Laryngeal cryptococcosis: Literature review and guidelines for laser ablation of fungal lesions

Clinical and immunological features of laryngeal cryptococcosis

The literature holds few descriptions on immune response findings for laryngeal cryptococcosis. Immunology has been more extensively described in cases involving the central nervous system and the lungs, although many of these studies were conducted in animal models. We aimed to analyze the clinical and immunological characteristics of three patients with laryngeal cryptococcosis. We observed a weak participation of the innate immune response, whereas adaptive immunity showed the predominance of a Th2-type response over a Th1-type response. Most cases occur in male older adults with immunosuppressive conditions, of which HIV infection was absent. Hoarseness configured the main symptom. We found a disease that was restricted to the larynx and possibly the lungs by contiguity. Patients with hoarseness and lesions in nasal endoscopy should be investigated for cryptococcosis by a biopsy of the larynx, including with negative serum cryptococcal antigen. The immunological aspects of our findings of laryngeal involvement resembled those in the most commonly affected systems.

Multiphotonic Ablation and Electro-Capacitive Effects Exhibited by Candida albicans Biofilms

This work reports the modification in the homogeneity of ablation effects with the assistance of nonlinear optical phenomena exhibited by C. albicans ATCC 10231, forming a biofilm. Equivalent optical energies with different levels of intensity were irradiated in comparative samples, and significant changes were observed. Nanosecond pulses provided by an Nd:YAG laser system at a 532 nm wavelength in a single-beam experiment were employed to explore the photodamage and the nonlinear optical transmittance. A nonlinear optical absorption coefficient -2 × 10-6 cm/W was measured in the samples studied. It is reported that multiphotonic interactions can promote more symmetric optical damage derived by faster changes in the evolution of fractional photoenergy transference. The electrochemical response of the sample was studied to further investigate the electronic dynamics dependent on electrical frequency, and an electro-capacitive behavior in the sample was identified. Fractional differential calculations were proposed to describe the thermal transport induced by nanosecond pulses in the fungi media. These results highlight the nonlinear optical effects to be considered as a base for developing photothermally activated phototechnology and high-precision photodamage in biological systems.

Vocal fold cryptococcal granuloma: A rare occurrence in immunocompetent patient

INTRODUCTION AND IMPORTANCE

Cryptoccous infection or cryptococcosis is a severe opportunistic infection occurring mainly in immunocompromised patients. Laryngeal cryptococcus infection is rare. In an immunocompetent patient, inhaled corticosteroid was reported to be a possible risk factor.

CASE PRESENTATION

We discuss a case of right vocal fold cryptococcus infection in a healthy, immunocompetent 71-year-old man with no history of inhaled corticosteroid, presented with hoarseness and intermittent aspiration symptom for 1 year duration. Further examination showed right anterior vocal fold mass with presence of right vallecular cyst.

CLINICAL DISCUSSION

Patient underwent direct laryngoscopy, excision of right vocal fold mass and marsupialization of vallecular cyst. Histopathological examination revealed cryptococcal infection. Patient subsequently treated with oral fluconazole 400 mg daily for 6 months. To date, hoarseness and aspiration symptoms have resolved.

CONCLUSION

We are sharing our experience in managing laryngeal cryptococcus infection in an immunocompetent patient where the associated risk factors discussed in previous literatures are absent.

Cryptococcal Laryngitis: Three Cases Managed With Potassium-Titanyl-Phosphate Laser and Literature Review

OBJECTIVES

To present three case reports of cryptococcal laryngitis managed with potassium-titanyl-phosphate (KTP) laser, where only one case managed with KTP laser has previously been published to date to our knowledge. Further, to systematically review the medical literature and describe the epidemiology, clinical assessment, treatment, and prognosis of laryngeal cryptococcosis.

METHODS

The PubMed, Embase, and OVID MEDLINE databases were searched using the terms "cryptococcal laryngitis" or "cryptococcus" and "larynx or laryngeal."

