A 28-year-old male patient known to have been on steroids for rheumatoid arthritis presented with itchy skin lesions over back for 10 days. The lesions were slightly raised with central scarring. The patient also had pallor, mild icterus, and generalized lymphadenopathy. Skin biopsy showed groups of yeastlike organisms in superficial dermis suggestive of dermatophytosis (PAS ×400)

(a, b) A 48-year-old female patient with prolonged h/o tobacco chewing presented with an ulcerated growth on the mucosa of the left cheek. The lesion was about 3 × 2 cm in size. Cervical lymph nodes were not enlarged. Chest X-ray and laboratory workup were WNL. The biopsy from the ulcer showed pseudo hyphae and yeasts of Candida (a PAS ×400) along with CIS (b HE ×200)

(a, b) A 36-year-old male patient with h/o tobacco chewing for >20 years presented with ulcerated swelling measuring 3 × 2 cm on the right lateral margin of the tongue. Lymph nodes in the drainage area were not involved. Punch biopsy from the lesion showed plenty of hyphae and pseudo hyphae of Candida (a PAS ×400) along with keratinizing squamous cell carcinoma (b HE ×200)

(a, b) A 50-year-old female patient presented with progressively increasing dysphagia. Upper GI endoscopy showed an ulceroproliferative friable growth in lower 1/3 of esophageal region. Endoscopic esophageal biopsy from the growth showed budding yeasts and pseudo hyphae of Candida (a PAS ×400) along with keratinizing squamous cell carcinoma of esophagus (b HE ×200)

(a, b) A 45-year-old female patient presented with progressively increasing dysphagia (grade III). Upper GI endoscopy showed a friable growth in mid esophageal region. Endoscopic esophageal biopsy from the growth showed pseudo hyphae, hyphae, and a few budding yeasts of Candida (a PAS ×200) along with nonkeratinizing squamous cell carcinoma (b HE ×100)

(a, b) A 74-year-old male patient presented with dysphagia and odynophagia for 6 weeks followed by weakness. Upper GI endoscopy revealed an ulcerated mid esophageal growth; endoscopic biopsy was obtained. Histological examination revealed the presence of plenty of pseudo hyphae of Candida (a PAS ×400) along with undifferentiated carcinoma esophagus (b HE ×200)

(a–c) A 38-year-old female patient presented with abdominal pain and melena. Ultrasonography of the upper abdomen revealed enlarged liver showing fatty change and multiple necrotic SOL with portal vein thrombosis and enlarged peripancreatic lymph nodes. Upper GI endoscopy revealed a polypoidal growth at GE junction. The biopsy from the polyp showed hyphae, pseudo hyphae, and budding yeasts of Candida (a PAS ×400) along with adenocarcinoma of GE junction (b HE ×200); guided FNAC of the liver nodule showed metastatic adenocarcinoma (c MGG ×400)

(a, b) A 55-year-old male patient presented with melena. Upper GI endoscopy revealed an ulcerated gastric central polyp. The biopsy from the polyp showed hyphae, pseudo hyphae, and budding yeasts of Candida (a PAS ×400) along with adenocarcinoma of the stomach (b HE ×200)

(a, b) A 55-year-old male patient presented with itching, anorexia, weakness, and jaundice for 1 month. USG showed dilated CBD with block at papilla. Upper GI endoscopy revealed an ulcerated mass at papilla and a biopsy was obtained. Histological examination revealed the presence of yeastlike bodies and plenty of pseudo hyphae of Candida (a PAS ×400) along with poorly differentiated adenocarcinoma of the ampula (b HE ×200)

