1. KCP - 814 토의자 가천대 길병원 R3 정주현

2. Clinical History  남자 / 41 세  주소 : 발열, 인후통, 설사 ( 약 1 개월 전 ) 중국 유학 (2000 년 부터 ) 중국 광동성과 홍콩에서 사업 (2 개월 전 귀국 )  HIV, syphilis 검사 양성  CT 소견 : 양측 폐 결절, 간비종대 흉부 및 복부의 림프절 크기 증가  폐 우상엽에서 기관지 폐포 세척 검사 시행

11. Cytologic characteristics  Cellularity; high  Cellular composition; - alveolar macrophages (m/c), inflammatory cells, ciliated columnar & squamous cells  Intracellular (alveolar macrophages) & extracellular organisms; - 2-4 ㎛, round to oval shape - clear halo

12. Differential diagnosis Fungal infection 1. Histoplasma capsulatum 2. Cryptococcus neoformans 3. Coccidiodes immitis 4. Blastomycosis dermatitidis 5. Pneumocystis jiroveci Parasitic infection 1. Leishmania donovani 2. Toxoplasma gondii

13. Toxoplasma gondii Differential diagnosis Toxoplasma gondiiKSP 814 -size; 4-6 ㎛ -crescentic and slightly pyriform in shape Australian Society of cytology.”histoplasmosis”,http://cytology-asc.com/cec/respiratory(2014.08.11.)

14. Leishmania donovani Differential diagnosis Leishmania donovaniKSP 814 -size; 2-4 ㎛ -small, intracellular, nonflagellatd oval body of uniform size Richard L. kradin.Diagnostic Patholog of Infectious Disease.Saunders.2010

15. Pneumocystis jiroveci Differential diagnosis Pneumocystis jiroveciKSP 814 -size; 4-7 ㎛ -cup-shaped cysts -dark staining single structure (dot, ring or comma) Daniel H. Connor.Pathology of Infectious diseases. Appleton&Lange.1997

16. Blastomycosis dermatitidis Differential diagnosis Blastomycosis dermatitidisKSP 814 -size; 8-15 ㎛ -thick double-contoured wall -single broad based budding Daniel H. Connor.Pathology of Infectious diseases. Appleton&Lange.1997

17. Cryptococcus neoformans Differential diagnosis Cryptococcus neoformansKSP 814 -size; 5-15 ㎛ (yeast form) -thick mucinous capsule -single “tear-drop” budding Australian Society of cytology.”histoplasmosis”,http://cytology-asc.com/cec/respiratory(2014.08.11.)

18. Coccidiodes immitis Differential diagnosis Coccidiodes immitisKSP 814 -size; 20-100 ㎛ -thick-walled cystic structures (spherules) -numerous endospores (2-5 ㎛ ) Australian Society of cytology.”histoplasmosis”,http://cytology-asc.com/cec/respiratory(2014.08.11.)

19. Histoplasma capsulatum Differential diagnosis Histoplasma capsulatumKSP 814 -size; 2-4 ㎛ (spherical-oval yeast-like cells) -thin cell wall (no true capsule) -clear peripheral halo Marluce Bibbo.Comprehensive Cytopathology.Saunders.2008 Infection. 2014;42:611-620

20. Differential diagnosis SizeCapsule or wallOthers Pneumocystis jiroveci 4-7 ㎛ -thick-walled, spherical intact cysts -dark staining single structure (dot, ring or comma) Blastomycosis dermatitidis 8-15 ㎛ -thick double-contoured wall-broad based budding Cryptococcus neoformans 5-15 ㎛ -thick mucinous capsule-narrow-neck bud Coccidiodes immitis 20-100 ㎛ -thick-walled cystic structure (spherules) -numerous pleomorphic endospores (2-5 ㎛ ) Histoplasma capsulatum 2-4 ㎛ -no true capsule -thin wall -clear peripheral halo -narrow-neck bud -intra- & extracellular location KSP 814 2-4 ㎛ -clear halo -intra- & extracellular parasites Richard L. kradin.Diagnostic Patholog of Infectious Disease.Saunders,2010 Daniel H. Connor.Pathology of Infectious diseases.Appleton&Lange.1997

22. Histoplasmosis  Systemic mycosis caused by fungus (Histoplasma capsulatum)  Epidemiology - Endemic areas; the Mississippi and Ohio River valleys, Mexico, Guatemala, Peru, and Venezuela - Primary infection occurs in patients with impaired cell-mediated immunity, specially those with HIV infection  Symptoms - Acute diffuse pulmonary form ; enlargement of the cervical LNs, liver and spleen Marluce Bibbo.Comprehensive Cytopathology.Saunders.2008 J Bras Pneumol. 2009;35(11):1145-1151 Infection. 2014;42:611-620

24. Final diagnosis Lung, right upper lobe, bronchoalveolar lavage ; Fungal infection, consistent with histoplasmosis