Cryptococcemia. An analysis of 28 cases with emphasis on the clinical outcome and its etiologic agent

Clinical protocols of 28 cases of cryptococcemia studied between April 1995 and November 2002 were reviewed. The varieties of Cryptococcus neorformans, the underlying disease, and the severity and outcome of the disease were emphasized. Most patients were immunossupressed (89.3% with AIDS) and Cryptococcus neoformans var. grubii was the main recovered variety (92.8%). Regardless of antifungal treatment, in-hospital mortality was 41% strongly associated with APACHE II score, >14 (p<0.01).

Human immunodeficiency virus infection in a patient with systemic lupus erythematosus

We describe a 47 years lady with systemic lupus erythematosus (SLE) who was infected with human immunodeficiency virus (HIV), due to transfusion either by blood or platelet concentrate. There was a near remission in the disease and during the course of follow up she developed cryptococcal meningitis. The approach to the diagnosis of HIV infection in a patient with SLE, the effect of SLE on the virus and vice versa and some management issues in this setting are discussed.

Sexual cycle of Cryptococcus neoformans var. grubii and virulence of congenic a and alpha isolates

Cryptococcus neoformans is a human-pathogenic fungus that has evolved into three distinct varieties that infect most prominently the central nervous system. A sexual cycle involving haploid cells of a and alpha mating types has been reported for two varieties (C. neoformans var. neoformans, serotype D, and C. neoformans var. gattii, serotypes B and C), yet the vast majority of infections involve a distinct variety (C. neoformans var. grubii, serotype A) that has been thought to be clonal and restricted to the alpha mating type. We recently identified the first serotype A isolate of the a mating type which had been thought to be extinct (strain 125.91). Here we report that this unusual strain can mate with a subset of pathogenic serotype A strains to produce a filamentous dikaryon with fused clamp connections, basidia, and viable recombinant basidiospores. One meiotic segregant mated poorly with the serotype A reference strain H99 but robustly with a crg1 mutant that lacks a regulator of G protein signaling and is hyperresponsive to mating pheromone. This meiotic segregant was used to create congenic a and alpha mating type serotype A strains. Virulence tests with rabbit and murine models of cryptococcal meningitis showed that the serotype A congenic a and alpha mating type strains had equivalent virulence in animal models, in contrast to previous studies linking the alpha mating type to increased virulence in congenic serotype D strains. Our studies highlight a role for sexual recombination in the evolution of a human fungal pathogen and provide a robust genetic platform to establish the molecular determinants of virulence.

Importance of a developmentally regulated pheromone receptor of Cryptococcus neoformans for virulence

Cryptococcus neoformans is the etiologic agent of cryptococcosis. Two mating types exist in this fungus, MAT alpha and MATa. The CPRa gene of C. neoformans is a MATa strain-specific gene and encodes a putative seven-transmembrane domain pheromone receptor. Unlike the other reported fungal pheromone receptors, CPRa shows functional diversity. Deletion of CPRa drastically affects mating efficiency but does not abolish mating. CPRa expression is developmentally regulated and is not affected by deletion of the transcriptional regulator STE12a. The expression of CPRa is markedly increased by shifting cultures from liquid to solid media. CPRa also plays a significant role in virulence. Delta cpra cells produce smaller capsules in the brains of mice than the wild-type cells, and the mice infected with Delta cpra survive significantly longer than those receiving the wild-type strain. Our results suggest that the MATa pheromone receptor of C. neoformans is not only required for mating but also important for survival and growth of the fungus in host tissue.

The efficacy of fluconazole 600 mg/day versus itraconazole 600 mg/day as consolidation therapy of cryptococcal meningitis in AIDS patients

Cryptococcal meningitis is one of the major complications affecting the central nervous system of patients suffering from AIDS. The results of treatment, when following current recommendation are still unsatisfactory.

OBJECTIVE

This study aimed to evaluate the efficacy of a higher than recommended dose of oral fluconazole and itraconazole as consolidation therapy for cryptococcal meningitis in AIDS patients.

DESIGN AND METHOD

HIV infected patients with primary cryptococcal meningitis, who had been treated initially with amphotericin B for 2 weeks were included in this study. They were randomized into two groups, to receive either fluconazole 600 mg daily or itraconazole 600 mg daily for 10 weeks. The response towards the two different treatments was clinically defined to be successful, if after 10 weeks of treatment no clinical symptoms and signs of meningitis remained and the cerebrospinal fluid (CSF) fungal culture was negative.

