Aetiology of meningitis in HIV-infected patients in a referral hospital in Phnom Penh, Cambodia

The HIV epidemic in Cambodia is one of the most extensive in Asia. Meningitis accounts for a substantial proportion of HIV-related morbidity and mortality in Cambodia. A retrospective chart review was performed to identify the clinical and spinal fluid characteristics of patients undergoing spinal tap at an AIDS referral hospital in Phnom Penh, Cambodia during a 16-month period. Of 932 charts reviewed, 89 met criteria for analysis. Overall mortality was 49.4%. Cryptococcus was the most commonly identified pathogen (83%), followed by mycobacteria (8%). No pathogen was identified in 9% of charts reviewed. In hospital mortality was similar in all groups.

Systemic Cryptococcus Albidus Infection in a Doberman Pinscher

Cryptococcus albidus is a saprophytic, encapsulated yeast usually found in air, both outdoor and indoor, and sometimes on human skin. It is not usually considered to be a primary pathogen. Most cryptococcal infections of humans and animals are caused by Cryptococcus neoformans. Several cases of C. albidus infection have been reported in humans over the past 20 years. In the veterinary literature, 2 equine cases have been described: genital infection and mycotic keratitis. The present report is the first documented case of C. albidus systemic infection in a dog. Veterinarians and diagnosticians should be aware that C. albidus may be a potential canine pathogen.

Sequencer-Based Capillary Gel Electrophoresis (SCGE) Targeting the rDNA Internal Transcribed Spacer (ITS) Regions for Accurate Identification of Clinically Important Yeast Species

Accurate species identification of Candida, Cryptococcus, Trichosporon and other yeast pathogens is important for clinical management. In the present study, we developed and evaluated a yeast species identification scheme by determining the rDNA internal transcribed spacer (ITS) region length types (LTs) using a sequencer-based capillary gel electrophoresis (SCGE) approach. A total of 156 yeast isolates encompassing 32 species were first used to establish a reference SCGE ITS LT database. Evaluation of the ITS LT database was then performed on (i) a separate set of (n = 97) clinical isolates by SCGE, and (ii) 41 isolates of 41 additional yeast species from GenBank by in silico analysis. Of 156 isolates used to build the reference database, 41 ITS LTs were identified, which correctly identified 29 of the 32 (90.6%) species, with the exception of Trichosporon asahii, Trichosporon japonicum and Trichosporon asteroides. In addition, eight of the 32 species revealed different electropherograms and were subtyped into 2–3 different ITS LTs each. Of the 97 test isolates used to evaluate the ITS LT scheme, 96 (99.0%) were correctly identified to species level, with the remaining isolate having a novel ITS LT. Of the additional 41 isolates for in silico analysis, none was misidentified by the ITS LT database except for Trichosporon mucoides whose ITS LT profile was identical to that of Trichosporon dermatis. In conclusion, yeast identification by the present SCGE ITS LT assay is a fast, reproducible and accurate alternative for the identification of clinically important yeasts with the exception of Trichosporon species.

Cryptococcus laurentii fungaemia in a cervical cancer patient

Infections caused by emerging Cryptococcus non-neoformans species are being reported with increasingly frequency. Here, we present a case of fungaemia by Cryptococcus laurentii in a woman receiving aggressive immunosuppressive therapy for cervical neoplasia. Three venous blood samples were aseptically collected on consecutive days and C. laurentii was isolated and identified through phenotypic and molecular methods. After central venous catheter removal and appropriate antifungal therapy, the patient showed significant improvement and blood culture became negative. Thus, patients following immunosuppressive therapies and using invasive medical devices are at risk of C. laurentii blood infections.