(a–c) A 47-year-old female patient developed postcholecystectomy cholangitis with fever, septicemia, and acute renal failure for which she received 20 sittings of hemodialysis; however, her clinical condition continued to deteriorate and she passed into coma. Blood counts revealed polymorphonuclear leukocytosis with total WBC count of 15,300/cu mm with 75 % neutrophils; patient had thrombocytopenia with platelet count of 46,000/cu mm. Her serum creatinine was 4.0 mg/dl and serum urea was 56.2 mg/dl. She continued to receive hemodialysis. During endotracheal suction, a necrotic soft tissue piece was sucked out. On histopathological examination, it revealed necrotic tissue with some degenerated squamous cells and plenty of budding yeasts and pseudo hyphae of Candida (a, b HE ×400, c PAS ×400)

(a–d) A 30-year-old male patient receiving live-related renal allograft was being maintained on triple drug immunosuppression. Six weeks posttransplant, he presented with acute graft dysfunction with rise in serum creatinine. Routine chest X-ray (PA) revealed nodular consolidation; CT-guided needle core biopsy from the nodule was performed. The histopathological examination revealed multiple ill-defined collections of epithelioid cells, macrophages, and few giant cells along with plentiful budding yeastlike fungus with occasional pseudo hyphae, the fungus was present both within the macrophages and giant cells (arrows) as well as extracellularly (a–c PAS ×400, d CSM ×400)

(a, b) A 30-year-old male patient known to have been suffering from ALL was admitted to the hospital with fever, generalized body ache, progressively increasing jaundice, and tenderness in both loins. Ultrasonographic examination of the abdomen revealed mild hepatomegaly and multiple enlarged retroperitoneal lymph nodes; both kidneys were of normal size. Laboratory workup revealed that the patient had severe anemia with hemoglobin level of 3.6 g/dl; total WBC count was 36,600/cu mm with 82 % lymphoblasts in peripheral circulation, and the platelet count was 52,000/cu mm. Serum bilirubin was 16.8 mg/dl (direct 8.9 mg/dl and indirect 7.9 mg/dl), SGPT was 63 IU/dl, and SGOT was 54 IU/dl. Blood culture did not grow any organisms up to 72 h. The patient died 4th day after hospitalization. Postmortem renal biopsy showed budding yeasts and pseudo hyphae of Candida infiltrating renal parenchyma (a, b PAS ×400) (From: Gupta RK. In Pathology of opportunistic infections in tropic. Jaypee; 2007)

A 54-year-old female patient, who had been suffering with diabetic glomerulosclerosis, received live-related renal allograft. Three years posttransplant, she presented with progressive graft dysfunction and anemia. Graft biopsy was inconclusive. While in the hospital, she passed grayish white fragments in the urine. Histopathological examination of these fragments revealed the structure of renal papilla (arrows) along with pseudo hyphae and yeastlike organisms suggestive of candidiasis of the renal pelvis (PAS ×400)

(a–d) A39-year-old female patient known to have been suffering with chronic kidney disease (CKD) and chronic lung disease (CLD) presented with h/o low backache for 1 year along with lower abdominal pain which increased in severity with inspiration followed by fever, nausea, loss of appetite, and loss of weight. Laboratory workup revealed that the patient was moderately anemic with hemoglobin level of 7.0 g/dl and total WBC count was 13,900/cu mm with 78 % polys. Her serum creatinine was 3.1 mg/dl. USG of the abdomen revealed that both kidneys were small, and a subcapsular mid polar mass was also identified in the right kidney. Clinical diagnosis of subcapsular hematoma of the right kidney was considered. Right PCN drained small amount of altered blood which was sterile on culture. PCD was removed after 4 days. During postoperative period, the patient received broad-spectrum antibiotics; postoperative recovery was uneventful, and the patient was discharged on the 10th day after hospitalization. Four months later, she again presented with fever and left ventricular failure. 2-D echo showed rounded 27 × 20 mm mass in anterior papillary muscle of the left ventricle. At surgery anterior leaflet of the mitral valve was found prolapsed with torn out chordae. Anterior leaflet of the mitral valve along with anterior papillary muscle of the left ventricle was excised. The postoperative recovery was uneventful. Gross examination of the resected specimen revealed anterior leaflet of mitral valve measuring 3.0 cm along with a globular soft tissue piece (papillary muscle) measuring 2 cm, its cut surface showed brownish yellow areas (a). Histological examination of the mitral valve leaflet revealed myxoid change with areas of geographical necrosis and that of the papillary muscle revealed necrotic area with microabscess formation infiltrated with mixed inflammatory infiltrate, histiocytes, and giant cells (b HE ×200) along with plentiful budding yeastlike fungus with the presence of pseudo hyphae (c PAS ×400, d CSM ×400). Diagnosis of candidiasis of the anterior papillary muscle of the left ventricle was offered