RESULTS

The trial was performed from April 1999 to April 2000 at Srinagarind Hospital, Khon Kaen, Thailand. At the beginning of the trial 44 cases were selected, but only 35 patients proved to be suitable for the final evaluation of the study. Out of those, 19 cases were assigned to the fluconazole and 16 cases to the itraconazole group. Ten weeks after treatment, all patients clinically recovered completely. The CSF sterilization rate for the fluconazole group and for the itraconazole group were 100 and 94 per cent respectively. The Fisher's exact test showed no significant difference in the CSF sterilization rate between both groups (p = 0.26).

CONCLUSION

The result of this study indicates that treatment with either 600 mg per day of fluconazole or itraconazole as consolidation treatment have the same efficacy for AIDS patients suffering from cryptococcal meningitis. The results of this study also suggest, comparing the result of this trial with the results of similar trials published somewhere else, that treatment with the higher doses may be superior to treatment regimens using lower doses, as can be judged from the clinical outcome and the results of the mycological cultures.

A cryptic cause of cryptococcal meningitis

Cryptococcus neoformans commonly causes opportunistic infection in immunocompromised patients, especially in patients with AIDS. The CD4+ T-lymphocyte count is measured in patients with HIV infection, because it signals an increased risk of opportunistic infection and a decline in immunological function. We report a case of cryptococcal meningitis in a patient with persistently low CD4+ cell counts without evidence of HIV infection. The patient's underlying immunocompromised state was attributed to idiopathic CD4+ T-lymphocytopenia (ICL), a recently described syndrome characterized by depletions in the CD4+ T-cell subsets without evidence of HIV infection. Immunodeficiency can exist in the absence of laboratory evidence of HIV infection, highlighting the importance of evaluating T-cell subsets in patients who present with unusual infections.

Cryptococcal meningitis: an analysis among 5,521 consecutive organ transplant recipients

Cryptococcal meningitis has been reported to be an important cause of morbidity and mortality in renal transplant recipients. However, additional studies of recipients of other organ transplants suggested that these patients might be at low risk for cryptococcal meningitis. We examined the incidence and clinical features of cryptococcal meningitis among different groups of organ transplant patients at the University of Pittsburgh Medical Center. From January 1989 through July 1999, 28 patients were diagnosed with cryptococcal meningitis among 5,521 transplant recipients. These included liver (11/2,539), heart (8/372), kidney (7/2,122), lung (1/432), and small bowel (1/56) recipients. The incidence of cryptococcal meningitis was higher in heart and small bowel recipients compared to other transplant populations (P = 0.005). The cryptococcal meningitis-related mortality in transplant recipients was 50% and was associated with altered mental status (P = 0.001), absence of headache (P = 0.02), and liver failure (P = 0.002). Multivariable analysis indicated that liver failure was the only independent risk factor for poor prognosis (P = 0.043). All cases of liver failure occurred among liver transplant recipients. Cryptococcal meningitis is associated with significant mortality among organ transplant recipients. The presence of allograft failure in liver transplant recipients with cryptococcal meningitis may be an indicator of poor prognosis in this patient population.

Iron overload exacerbates experimental meningoencephalitis by Cryptococcus neoformans

This study was aimed at investigating the effects of iron overload on the onset and outcome of cerebral cryptococcosis. To this purpose, iron dextran-administered mice were intracerebrally challenged with virulent melanogenic and avirulent non-melanogenic strains of Cryptococcus neoformans. The results shown here provide the first evidence that iron overload exacerbates the outcome of cryptococcal meningoencephalitis, irrespective of the fungal strain employed; pathogen colonization of the brain is facilitated, local cytokine response is delayed and/or prevented.