Systemic Review of Published Reports on Primary Cutaneous Cryptococcosis in Immunocompetent Patients

Primary cutaneous cryptococcosis (PCC) has been confirmed as a distinct clinical entity with secondary cutaneous cryptococcosis from systematic infection since 2003. Although it has been confirmed as a distinct clinical entity, little has progressed on PCC in immunocompetent hosts compared to their immunocompromised counterpart. We reviewed the literature on cases of PCC in immunocompetent patients from 2004 to 2014, and 21 cases from 16 reports were identified. Males are more likely to develop PCC infections, with a ratio of 17:4 male to female. These patients were found to be almost all senior population except for patients from Asia. Asymptomatic or moderate itching manifesting in a painful nodule is the most common presentation, although there is no typical clinical manifestation recorded. Upper limbs are the most common site of infection, accounting for 71.4 % of all patients. Of the 12 identified isolates, 6 strains are identified as C. neoformans, 5 as C. gattii, and 1 as C.laurentii. Fluconazole was used in 10 cases; however, only 80 % of the 10 cases could confirm that fluconazole was effective in clearing the infections. Interestingly although not approved as a treatment option, Itraconazole was effective in the seven cases it was used to treat cryptococcosis, with a dosage range of 100-400 mg/d and duration from 3 to 6 months. Even though the prognosis of these patients was generally good, more data are need to determine which antifungal azole is the better treatment option and whether primary skin infections could disseminate to systematic infection.

Cryptococcal infection of the femoral bone similar with pathologic features of vascular tumors: a case report and review of literature

A rare case is presented of a 62-year-old man with primary isolated cryptococcal femoral osteomyelitis. Magnetic resonance imaging (MRI) revealed osteolytic destruction of his left femur. Biopsy was performed firstly. Under microscope, the lesion was compose of numerous large mononuclear cells, scattered multinucleated giant cells, a few lymphocytes and neutrophils, necrosis with serious artificial deformation. By immunohistochemistry (IHC), only CD31 and CD68 were positive, while CK, CK8/18, EMA, P63, CK7, CK20, PSAP, PSA, CD34 negative. It was considered a low grade vascularsarcoma, but not confirmed. Then the operation was done. Surgical specimen showed a lot of red-sphere materials in most cells cytoplasm. The Gomorra methenamine silver staining and PAS revealed the mucopolysaccharide-containing capsule of the Cryptococcus. Laboratory culture of lesion liquid grew a kind of yeast at 37°C. Cryptococcal femoral osteomyelitis was diagnosed at last. The patient is good now after the thorough debridement and anti-fungal treatment.

Prevalence, correlates, and outcomes of cryptococcal antigen positivity among patients with AIDS, United States, 1986-2012

BACKGROUND

Cryptococcal meningitis (CM) is one of the most common causes of AIDS-related mortality worldwide, accounting for 33%-63% of all cases of adult meningitis in sub-Saharan Africa and >500 000 deaths annually. In sub-Saharan Africa, the World Health Organization recommends routinely screening AIDS patients with a CD4 count ≤100 cells/µL for cryptococcal infection. In the United States, there are no recommendations for routine screening. We aimed to determine the prevalence of cryptococcal infection and outcomes of those infected among people living with advanced AIDS in the United States, to inform updates in the prevention and management of CM.

METHODS

Using stored sera from participants in the Multicenter AIDS Cohort Study and the Women's Interagency HIV Study from 1986 to 2012, we screened 1872 specimens with CD4 T-cell counts ≤100 cells/µL for cryptococcal antigen (CrAg) using the CrAg lateral flow assay.

RESULTS

The overall prevalence of CrAg positivity within the study population was 2.9% (95% confidence interval, .2%-3.8%). Results from multivariable analysis revealed that a previous diagnosis with CM and a CD4 count ≤50 cells/µL were significantly associated with CrAg positivity. Participants who were CrAg positive had significantly shorter survival (2.8 years) than those who were CrAg negative (3.8 years; P = .03).

CONCLUSIONS

The prevalence of cryptococcal infection among advanced AIDS patients in the United States was high and above the published cost-effectiveness threshold for routine screening. We recommend routine CrAg screening among human immunodeficiency virus-infected patients with a CD4 count ≤100 cells/µL to detect and treat early infection.