RESULTS

Thirty-eight cases were identified. The median age was 65 years with a 1 male:1.2 female ratio. Thirty-six cases (95%) presented with hoarseness. Twenty-one cases (55%) were systemically immunosuppressed and 19 (50%) were taking an inhaled corticosteroid. This paper lists the five clinical features (i. white exudate or lesion; ii. exophytic, verrucous or tumor-like mass; iii. diffuse erythema; iv. mucosal irregularity; v. thickened vocal fold) and four pathologic features or tests (i. Grocott Gomori Methenamine stain; ii. Mucicarmine stain; iii. fungal or yeast organisms; iv. fungal culture) that encompass 97% of cases of cryptococcal laryngitis reported in the medical literature. In 34 cases (89%), antifungal therapy was given. Four cases (11%) had excisional biopsy and 11 (29%) received combined surgery and medical therapy. There was uncomplicated resolution in 24 cases (63%).

CONCLUSION

Cryptococcal laryngitis is a rare cause of hoarseness that may be mistaken for malignancy or may be a manifestation of disseminated cryptococcal infection or underlying immunosuppression. Clinicians should be aware of the diagnostic features of cryptococcal laryngitis to facilitate diagnosis and treatment to prevent complicated disease and overly aggressive treatment.

Cryptococcosis in the Vocal Cords, Trachea, and Bronchi

Laryngeal and endobronchial cryptococcosis are rare conditions, and to our knowledge, there have been only 23 cases of laryngeal cryptococcosis, and 18 cases of endobronchial cryptococcosis previously reported in the English literature. We herein report an extremely rare case of cryptococcosis with simultaneous laryngeal and endobronchial involvement. This case highlights the importance of paying close attention to possible occurrence of cryptococcosis of the airway tract in patients with asthma treated with high-dose inhaled corticosteroids.

Tongue lesion due to Cryptococcus neoformans as the first finding in an HIV-positive patient

BACKGROUND

Cryptococcosis is a severe universally distributed mycosis which mainly affects immunocompromised hosts. This mycosis is caused by yeasts of two species complex of the genus Cryptococcus: Cryptococcus neoformans and Cryptococcus gattii. Meningeal cryptococcosis is the most frequent clinical presentation of this disseminated mycosis. The oral mucosa involvement is extremely unusual.

CASE REPORT

We present a case of cryptococcosis with an unusual clinical form. The patient was assisted because she had an ulcerated lesion on the lingual mucosa. Encapsulated yeasts compatible with Cryptococcus were found in microscopic exams of wet preparations from lingual ulcer clinical samples obtained for cytodiagnosis and mycological studies. Cryptococcus neoformans (C. neoformans var. grubii VNI) was isolated in culture. This patient did not know her condition of HIV seropositive before the appearance of the tongue lesion.

CONCLUSIONS

The involvement of the oral mucosa is uncommon in this fungal infection, but is important to include it in the differential diagnosis in HIV positive patients.

Risk factors of laryngeal cryptococcosis: A case report

Cryptococcal infections are acquired by inhalation of encapsulated yeast cells or basidiospores. While Cryptococcus has a propensity to invade the lungs and central nervous system, other sites can be affected. Laryngeal cryptococcosis is rare with less than 30 previously reported cases, which commonly occurred in apparently immunocompetent hosts on inhaled corticosteroids. We present a case of laryngeal cryptococcosis with a long-term inhaled corticosteroid use, co-infection of pulmonary Mycobacterium avium-intracellulare, and mannose-binding lectin deficiency.

Laryngeal Cryptococcosis: An Evolving Rare Clinical Entity

Objectives:

Describe the demographics and clinical manifestations of laryngeal cryptococcosis. Develop a simple approach to the diagnostic workup and treatment of localized laryngeal cryptococcal infection.