Relationship of the glyoxylate pathway to the pathogenesis of Cryptococcus neoformans

Functional genomics has become a major focus in the study of microbial pathogenesis. This study used a functional genomic tool, differential display reverse transcription-PCR, to identify a transcriptional profile of Cryptococcus neoformans cells as they produced meningitis in an immunosuppressed host. This serial global gene expression during infection allowed for the identification of up- and down-regulated genes during infection. During this profiling, a single gene for the enzyme isocitrate lyase (ICL1) was found to be up regulated at 1 week of infection in a rabbit meningitis model and during a time of maximum host cellular response. The finding suggested that this enzyme and the glyoxylate shunt pathway are important to this yeast's energy production during infection. However, site-directed icl1 mutants had no apparent virulence defect in two animal models and no growth defect within macrophages. These observations suggest that although the yeast responded to a certain environmental cue(s) by an increase in ICL1 expression during infection, this gene was not necessary for progression of a C. neoformans infection. Compounds that specifically target only ICL1 are unlikely to cripple C. neoformans growth in vivo.

Molecular genetic analyses of mating pheromones reveal intervariety mating or hybridization in Cryptococcus neoformans

The sexual mating of the pathogenic yeast Cryptococcus neoformans is important for pathogenesis studies because the fungal virulence is linked to the alpha mating type (MAT(alpha)). We characterized C. neoformans mating pheromones (MF(alpha) 1 and MFa1) from 122 strains to understand intervariety hybridization or mating and intervariety virulence. MF(alpha) 1 in three C. neoformans varieties showed (a) specific nucleotide polymorphisms, (b) different copy numbers and chromosomal localizations, and (c) unique deduced amino acids in two geographic populations of C. neoformans var. gattii. MF(alpha) 1 of different varieties cross-hybridized in Southern hybridizations. Their phylogenetic analyses showed purifying selection (neutral evolution). These observations suggested that MAT(alpha) strains from any of the three C. neoformans varieties could mate or hybridize in nature with MATa strains of C. neoformans var. neoformans. A few serotype A/D diploid strains provided evidence for mating or hybridization, while a majority of A/D strains tested positive for haploid MF(alpha) 1 identical to that of C. neoformans var. grubii. MF(alpha) 1 sequence and copy numbers in diploids were identical to those of C. neoformans var. grubii, while their MFa1 sequences were identical to those of C. neoformans var. neoformans; thus, these strains were hybrids. The mice survival curves and histological lesions revealed A/D diploids to be highly pathogenic, with pathogenicity levels similar to that of the C. neoformans var. grubii type strain and unlike the low pathogenicity levels of C. neoformans var. neoformans strains. In contrast to MF(alpha) 1 in three varieties, MFa1 amplicons and hybridization signals could be obtained only from two C. neoformans var. neoformans reference strains and eight A/D diploids. This suggested that a yet undiscovered MFa pheromone(s) in C. neoformans var. gattii and C. neoformans var. grubii is unrelated to, highly divergent from, or rarer than that in C. neoformans var. neoformans. These observations could form the basis for future studies on the role of intervariety mating in C. neoformans biology and virulence.

Cryptococcal lymphadenitis and meningitis in human immunodeficiency virus infection--a case report

Cryptococcal meningitis (CM) is the commonest life threatening opportunistic fungal disease in Human Immunodeficiency Virus (HIV) infected individuals. But there are very little reports of lymphadenopathy along with cryptococcal meningitis, although cases of pulmonary, Intestinal, Bone marrow and retinal involvement have been described earlier. Here we report a case of cryptococcal meningitis associated with generalized lymphadenopathy and hepatosplenomegaly.

Cryptococcal infection in a cohort of HIV-1-infected Ugandan adults

OBJECTIVE

Despite the recognition of Cryptococcus neoformans as a major cause of meningitis in HIV-infected adults in sub-Saharan Africa, little is known about the relative importance of this potentially preventable infection as a cause of mortality and suffering in HIV-infected adults in this region.

DESIGN

A cohort study of 1372 HIV-1-infected adults, enrolled and followed up between October 1995 and January 1999 at two community clinics in Entebbe, Uganda.

METHODS

Systematic and standardized assessment of illness episodes to describe cryptococcal disease and death rates.

RESULTS

Cryptococcal disease was diagnosed in 77 individuals (rate 40.4/1000 person-years) and was associated with 17% of all deaths (77 out of 444) in the cohort. Risk of infection was strongly associated with CD4 T cell counts < 200 x 10(6) cells/l(75 patients) and World Health Organization (WHO) clinical stage 3 and 4 (68 patients). Meningism was present infrequently on presentation (18%). Clinical findings had limited discriminatory diagnostic value. Serum cryptococcal antigen testing was the most sensitive and robust diagnostic test. Cryptococcal antigenaemia preceded symptoms by a median of 22 days (> 100 days in 11% of patients). Survival following diagnosis was poor (median survival 26 days; range 0-138).