A rare case report of central line-associated bloodstream infection caused by Cryptococcus arboriformis

Cryptococcus arboriformis (C. arboriformis) is a novel Cryptococcus species belonging to the genus Trichosporonales. This novel species was identified definitively in 2007 using D1/D2 26S ribosomal DNA gene sequencing. In this article, we present a rare case of central line-associated bloodstream infection caused by C. arboriformis with successful treatment of this infection.

Successful treatment of Cryptococcus laurentii peritonitis in a patient on peritoneal dialysis

A 32-year-old man on peritoneal dialysis (PD) was hospitalized for seven days due to fever. A diagnosis of yeast-like fungal peritonitis was made by Gram staining. The patient was started on intravenous micafungin and oral fluconazole therapy following removal of the PD catheter. A fungal pathogen was isolated from the peritoneal fluid and identified as Cryptococcus species. Based on antifungal susceptibility testing, the treatment was changed to voriconazole and continued for 3 months. A genetic analysis identified the isolate as Cryptococcus laurentii (C. laurentii). This patient was diagnosed with C. laurentii PD-related peritonitis and was successfully treated with voriconazole and removal of the PD catheter.

Cryptococcosis in patients living with hepatitis C and B viruses

Cryptococcosis, a systemic fungal infection, has become a significant, global public health problem. Patients with liver disease have an increased predisposition to infections, such as Cryptococcosis. To report the underlying disease, the variety of etiologic agents involved and the outcomes of the Cryptococcosis in patients living with HBV and/or HCV, we reviewed 34 medical records of patients who were diagnosed with Cryptococcosis by the Mycology Laboratory of Santa Casa Hospital, Porto Alegre, Brazil. Males corresponded to 79% of the patients, and the average patient age was 46.9 years. The cultures of 26/34 patients were positive: 25 patients were infected with Cryptococcus neoformans and one with C. gattii. A total of 14 deaths (41%) occurred. As a criterion of our study, all patients had viral hepatitis infection: 27 (80%) were infected with HCV, five (15%) were infected with HBV, and two patients were infected with both viruses. Because HBV and/or HCV are transmitted among drug users through infected blood, and the end-stage cirrhotic liver must be transplanted, these two population types were well represented in this study and were analyzed in detail. Cryptococcosis patients living with HCV and/or HBV appear to have the same symptoms, mean age and gender distribution as the general Cryptococcosis population. Once Cryptococcosis affects the brain, a high mortality rate ensues; therefore, physicians must be aware of the possible occurrence of this disease in patients living with HCV and HBV.

Cryptococcosis diagnosis and treatment: What do we know now

Cryptococcosis has evolved into a major invasive fungal disease over the last century. Its primary epidemiology has been focused on three major outbreaks of disease that reflects both changing environmental exposures and growth of host risk factors. The molecular understandings of yeast pathobiology have been bolstered by identification of the yeast's dynamic genomic structures and functions. It is during these new insights into epidemiology and pathobiology that we have also improved our diagnosis of this infection with a new point-of-care, simple, cheap test which utilizes a lateral flow assay for antigen detection. With methods for effective identification of Cryptococcus in the host, the principles for management of this deadly infection include both use of old drugs and new insights into treatment strategies to improve outcome. In this review there are a series of recent insights, opinions, and facts which attempt to summarize our present knowledge base for this deadly fungal central nervous system infection with a particular emphasis on its diagnosis and management.