A 35-year-old male patient who had been suffering from long-standing pulmonary tuberculosis and was on irregular antitubercular treatment, presented with low-grade fever with evening rise of temperature, headache, and diminution of vision for 1 month. The clinical examination revealed that the patient was in altered state of sensorium, responding only to painful stimuli with bilateral papilledema and VI and VII cranial nerve paresis. Chest X-ray revealed pleural thickening. Cranial CT showed a ring lesion in the right parietal region. CSF examination revealed protein 40 mg/dl and sugar 50 mg/dl; there was no pleocytosis. Serum and CSF were negative for antimycobacterial antibody but were positive for cryptococcal antigen. India ink preparation showed budding forms of cryptococci and Cryptococcus neoformans was isolated on CSF culture. The patient received amphotericin and anti-edema measures but succumbed to his illness the next day. At autopsy the meninges were hazy and histological examination revealed plenty of cryptococci in meningeal space suggestive of cryptococcal meningitis (Masson-Fontana ×400) (Contributors – Dr. Anita Mahadevan and Prof. SK Shankar, Human Brain Bank, Department of Neuropathology, NIMHANS, Bangalore, India) (From: Gupta RK. In Pathology of opportunistic infections in tropic. Jaypee; 2007)

A 50-year-old male patient presented with mild to moderate fever without any localizing symptoms for 8 months and abnormal movements of the right upper limb for 2 weeks. Two weeks earlier, he developed holocranial headache associated with “paroxysmal tremor”-like movements both at rest and activity but not during sleep. He also had inability to hold objects in the right hand. He had lost 8 kg of weight during the past 8 months. Fever did not respond to various antibiotics and antitubercular therapy. Clinical examination, except for the presence of coarse tremors, was WNL. Laboratory investigations revealed TLC of 6600/cu mm with 20 % lymphocytes (absolute lymphocyte count of 1320/cu mm). Bone marrow examination did not reveal any abnormality. The patient was nondiabetic, and other laboratory parameters including liver and renal function tests were WNL. Chest X-ray did not reveal any abnormality. Multiple blood and urine culture were negative for tuberculosis, fungus, and pyogenic organisms. US of the abdomen did not reveal any organomegaly, and 2D echocardiography was normal. MRI of the brain showed a large lesion in the frontoparietal and right occipital region, which was hypertense in T2-weighted images. CSF examination showed mildly elevated proteins (80 mg/dl) with lymphocytic pleocytosis, India ink preparation showed capsulated yeasts of cryptococci. CSF was also positive for cryptococcal antigen by latex agglutination and was negative for IgM anti-toxoplasma antibody. Serology for CMV and HIV-1 and HIV-2 was negative. CD4 cell count was 17/μl. Patient responded well to the therapy (Courtesy Neurology India. Photograph courtesy Prof. KN Prasad, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India) (From: Gupta RK. In Pathology of opportunistic infections in tropic. Jaypee; 2007)

A 25-year-old female patient presented with cough and breathlessness for 1 month. She was found to be HIV positive. Chest X-ray revealed mass in the upper lobe of the right lung with erosion of the overlying rib. CT-guided aspiration of the mass showed capsulated budding yeastlike bodies suggestive of Cryptococcus (Melanin ×400) (Contributor – Dr. S Radha, Aware Global Hospital, Hyderabad, India)