CONCLUSIONS

Cryptococcal infection is an important contributor to mortality and suffering in HIV-infected Ugandans. Improvements in access to effective therapy of established disease are necessary. In addition, prevention strategies, in particular chemoprophylaxis, should be evaluated while awaiting the outcome of initiatives to make antiretroviral therapy more widely available.

[An elderly case of ANCA-positive membranous nephropathy]

We report a rare case of nephrotic syndrome in an elderly woman with positive antineutrophil cytoplasmic antibody(ANCA). The patient was 81 years of age and had a history of interstitial pneumonia. She was diagnosed rheumatoid arthritis(RA) at admission. Rapidly progressing renal damage was found with mild microscopic hematuria and positive ANCA. The renal biopsy findings indicated membranous nephropathy. Neither gold nor anti-rheumatic drugs had been previously administered. She may have had an RA-specific membranous nephropathy. Crescentic formation was not clear. With hematuria, the leukocyte infiltration in the capillary lumen and the change in epithelial cells of Bowman's capsules would be histological findings suggesting ANCA-associated nephritis. This is a rare report on membranous nephropathy in an RA patient with ANCA-associated nephritis.

Sinusitis complicated by meningitis: current management

OBJECTIVES

Meningitis is the most common intracranial complication of sinusitis. We review the incidence, current management, outcomes, and complications of this serious infection. Our study also examines the evolving roles of endoscopic sinus surgery and other new therapeutic and diagnostic modalities in our armamentarium.

STUDY DESIGN

A retrospective chart review was performed at a tertiary academic medical center of all patients diagnosed with sinusitis with complications between January 1985 and December 1999.

METHODS

The patients were divided into two main groups: intracranial versus orbital complications. Meningitis was the most common intracranial complication. Data on patients with sinusitis and meningitis were collected and analyzed.

RESULTS

Intracranial complications were present in 39 of 82 patients whereas orbital complications were noted in 43 patients. Twenty-one of the 39 intracranial complications were meningitis. The most common computed tomography finding in adults (54%) was sphenoid sinusitis. All patients with AIDS (6 of 21) had unique cryptococcus meningitis. In patients without AIDS, the most common organism was Streptococcus pneumoniae (10 of 21). The most common sequela was seizure disorder (4 of 21). Endoscopic sinus surgery was performed on 7 of 21 patients. One patient with AIDS who had sinusitis and meningitis died.

CONCLUSIONS

Meningitis as a complication of sinusitis may still pose a serious threat. Although outcomes are encouraging, sequelae such as seizure disorders and hearing loss are common complications. The introduction of high-resolution computed tomography scans and magnetic resonance imaging and the availability of wide-spectrum antibiotics have improved our management significantly.

[A case of SLE presenting the features of antiphospholipid antibody syndrome during a treatment for complicated cryptococcal meningitis]

A 39-year-old woman had developed systemic lupus erythematosus(SLE) at the age of 29. She had a long history of immunosuppressant therapies such as corticosteroid. On admission, she presented a headache due to the cryptococcal meningitis which was confirmed by lumbar puncture. Combined medications of amphotericin B and fluconazole were not effective, and combined amphotericin B and flucytosine were replaced. Prednisolone and methotrexate had been tapered gradually. Fifty days after the initial treatment for meningitis Cryptococcal neoformans was not observed in the cerebrospinal fluid. Sixty days after the treatment, thrombocytopenia was observed with positive lupus anticoagulant and anticardiolipin antibody. Following which, thrombophlebitis occurred in the left brachium. We suggest that the provoked pathoimmunological reaction such as antiphospholipid antibody syndrome during the treatment for meningitis needs to be cared during the course of SLE.

Ventriculitis due to Cryptococcus uniguttulatus

Infections due to non-neoformans cryptococci are rare. We report the first case of a human infection caused by Cryptococcus uniguttulatus. Ventriculitis caused by this organism developed in a 65-year-old woman who had had repair of an internal carotid aneurysm. In vitro sensitivity testing showed the Cryptococcus species sensitive to amphotericin B and itraconazole. Treatment with amphotericin led to resolution of the infection.

