cultures were negative. Serologic testing for cryptococcal antigen using latex agglutination was negative in the cerebrospinal fluid but elevated in the serum (greater than 1 :8090). An abdominal and pelvic computerized tomogram (CT) demonstrated multiple small iliac and mesenteric lymph nodes, and an enlarged prostate with a fluid collection consistent with an abscess (fig. 1). Chest x-ray was normal. Cystoscopy revealed a moderately obstructing prostate and a normal bladder. Transperineal prostate biopsies were obtained and the abscess was aspirated. Approximately 4 cc purulent fluid were drained. The biopsies showed fibromuscular prostatic Accepted for publication March 20, 1992.
889
tissue with an inflammatory reaction containing multiple fun gal organisms (fig. 2). Alcian blue and mucicarmine stains were positive for C. neoformans. Prostatic tissue cultures using Sabouraud's dextrose agar yielded C. neoformans. All bacterial cultures were negative. Fluconazole (400 mg. per day) was begun and the amphotericin B was increased to 40 mg. per day. The overall condition of the patient improved during the next 10 days. He was able to void with minimal difficulty and was discharged from the hospital on fluconazole. A pelvic CT scan 1 month later demonstrated a prostatic abscess that was unchanged from the original CT scan. Transurethral resection of the prostate to drain the abscess was recommended to the patient but he refused treatment. The patient had 2 subsequent minor hospitalizations: 1 for gastroenteritis and 1 for biopsy of an enlarged posterior cervical lymph node, which was infiltrated with cryptococcus. The patient was rehospitalized 1 month later with Kaposi's sarcoma of the nasopharynx. He also had staphylococcal bacteremia and cryptococcal pneumoni?.. The condition deteriorated during the next 2 weeks until he died of sepsis, respiratory failure and disseminated cryptococcosis. Postmortem examination revealed a firm prostate with patchy areas of yellowish, round lesions containing small abscess cavities. DISCUSSION
C. neoformans is an encapsulated yeast-like soil organism commonly associated with excreta of pigeons. 10 The lung is usually the primary focus of infection. The puimonary infection can develop into a progressive cryptococcosis with ,,,,,,uacv,," nous spread to other organ systems, ·-··--·--··J the central nervous system. Involvement of the tract is un-
FIG. 1. CT scan demonstrates abscess cavity (arrow) within left lobe of prostate gland.
890
MAMO, RIVERO AND JACOBS
Fm. 2. Multiple budding yeast forms of cryptococcus seen in center of granuloma. Thick capsule typically seen around organism is clearly demonstrated (arrows). Mucicarmine, reduced from X450.
usual. The kidney, prostate, epididymis and testes are involved in descending order of frequency. Prostatic cryptococcosis is usually asymptomatic but it may present with irritative voiding symptoms or even obstruction. 11 Positive urine cultures, as found in our patient, are common in patients with cryptococcosis, even in the absence of demonstrable genitourinary tract involvement. Recent experiences with cryptococcal disease in AIDS patients has demonstrated that the prostate is a common site of persistent infection after apparently effective systemic treatment for other organ involvement, such as meningitis. 5 This finding may explain the 50% relapse of cryptococcal meningitis following therapy. 6 In 1 report urine cultures in such patients were positive in 29% of the cases after prostatic massage despite the lack of urinary symptoms. 5 C. neoformans can be isolated and cultured from the prostate by needle biopsy, aspiration or transurethral resection. Microscopic examination of the specimen usually reveals an acute and chronic inflammatory cell infiltrate separated by fibromuscular bundles and normal prostatic tissue. Necrotic debris, neutrophils, foreign body giant cells and fungi are seen mixed within the granulomatous reaction. The organisms can be identified easily by the surrounding capsule, which appears as a halo when stained with periodic acid, Schiff and mucicarmine. Urine cultures are usually positive for the organism. Systemic cryptococcosis can be diagnosed by serologic tests for the cryptococcal antigen. Patients with prostatic abscesses are generally symptomatic and can present with obstructive voiding symptoms, urinary retention, pyrexia, epididymitis, rectal discomfort, backache or hematuria. The pathogenesis of abscess formation involves 1 of 2 distinct mechanisms: 1) underlying lower genitourinary tract disease or 2) metastatic seeding from