Objectives: Flexible bronchoscopy with exfoliative cytology is an important tool for the diagnosis of pulmonary fungal infections. The question of colonization versus true fungal infection is of critical importance. Study Design: A 5-year retrospective analysis of all cases of pulmonary fungal infection diagnosed using exfoliative cytology was performed. Clinical, radiological, bronchoscopy and histopathology findings were recorded. Results: A total of 69 cases of mycoses were retrieved. The most common fungal organism identified was Aspergillus followed by Candida and Pneumocystis. Most cases of Aspergillus and Candida in cytological specimens presented as a pulmonary mass or endobronchial growth and were diagnosed as carcinomas in biopsy specimens, thus representing colonization. All cases of Pneumocystis with bilateral ground glass infiltrates and cryptococcosis with parenchymal mass lesion in radiology represented true infection. Histoplasma was identified in pleural fluid from a known case of lung carcinoma. Conclusion: Aspergillus and Candida species are the most common fungal organisms. Most of these represent colonization of malignant growths. However, true fungal infections may also present as mass lesions and may masquerade malignancy clinically. Fluid cytological examination is an important diagnostic modality for pulmonary mycoses; however, it is important to correlate results with clinical, bronchoscopy and biopsy findings for accurate diagnosis and appropriate management.

Keywords:
Pulmonary mycoses, Exfoliative cytology, Colonization, Infection
1.
Ascioglu S, Rex JH, de Pauw B, Bennett JE, Bille J, Crokaert F, Denning DW, Donnelly JP, Edwards JE, Erjavec Z, Fiere D, Lortholary O, Maertens J, Meis JF, Patterson TF, Ritter J, Selleslag D, Shah PM, Stevens DA, Walsh TJ; Invasive Fungal Infections Cooperative Group of the European Organization for Research and Treatment of Cancer; Mycoses Study Group of the National Institute of Allergy and Infectious Diseases: Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus. Clin Infect Dis 2002;34:7-14.
2.
Shahid M, Malik A, Bhargava R: Bronchogenic carcinoma and secondary aspergillosis - common yet unexplored: evaluation of the role of bronchoalveolar lavage-polymerase chain reaction and some nonvalidated serologic methods to establish early diagnosis. Cancer 2008;113:547-558.
3.
Luo BL, Zhang LM, Hu CP, Xiong Z: Clinical analysis of 68 patients with pulmonary mycosis in China. Multidiscip Respir Med 2011;6:278-283.
4.
Smahi M, Serraj M, Ouadnouni Y, Chbani L, Znati K, Amarti A: Aspergilloma in combination with adenocarcinoma of the lung. World J Surg Oncol 2011;9:27.
5.
Schwarz J: The diagnosis of deep mycoses by morphologic methods. Hum Pathol 1982;13:519-533.
6.
Levy H, Horak DA, Tegtmeier BR, Yokota SB, Forman SJ: The value of bronchoalveolar lavage and bronchial washings in the diagnosis of invasive pulmonary aspergillosis. Respir Med 1992;86:243-248.
7.
Knox KS, Meinke L: Role of bronchoalveolar lavage diagnostics in fungal infections. Clin Chest Med 2009;30:355-365.
8.
Huang L, Morris A, Limper AH, Beck JM; ATS Pneumocystis Workshop Participants: An Official ATS Workshop Summary: recent advances and future directions in pneumocystis pneumonia (PCP). Proc Am Thorac Soc 2006;3:655-664.
9.
Hope WW, Walsh TJ, Denning DW: Laboratory diagnosis of invasive aspergillosis. Lancet Infect Dis 2005;5:609-622.
10.
Musher B, Fredricks D, Leisenring W, Balajee SA, Smith C, Marr KA: Aspergillus galactomannan enzyme immunoassay and quantitative PCR for diagnosis of invasive aspergillosis with bronchoalveolar lavage fluid. J Clin Microbiol 2004;42:5517-5522.
11.
Hayden RT, Isotalo PA, Parrett T, Wolk DM, Qian X, Roberts GD, Lloyd RV: In situ hybridization for the differentiation of Aspergillus, Fusarium, and Pseudallescheria species in tissue section. Diagn Mol Pathol 2003;12:21-26.
12.
Franquet T, Müller NL, Giménez A, Guembe P, de La Torre J, Bagué S: Spectrum of pulmonary aspergillosis: histologic, clinical, and radiologic findings. Radiographics 2001;21:825-837.
13.
Babbin BA, Greene JN, Vega R, Iravani S, Ku NN, Sandin RL: Pathologic manifestations of invasive pulmonary aspergillosis in cancer patients: the many faces of aspergillus. Cancer Control 2000;7:566-571.
14.
Nilsson JR, Restrepo CS, Jagirdar J: Two cases of endobronchial carcinoid masked by superimposed aspergillosis: a review of the literature of primary lung cancers associated with Aspergillus. Ann Diagn Pathol 2013;17:131-136.
15.
Olobatoke AO, David D, Hafeez W, Van T, Saleh HA: Pulmonary carcinosarcoma initially presenting as invasive aspergillosis: a case report of previously unreported combination. Diagn Pathol 2010;5:11.
16.
