Cryptococcal inflammatory pseudotumors

Inflammatory pseudotumors (IPTs) embrace a heterogeneous spectrum of reactive, infective, and neoplastic entities, that are characterized by a clinical mass composed of a histologic proliferation of spindle cells in a background of inflammatory cells and collagen fibers. Although a spectrum of microorganisms have been identified in infective IPTs, mycobacterial infective IPTs are reported most commonly. We document 5 solitary cryptococcal IPTs, in 2 males and 3 females, aged 19 to 43 years, in the soft tissues of the anterior chest wall, thigh, and arm. All were HIV-positive and had been treated for disseminated cutaneous and/or meningeal cryptococcosis with antifungal therapy, 6 to 12 months earlier. The specimens demonstrated a storiform arrangement of plump spindle cells, in addition to spindle and polygonal cells that were arranged in a haphazard manner. Background lymphocytes, plasma cells, and fibrosis were noted, in addition to scattered giant cells and focal necrosis. On high-power examination, Cryptococcus neoformans yeasts were identified within and between vacuolated spindle and polygonal cells on routine and special stains, confirming cryptococcal IPTs. Immunophenotyping of the spindle cells confirmed a mixed histiocytic and myofibroblastic lineage, with a predominance of the former. In documenting 5, hitherto unreported, pseudotumoral spindle cell reactions to C. neoformans, we not only highlight the need for intense appraisal of all IPTs for infective agents on routine and special stains and investigations, but also postulate that a complex host-fungus interaction, coupled with an exuberant, myofibroblastic response to incomplete therapy, are the pathogenetic drive for the pseudotumoral presentation.