a septic focus elsewhere. The latter mechanism is involved in most fungal infections in the prostate. Diagnosing a prostatic abscess is straightforward if one has a high index of suspicion. CT is the best modality; however, transrectal ultrasound is also useful especially when biopsy or aspiration is considered. The optimal treatment of prostatic cryptococcosis is with antifungal agents. Surgical drainage is required when an abscess is present. Amphotericin B is the drug of choice for severe cases, while 5-fluorocytosine can be used alone in less severe cases or synergistically with amphotericin B in advanced cases. Fluconazole, a synthetic broad-spectrum bis-triazole antifungal agent that selectively inhibits fungal cytochrome P-450 sterol
C-14 a-demethylation, is a relatively new drug that can also be used to treat such patients. The absorption of fluconazole by prostatic tissue has not been tested in humans. However, preliminary unpublished data in New Zealand rabbits indicate that penetration of fluconazole into prostate tissue is approximately a third of the penetration into the serum at doses of 80 mg./ kg. Surgical drainage is the treatment of choice for all types of prostatic abscesses. Transurethral resection is generally the preferred method because it is the most effective. Other modalities that have been described include transurethral incision and drainage of the prostate, transrectal or perinea! aspiration, perinea! incision and drainage, and blind digital rupture transrectally. Transperineal aspiration was insufficient treatment in our patient even though the symptoms improved after the procedure. A repeat CT or transrectal ultrasound study immediately after the aspiration might have been helpful in evaluating for a residual abscess. Successful transrectal ultrasoundguided needle aspiration also is a method that has been reported12• 13 and appears to be effective. Another consideration in the treatment of prostatic abscesses is to insert antibiotics into the cavity following aspiration. However, this is not well substantiated in the literature. C. neoformans currently is number 4 on the list of opportunistic life-threatening infections in patients with AIDS (after pneumocystis, cytomegalovirus and mycobacterial infections). The current consensus is that in AIDS patients, unlike other patients with cryptococcosis, the infection should rarely be considered cured following diagnosis. This is certainly illustrated in our patient. Furthermore, cryptococcosis should be considered as a potential cause of prostatic abscess in patients with AIDS. REFERENCES
1. Pai, M. G. and Bhat, H. S.: Prostatic abscess. J. Urol., 108: 599, 1972. 2. Brawer, M. K. and Stamey, T. A.: Prostatic abscess owing to anaerobic bacteria. J. Urol., 138: 1254, 1987. 3. Bissada, N. K., Finkbeiner, A. E. and Redman, J. F.: Prostatic mycosis: nonsurgical diagnosis and management. Urology, 9: 327, 1977. 4. Brooks, M. H., Scheerer, P. P. and Linman, J. W.: Cryptococcal prostatitis. J.A.M.A., 192: 639, 1965. 5. Larsen, R. A., Bozzette, S., McCutchan, J. A., Chiu, J., Leal, M.A. and Richman, D. D.: Persistent Cryptococcus neoformans infection of the prostate after successful treatment of meningitis. Ann. Intern. Med., 111: 125, 1989. 6. Kovacs, J. A., Kovacs, A. A., Polis, M., Wright, W. C., Gill, V. J., Tuazon, C. U., Gelmann, E. P., Lane, H. C., Longfield, R., Overturf, G., Macher, A. M., Fanci, A. S., Parrillo, J.E., Bennett, J. E. and Masur, H.: Cryptococcosis in acquired immunodeficiency syndrome. Ann. Intern. Med., 103: 533, 1985. 7. Lentino, J. R., Zielinski, A., Stachowski, M., Cummings, J. E., Maliwan, N. and Reid, R. W.: Prostatic abscess due to Candida albicans. J. Infect. Dis., 149: 282, 1984. 8. Bergner, D. M., Krause, S. D., Duck, G. B. and Lewis, R.: Systemic blastomycosis presenting with acute prostatic abscess. J. Urol., 126: 132, 1981. 9. Marans, H. Y., Mandell, W., Kislak, J. W., Starrett, B. and Moussouris, H.F.: Prostatic abscess due to Histoplasma capsulatum in the acquired immunodeficiency syndrome. J. Urol., 145: 1275, 1991. 10. Lief, M. and Sarfarazi, F.: Prostatic cryptococcosis in acquired immune deficiency syndrome. Urology, 28: 318, 1986. 11. Huynh, M. T. and Reyes, C. V.: Prostatic cryptococcosis. Urology, 20: 622, 1982. 12. Rf/lrvik, J. and Daehlin, L.: Prostatic abscess: imaging with transrectal ultrasound. Case report. Scand. J. Urol. Nephrol., 23: 307, 1989. 13. Cytron, S., Weinberger, M., Pitlik, S. D. and Servadio, C.: Value of transrectal ultrasonography for diagnosis and treatment of prostatic abscess. Urology, 32: 454, 1988.