A 37-year-old male renal allograft recipient who was HBsAg positive, 1 year posttransplant, presented with rising serum creatinine, proteinuria, and deteriorating liver functions. The patient was suspected to have chronic transplant nephropathy with chronic liver disease. During hospital stay, the patient developed hepatic encephalopathy and died. Postmortem kidney biopsy revealed tubules filled with capsulated, spherical budding yeastlike organisms surrounded by a clear halo suggestive of cryptococcosis (PAS ×400) (From: Gupta RK. In Pathology of opportunistic infections in tropic. Jaypee; 2007)

(a–d) A 57-year-old male patient known to have pauci-immune crescentic glomerulonephritis on steroid and cyclophosphamide presented with fever, decreased appetite, and weight loss (11 kg) since 4 months. The patient was empirically on ATT before presentation to the hospital. He had no lymphadenopathy. Routine hematological workup revealed hemoglobin 11.5 g/dl, and total WBC count was 5600/cu mm, with N-59, L-38, E-1, and M-2 %, respectively; ESR was 16 mm. The patient was nondiabetic; he tested negative for HBsAg, HCV, and HIV. Further laboratory workup revealed C-ANCA 40 U/ml, HbA1c 5.7 %, and serum ACE 23 U/l. Sputum smear was negative for AFB; sputum culture was also negative for tubercle bacilli. Chest CT showed a nodular lesion with eccentric cavitation in the upper lobe of the right lung, and small nodular lesions in the upper lobe of the left lung were also identified; mediastinal lymph nodes were enlarged. CT-guided biopsy from the right upper lobe of the lung showed noncaseating epithelioid granuloma (a. HE ×200); Ziehl-Neelsen stain for AFB was negative. The lung biopsy also showed plenty of capsulated, spherical budding yeastlike organisms surrounded by a clear halo suggestive of cryptococcosis (b HE ×400 and c PAS ×400). The renal biopsy revealed necrotizing crescentric glomerulonephritis (d PAS ×200)

(a–c) A 60-year-old male diabetic patient presented with fever, anemia, drowsiness, gastrointestinal bleeds, and mental confusion. Radiological evaluation revealed multiple skeletal hypodense areas which on FNAC revealed mixed inflammatory infiltrate with few giant cells and capsulated yeastlike bodies both extracellular and intracellular within the histiocytes and giant cells, suggestive of cryptococcosis (a HE ×400, b PAS ×400 and c Masson-Fontana ×400) (From: Gupta RK. In Pathology of opportunistic infections in tropic. Jaypee; 2007)

(a–c) A 36-year-old male patient who received live-related renal allograft, 3-month posttransplant presented with fever and chills along with cough and breathlessness of short duration. Chest X-ray (PA view) showed extensive bilateral patchy consolidation (a). The patient died 3 days after hospitalization. Postmortem lung biopsy revealed foamy acellular PAS-positive alveolar exudates (b. PAS ×400); on CSM stain, the exudate showed multiple rounded or oval organisms suggestive of Pneumocystis carinii (c. CSM ×400) (From: Gupta RK. In Pathology of opportunistic infections in tropic. Jaypee; 2007)

(a, b) An 18-year-old male patient received live-related renal allograft 6 years back. He presented with irregular fever for 4 months and dry cough and breathlessness for 10 days. Chest X-ray showed left lung consolidation. Bronchoalveolar lavage showed boat-shaped cysts of P. carinii (a CSM ×400). Transbronchial lung biopsy revealed foamy acellular PAS-positive alveolar exudates suggestive of P. carinii (b PAS ×400). The patient responded to cotrimoxazole and recovered (From: Gupta RK. In Pathology of opportunistic infections in tropic. Jaypee; 2007)

Smear from urine culture of a renal allograft recipient showing Gram-positive yeast forms of Torulopsis (Grams stain ×1000) (Contributor – Prof. K N Prasad, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Inida) (From: Gupta RK. In Pathology of opportunistic infections in tropic. Jaypee; 2007)