title: Case study documenting the diagnosis of idiopathic CD4+ Lymphocytopenia in a patient with atypical fungal infection (disseminated blastomycosis) by FNA of adrenal mass.
abstract: Idiopathic CD4+ lymphocytopenia, described in 1992 by the Centers for Disease Control, is characterized by persistent CD4+ lymphocytopenia (less than 300 cells per micro-liter) in nonimmunosuppressed, HIV negative individuals, who present with atypical infections. This rare though likely undiagnosed entity is associated with chronic disseminated forms of either fungal or bacterial infections in otherwise healthy adults. We report a case of a 59-year-old male with ring-enhancing brain lesions, bilateral adrenal masses, lung and vocal cord nodules, where the diagnosis of exclusion was metastatic malignancy. Fine needle aspiration (FNA) of the adrenal mass and a subsequent vocal cord biopsy confirmed chronic widely disseminated blastomycosis. Flow cytometric evaluation of peripheral blood documented persistent selective CD4+ lymphocytopenia with T8 (suppressor) T-Lymphocyte count within normal range. We believe that idiopathic CD4+ lymphocytopenia is an important etiologic factor to be considered for patients who present with mass lesions and are diagnosed by FNA with atypical fungal infections. We relate the diagnostic criteria for idiopathic CD4+ lymphocytopenia and the importance of providing on-site triage for FNA samples for fungal studies and correlation for flow cytometry.
authors.affiliation: Robert Wood Johnson University Hospital Hamilton, New Brunswick, USA.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Siderits
authors.forename: Osman
authors.initials: O
authors.lastname: Ouattara
authors.forename: Alan
authors.initials: A
authors.lastname: Marcus
authors.forename: Hong Guang
authors.initials: HG
authors.lastname: Gao
authors.forename: Hong Bing
authors.initials: HB
authors.lastname: Deng
authors.forename: Janusz
authors.initials: J
authors.lastname: Godyn
references.citation: FEMS Immunol Med Microbiol. 2008 Dec;54(3):283-9
references.pmid: 19049641
references.citation: Mycopathologia. 2009 Mar;167(3):115-24
references.pmid: 18931937
references.citation: Med Clin North Am. 1997 Mar;81(2):381-409
references.pmid: 9093234
references.citation: Clin Infect Dis. 2000 Apr;30(4):679-83
references.pmid: 10770729
references.citation: South Med J. 2007 Jun;100(6):570-8
references.pmid: 17591310
references.citation: Med Mycol. 2005 Aug;43(5):381-9
references.pmid: 16178365
references.citation: Curr Opin Rheumatol. 2006 Jul;18(4):389-95
references.pmid: 16763460
references.citation: Blood. 2008 Jul 15;112(2):287-94
references.pmid: 18456875
references.citation: JAMA. 1977 Dec 12;238(24):2629-30
references.pmid: 579201
references.citation: Arch Dermatol. 2000 Apr;136(4):547, 550
references.pmid: 10768656
references.citation: Semin Respir Infect. 1997 Sep;12(3):243-51
references.pmid: 9313296
references.citation: J Am Osteopath Assoc. 1997 Sep;97(9):525-32
references.pmid: 9313349
references.citation: J Exp Med. 2003 Jun 2;197(11):1405-16
references.pmid: 12782709
references.citation: Ultrastruct Pathol. 1996 Sep-Oct;20(5):429-35
references.pmid: 8883326
references.citation: Allergy Asthma Proc. 2008 Jul-Aug;29(4):421-4
references.pmid: 18702891
references.citation: Ann Diagn Pathol. 2000 Dec;4(6):391-406
references.pmid: 11149972
references.citation: Clin Exp Immunol. 1999 May;116(2):322-5
references.pmid: 10337025
references.citation: Clin Orthop Relat Res. 2004 Apr;(421):255-9
references.pmid: 15123956
references.citation: South Med J. 1994 Jul;87(7):715-9
references.pmid: 8023204
references.citation: Clin Exp Immunol. 2009 Jun;156(3):440-5
references.pmid: 19438596