Fungal prostatitis: an update

Prostate pathology is a daily occurrence in urological and general medical consultations. Besides hyperplasia and neoplastic pathology, other processes, such as infectious ones, are also documented. Their etiology is diverse and varied. Within the infectious prostatic processes, fungi can also be a specific cause of prostatitis. Fungal prostatitis often appears in patients with impaired immunity and can also be rarely found in healthy patients. It can result from a disseminated infection, but it can also be localized. Fungal prostatitis is a nonspecific and harmless process. Diagnosis is commonly made by fine needle aspiration cytology or by biopsy. A number of fungi can be involved. Although there are not many reported cases, they are becoming more frequent, in particular in patients with some degree of immunodeficiency or those who live in areas where specific fungi are endemic or in visitors of those areas. We present a comprehensive review of the various forms of fungal prostatitis, and we describe the morphological characteristics of the fungi more frequently reported as causes of fungal prostatitis. We also report our own experience, aiming to alert physicians, urologists and pathologists of these particular infections.

Cavitary pulmonary cryptococcosis with an Aspergillus fungus ball

We herein present the case of a 64-year-old immunocompetent man with a diagnosis of pulmonary cryptococcosis who presented with cavitary nodules, one of which contained a fungus ball, on chest CT. The coincidence of cavitary cryptococcosis and an Aspergillus fungus ball was histologically confirmed on a thoracoscopic lung biopsy. Encapsulated round-to-oval yeasts (Cryptococcus) were observed throughout the entire specimen, including the cavity, cavity wall and lung parenchyma. In contrast, filamentous fungi (Aspergillus) were noted within the cavity only. The probable mechanism of this rare manifestation is that the Cryptococcus formed cavities, after which an Aspergillus fungus ball developed within one cavity.

The Basidiomycetous YeastsCryptococcus diffluensandC. liquefaciensColonize the Skin of Patients with Atopic Dermatitis

Our previous research showed that lipophilic yeasts, Malassezia species, colonize the skin of patients with atopic dermatitis (AD) at a high frequency. In this study, we found that two basidiomycetous yeasts, Cryptococcus diffluens and C. liquefaciens, colonize the skin significantly more frequently in AD patients than in healthy subjects. Transparent dressings were applied to the skin of 36 AD patients and 30 healthy subjects and then transferred onto Sabouraud dextrose agar. Colonies recovered from the medium were identified by DNA sequence analysis of internal transcribed spacer regions and the D1/D2 26S rRNA gene. C. diffluens and C. liquefaciens were isolated from 42% (15/36) and 33% (12/36) of AD patients and from 20% (6/30) and 20% (6/30) of healthy subjects, respectively. In addition, fungal DNA was extracted directly from the dressings and amplified in a specific nested PCR assay. C. diffluens and C. liquefaciens DNA were detected in dressings from 97% (35/36) and 86% (31/36) of the AD patients and 47% (14/30) and 37% (11/30) of the healthy subjects, respectively. These findings show that Malassezia spp. are not the only yeasts that colonize the skin of AD patients; Cryptococcus spp. also are present in a high proportion of patients. The role of these microorganisms in AD is as yet unknown, but the current findings, in combination with previous results, indicate that C. diffluens, C. liquefaciens, M. globosa, and M. restricta together colonize the skin surface of AD patients at a high frequency.

PRESENCE OF CRYPTOCOCCUS SPECIES IN DOMESTIC CHICKEN (GALLUS GALLUS) DROPPINGS AND THE POSSIBLE RISK IT POSED TO HUMANS IN KABIGERIET VILLAGE, NAKURU COUNTY, KENYA

OBJECTIVE

To isolate and identify Cryptococcus from domestic Chicken dropping.

DESIGN

cross sectional study.

SETTING

Kabigeriet village, Olenguorone Division, Nakuru county, approximately 282 km from Nairobi, Kenya.

SUBJECTS

Sixty four domestic chicken droppings were sampled in thirty two homesteads after obtaining the farmers consent.

RESULTS

Two species of Cryptococcus were isolated.

CONCLUSION

Domestic chicken (Gallus gallus) harbor Pathogenic Cryptococcus in their dropping and their close proximity to human habitation poses a risk of AIDS to immunocompromised persons.