Methods:

A new case of laryngeal cryptococcosis encountered at our institution is presented and placed in context of the literature surrounding prior reported cases. PubMed, Google Scholar, SCOPUS, and Web of Science were queried from inception to August 2018 with the terms Larynx or Laryngeal and Cryptococcosis or Cryptococcus by two independent reviewers for English-language cases of cryptococcal infection of the larynx.

Results:

Twenty-nine unique cases of laryngeal cryptococcosis were identified. Median age at presentation was 65 years old. All patients presented with persistent or progressive hoarseness. Lesions were predominantly on the true vocal cords (79%), 38% associated with an adherent white exudate or leukoplakia. A minority (28%) was immunocompromised, and of the remaining immunocompetent hosts, 67% were found to be using nebulized or inhaled corticosteroids (ICS) prior to infection. Diagnosis should be suspected in patients with chronic laryngitis or mass lesions with the aforementioned risk factors. Diagnosis was made by histopathology with cryptococcal yeasts identified on methenamine silver (55%) and/or mucicarmine stains (48%). Serum cryptococcal antigen testing was unreliable (sensitivity = 39%). The mainstay of effective treatment was prolonged oral Fluconazole therapy, with two cases of laser therapy ablation of residual lesions. Improvement in voice and vocal lesions varied from weeks to months.

Conclusions:

Laryngeal cryptococcosis is a rare cause of persistent hoarseness, which appears to be clinically evolving and more frequently affecting immunocompetent hosts chronically using nebulized or inhaled corticosteroids. Laryngeal cryptococcal infection is readily treatable with prolonged oral antifungals once biopsy and histopathological stains confirm the diagnosis.

Pseudoepitheliomatous Hyperplasia of the Larynx Requiring Total Laryngectomy

Patient: Male, 57

Final Diagnosis: Pseudoepitheliomatous hyperplasia

Symptoms: Dysphonia

Medication: —

Clinical Procedure: Progressive speudoepitheliomaous hyperplasia spreaded

Specialty: Oncology

Laryngeal Cryptococcosis Associated With Inhaled Corticosteroid Use: Case Reports and Literature Review

Laryngeal cryptococcosis is a rare clinical entity. There have been a limited number of case reports in the literature with no consensus regarding optimal management. This review contributes two additional case reports of immunocompetent patients with cryptococcal infection of the larynx in whom exposure to high doses of inhaled corticosteroids is proposed as a significant risk factor. Twenty cases were identified from review of the literature. All patients presented with hoarseness and a spectrum of microlaryngoscopic features, often mimicking laryngeal malignancy. The majority of cases were treated with systemic antifungal therapy, three cases had surgical excision alone, and another three had a combination of medical and surgical management. Risk factor modification, in the form of a reduction in inhaled corticosteroid was employed in the two new cases, and in some previously published cases. Risk factor modification, such as reduction of inhaled corticosteroid dose, in addition to oral antifungal agents can be effective in managing cryptococcal laryngitis.

Pulsed dye laser treatment of primary cryptococcal laryngitis: A novel approach to an uncommon disease

An 82-year-old supplemental oxygen dependent woman with severe COPD presented with an eight month history of worsening hoarseness and stridor. Office laryngoscopy revealed laryngeal edema and ulcerative masses throughout the larynx. In-office biopsies were positive for Cryptococcus neoformans. This report details a novel approach to the treatment of cryptococcal laryngitis, a combination of in-office pulsed-dye laser (PDL) ablation and medical therapy. Despite treatment with oral fluconazole, the recommended treatment for cryptococcal laryngitis the patient continued to be symptomatic with dysphonia and throat discomfort. Repeated laryngeal exam demonstrated persistent cryptococcal nodules. The patient was subsequently effectively treated with an in-office PDL laser. This case demonstrates the efficacy of in-office laser treatment for residual laryngeal Cryptococcus. For patients like this one, who have failed medical therapy and are unfit for general anesthetic, the in-office laser provides an excellent alternative treatment approach.