Greaves TS, Strigle SM: The recognition of Pneumocystis carinii in routine Papanicolaou-stained smears. Acta Cytol 1985;29:714-720.
17.
Paradis IL, Ross C, Dekker A, Dauber J: A comparison of modified methenamine silver and toluidine blue stains for the detection of Pneumocystis carinii in bronchoalveolar lavage specimens from immunosuppressed patients. Acta Cytol 1990;34:511-516.
18.
Johnston WW, Schlein B, Amatulli J: Cytopathologic diagnosis of fungus infections. 1. A method for the preparation of simulated cytopathologic material for the teaching of fungus morphology in cytology specimens. 2. The presence of fungus in clinical material. Acta Cytol 1969;13:488-495.
19.
Whitaker D, Sterrett GF: Cryptococcus neoformans diagnosed by fine needle aspiration cytology of the lung. Acta Cytol 1976;20:105-107.
20.
Powers CN: Diagnosis of infectious diseases: a cytopathologist's perspective. Clin Microbiol Rev 1998;11:341-365.
21.
Austin P, Dekker A, Kennerdall JS: Orbital aspergillosis: report of a case diagnosed by fine needle aspiration. Acta Cytol 1983;27:166-169.
22.
Ashton PR: Infectious organisms in cytologic material. Lab Med 1983;14:227-233.
23.
Neumann MP, Eng MH, Rholl KE, Swedo GJ, Meranze SG: Disseminated histoplasmosis diagnosed by percutaneous needle biopsy of a retroperitoneal lymph node. A case report. Acta Cytol 1992;36:527-528.
24.
Itano H, Andou A, Date H, Shimizu N: Non-small cell lung cancer coexisting with pulmonary aspergilloma. Jpn J Thorac Cardiovasc Surg 2005;53:513-516.
25.
Shimizu J, Watanabe Y, Oda M, Watanabe S, Hayashi Y, Iwa T, Kamimura R, Takashima T, Nonomura A: A case of lung cancer suspected to be pulmonary mycosis of the fungus ball type. Nihon Kyobu Shikkan Gakkai Zasshi 1990;28:1252-1256.
26.
Sangoi AR, Rogers WM, Longacre TA, Montoya JG, Baron EJ, Banaei N: Challenges and pitfalls of morphologic identification of fungal infections in histologic and cytologic specimens: a ten-year retrospective review at a single institution. Am J Clin Pathol 2009;131:364-375.
27.
Crapanzano JP, Zakowski MF: Diagnostic dilemmas in pulmonary cytology. Cancer 2001;93:364-375.
28.
Limper AH: The changing spectrum of fungal infections in pulmonary and critical care practice: clinical approach to diagnosis. Proc Am Thorac Soc 2010;7:163-168.
29.
Greene RE, Schlamm HT, Oestmann JW, Stark P, Durand C, Lortholary O, Wingard JR, Herbrecht R, Ribaud P, Patterson TF, Troke PF, Denning DW, Bennett JE, de Pauw BE, Rubin RH: Imaging findings in acute invasive pulmonary aspergillosis: clinical significance of the halo sign. Clin Infect Dis 2007;44:373-379.
30.
Jain D, Kumar Y, Vasishta RK, Rajesh L, Pattari SK, Chakrabarti A: Zygomycotic necrotizing fasciitis in immunocompetent patients: a series of 18 cases. Mod Pathol 2006;19:1221-1226.
31.
Lui G, Lee N, Ip M, Choi KW, Tso YK, Lam E, Chau S, Lai R, Cockram CS: Cryptococcosis in apparently immunocompetent patients. QJM 2006;99:143-151.
32.
Chabé M, Dei-Cas E, Creusy C, Fleurisse L, Respaldiza N, Camus D, Durand-Joly I: Immunocompetent hosts as a reservoir of pneumocystis organisms: histological and rt-PCR data demonstrate active replication. Eur J Clin Microbiol Infect Dis 2004;23:89-97.
33.
Rozenbaum R, Gonçalves AJ: Clinical epidemiological study of 171 cases of cryptococcosis. Clin Infect Dis 1994;18:369-380.
34.
Feigin DS: Pulmonary cryptococcosis: radiologic-pathologic correlates of its three forms. AJR Am J Roentgenol 1983;141:1262-1272.
35.
Robinson TD, Barnes DJ, Watson GF: Coexistent cryptococcosis and carcinoma within a solitary pulmonary nodule. Aust NZ J Med 1999;29:561-562.
36.
Kawasaki H, Ishikawa K, Kuniyoshi M, Ohta M, Kawabata T, Hirayasu T: Lung adenocarcinoma with coexisting pulmonary cryptococcoma. Jpn J Thorac Cardiovasc Surg 2004;52:21-25.
37.
Hayden RT, Qian X, Roberts GD, Lloyd RV: In situ hybridization for the identification of yeastlike organisms in tissue section. Diagn Mol Pathol 2001;10:15-23.
38.
Vélez L, Correa LT, Maya MA, Mejía P, Ortega J, Bedoya V, Ortega H: Diagnostic accuracy of bronchoalveolar lavage samples in immunosuppressed patients with suspected pneumonia: analysis of a protocol. Respir Med 2007;101:2160-2167.
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2013
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