High prevalence of Cryptococcal antigenemia among HIV-infected patients receiving antiretroviral therapy in Ethiopia

Background

Cryptococcal disease is estimated to be responsible for significant mortality in Sub-Saharan Africa; however, only scarce epidemiology data exists. We sought to evaluate the prevalence of and risk factors for cryptococcal antigenemia in Ethiopia.

Methods

Consecutive adult HIV-infected patients from two public HIV clinics in Addis Ababa, Ethiopia were enrolled into the study. A CD4 count ≤200 cells/μl was required for study participation. Patients receiving anti-retroviral therapy (ART) were not excluded. A cryptococcal antigen test was performed for all patients along with an interview, physical exam, and medical chart abstraction. Logistic regression analysis was used to assess risk factors for cryptococcal antigenemia.

Results

369 HIV-infected patients were enrolled; mean CD4 123 cells/μl and 74% receiving ART. The overall prevalence of cryptococcal antigenemia was 8.4%; 11% in patients with a CD4 count <100 cells/μl, 8.9% with CD4 100 to 150 cells/μl and 5.7% with CD4150-200 cell/μl. 84% of patients with cryptococcal antigenemia were receiving ART. In multivariable analysis, increasing age, self reported fever, CD4 count <100 cells/μl, and site of screening were associated with an increased risk of cryptococcal antigenemia. No individual or combination of clinical symptoms had optimal sensitivity or specificity for cryptococcal antigenemia.

Conclusion

Cryptococcal antigenemia is high in Ethiopia and rapid scale up of screening programs is needed. Screening should be implemented for HIV-infected patients with low CD4 counts regardless of symptoms or receipt of ART. Further study into the effect of location and environment on cryptococcal disease is warranted.

Ecological surveys of the Cryptococcus species complex in China

BACKGROUND

Despite recent reports on the molecular epidemiology of cryptococcal infections in China, clinical isolates have been mostly reported from human immunodeficiency virus (HIV)-negative patients, and environmental isolates from China have rarely been included. The aim of this study was to investigate the ecological profile of Cryptococcus (C.) neoformans and C. gattii in China.

METHODS

A survey was performed in 10 cities from 20°N (North latitude) to 50°N and in a Eucalyptus (E.) camaldulensis forestry farm at the Guixi forestry center, China.

RESULTS

Six hundred and twenty samples of pigeon droppings from 10 cities and 819 E. camaldulensis tree samples were collected and inoculated on caffeic acid cornmeal agar (CACA). The brown-colored colonies were recultured to observe their morphology, growth on canavanine-glycine-bromothymol-blue (CGB) medium, phenol oxidase and urease activities, serotype and mating type. There were obvious differences in the positive sample rates of C. neoformans in pigeon droppings collected from the different cities, ranging from 50% in the cities located at latitudes from 30°N - 40°N, 29% at 20°N - 30°N and 13% at 40°N - 50°N.

CONCLUSIONS

There were no differences in positive bevy rates (approximately 80%) among the three grouped cities. Mycological tests of 101 isolates purified from pigeon droppings revealed that they were C. neoformans var. grubii. We also observed variable capsular size around the C. neoformans cells in colonies with variable melanin production and the bio-adhesion of the natural C. neoformans cells with other microorganisms. One urease-negative C. neoformans isolate was isolated from pigeon droppings in Jinan city. No C. gattii was isolated in this study.

