Photo Quiz: Globose Yeast-Like Forms With Multiple Peripheral Buds in Urine and Cervical Cytology

A 26-year-old immunocompetent woman with a history of noninvasive, low-grade papillary urothelial carcinoma presented with persistent upper abdominal pain. Urine cytology, performed for bladder tumor surveillance, revealed globose, yeast-like forms (10-30 μm) with thick walls and multiple narrowly attached peripheral buds in a "ship wheel" configuration-morphology classically associated with Paracoccidioides brasiliensis. Three months later, morphologically identical organisms were identified on routine cervical Papanicolaou (Pap) test, confirmed by PAS and GMS stains on cell block material. Neither specimen showed significant inflammation or epithelial abnormality. Clinical and epidemiologic features were inconsistent with paracoccidioidomycosis: the patient was a young woman of reproductive age (male-to-female ratio 13-20:1 in chronic paracoccidioidomycosis), had no travel to an endemic region, and lacked pulmonary, mucocutaneous, or systemic disease. The morphologic findings were attributed to Cokeromyces recurvatus, a rare dimorphic mucormycete whose sporangiola are virtually indistinguishable from the multiple-budding yeast cells of P. brasiliensis on cytologic preparations. This case is novel in two respects: (1) it represents the first reported simultaneous detection of C. recurvatus in both urine and cervical cytology from the same patient, demonstrating multisite genitourinary colonization and (2) identification via urine cytology performed for bladder tumor surveillance extends awareness of this organism beyond the Pap test setting to urinary cytopathology. With fewer than 15 published human cases, this report reinforces that morphology alone is insufficient for definitive fungal identification when an endemic dimorphic fungus is suspected, and that culture or molecular confirmation (broad-range fungal PCR with DNA sequencing) is essential to avoid misdiagnosis and unnecessary prolonged antifungal therapy.