Capsules from pathogenic and non-pathogenic Cryptococcus spp. manifest significant differences in structure and ability to protect against phagocytic cells

Capsule production is common among bacterial species, but relatively rare in eukaryotic microorganisms. Members of the fungal Cryptococcus genus are known to produce capsules, which are major determinants of virulence in the highly pathogenic species Cryptococcus neoformans and Cryptococcus gattii. Although the lack of virulence of many species of the Cryptococcus genus can be explained solely by the lack of mammalian thermotolerance, it is uncertain whether the capsules from these organisms are comparable to those of the pathogenic cryptococci. In this study, we compared the characteristic of the capsule from the non-pathogenic environmental yeast Cryptococcus liquefaciens with that of C. neoformans. Microscopic observations revealed that C. liquefaciens has a capsule visible in India ink preparations that was also efficiently labeled by three antibodies generated to specific C. neoformans capsular antigens. Capsular polysaccharides of C. liquefaciens were incorporated onto the cell surface of acapsular C. neoformans mutant cells. Polysaccharide composition determinations in combination with confocal microscopy revealed that C. liquefaciens capsule consisted of mannose, xylose, glucose, glucuronic acid, galactose and N-acetylglucosamine. Physical chemical analysis of the C. liquefaciens polysaccharides in comparison with C. neoformans samples revealed significant differences in viscosity, elastic properties and macromolecular structure parameters of polysaccharide solutions such as rigidity, effective diameter, zeta potential and molecular mass, which nevertheless appeared to be characteristics of linear polysaccharides that also comprise capsular polysaccharide of C. neoformans. The environmental yeast, however, showed enhanced susceptibility to the antimicrobial activity of the environmental phagocytes, suggesting that the C. liquefaciens capsular components are insufficient in protecting yeast cells against killing by amoeba. These results suggest that capsular structures in pathogenic Cryptococcus species and environmental species share similar features, but also manifest significant difference that could influence their potential to virulence.

Primary cutaneous cryptococcosis due to Cryptococcous laurentii in a renal transplant recipient

We report a patient with primary cutaneous cryptococcosis caused by Cryptococcous laurentii following renal transplantation, probably due to repeated insulin and heparin subcutaneous injections on his thigh. Although cutaneous cryptococcosis due to C. neoformans is well known, reports of skin infections due to non-neoformans cryptococci are uncommon.

Epidemiology of bloodstream infections and predictive factors of mortality among HIV-infected adult patients in Thailand in the era of highly active antiretroviral therapy

Few studies have described the pattern of bloodstream infections (BSI) among HIV-infected patients in the highly active antiretroviral therapy (HAART) era, particularly in resource-limited settings. A retrospective cohort study was conducted among 140 HIV-infected patients who had a positive blood culture from 2004-2008. Of the 140 patients, 91 (65%) were male with a mean (SD) age of 38 (9.1) years and a median (IQR) CD4 cell count of 32 (9-112) cells/mm(3). Community-acquired infection was detected in 89% of patients. The blood cultures contained Gram-negative bacteria, 40%; fungi, 24%; Mycobacterium spp., 20%; and Gram-positive bacteria, 16%. Common causative pathogens were Cryptococcus neoformans, 21%; Salmonella spp., 15%; and Mycobacterium tuberculosis, 12%. Common focal sites of infection were the central nervous system, 24%; respiratory tract, 20%; and gastrointestinal tract, 18%. CD4 cell count (OR, 0.61 per 50 cells/mm(3) increment; 95% CI, 0.39-0.96; P = 0.031) was the only factor associated with mycobacterial or fungal BSI. The crude mortality was 21%. HAART (OR, 0.23; 95% CI, 0.01-0.77; P = 0.017), focal infection (OR, 0.31; 95% CI, 0.10-0.97; P = 0.044), and complication (e.g., shock) (OR, 9.26; 95% CI, 3.25-26.42; P < 0.001) were the predictive factors of mortality. In conclusion, opportunistic infections are still the leading causes of BSI among HIV-infected patients in the HAART era.

Cryptococcal osteomyelitis of the femur: a case report and review of literature

Fungal osteomyelitis is a rare opportunistic infection. It exhibits some clinical and radiological similarities to several other bone pathologies. A diagnostic delay may result in significant increase in morbidity. We report a case of a 37-year-old man with underlying hypogammaglobulinaemia presented with isolated cryptococcal osteomyelitis of the femur.