Cryptococcosis in the immunocompromised host with special reference to AIDS

Cryptococcosis is increasing because of an ever rising population of immunocompromised individuals especially those with acquired immune deficiency syndrome (AIDS). Cryptococcal infection of the central nervous system (CNS) were diagnosed in 149 cases over a period of 19.5 years (January 1978-June 1998). Culture was positive in all cases except three who were already on antifungal therapy. India ink mounts of cerebrospinal fluid (CSF) revealed encapsulated cryptococci in 134, and cryptococcal antigen was detected in 111 of 114 patients tested. A comparison of laboratory and certain clinical parameters in patients with and without associated HIV infection showed that a poor CSF cell response and culture of cryptococci from extra-neural sites was more often associated with HIV infection and was statistically significant. Further, presence of concomitant infection especially tuberculosis, and mortality were higher in the HIV positive group.

[Neurological complications of renal transplant]

Advances in surgical procedures and new immunosuppressor therapies have improved the outcome of renal grafts. However, these changes have been accompanied by infectious, neoplastic and neurologic complications. The purpose of this study was to determine the incidence of neurologic complications among 542 patients receiving a renal transplant (from living or cadaveric donors) at CEMIC between 1970 and 1996. Neurologic complications occurred in 43 patients (8%) as follows: 8 meningitis (1.5%), 8 acute confusional syndrome (1.5%), 7 encephalitis (1.3%), 7 cerebrovascular accidents (1.3%), 6 convulsions (1.1%), 3 tumors (0.5%), 3 femoral nerve lesion (0.5%), and 1 epidural lipomatosis (0.1%). Etiologic agents most commonly observed in meningitis were: Cryptococcus neoformans, Listeria monocytogenes and Mycobacterium tuberculosis. Major difficulties arose in the diagnosis of encephalitis. Diagnosis of the above complications required clinical astuteness and repeated bacteriologic, serologic and imaging studies.

Cryptococcal meningitis in non-HIV-infected patients

There are few reports on cryptococcal meningitis in non-HIV-infected patients in subtropical areas. We reviewed 94 non-HIV-infected patients microbiologically diagnosed with cryptococcal meningitis and hospitalized at National Taiwan University Hospital, 1977-1996. Forty-two patients (44.7%) had underlying diseases. The main initial manifestations were headache (86.2%), vomiting (72.3%) and fever (69. 1%). The 30 patients with T-cell suppression had more acute illnesses (median duration of symptoms: 14 days vs. 29 days), less typical presentations of meningitis, and reduced inflammatory responses compared with the 64 without T cell suppression. There was no statistical difference between patients who received amphotericin B treatment for 10 weeks and those received amphotericin B with subsequent fluconazole treatment, in terms of mortality rate and recurrence rate. Seventy-five patients (79.8%) had satisfactory clinical responses, and two relapsed. Eighteen patients died (19.1%) and 10 of these died within 2 weeks of hospitalization. Patients in this series had outcomes comparable with those from temperate and even tropical countries with high percentages of immunocompetent hosts. Factors significantly associated with death were lymphoma, semicoma, leukocytosis, and initial high titres of cryptococcal antigen in cerebral spinal fluid (especially >/=1 : 512). On multivariate analysis, lymphoma and initial high cryptococcal antigen titres were independent predictors of mortality.

[CNS cryptococcosis with idiopathic CD4+ T lymphocytopenia]

A 33-year-old Japanese man, with a history of recurrent skin cryptococcosis, was admitted complaining of fever and severe headache for 3 weeks. He had no known risk factors for human immunodeficiency virus (HIV) infection. Cerebrospinal fluid examination revealed an elevated opening pressure of 32 cm H2O, cell counts of 884/mm3, a total protein value of 184 mg/dl, a glucose level of 16 mg/dl, and demonstrated a positive India ink stain for fungus. Cultures grew Cryptococcus neoformans. Hematological studies showed a persistently low CD4+ cell count (30/mm3) and a low CD4/CD8 ratio of 0.1. He has been repeatedly seronegative (ELISA and Western blot) for HIV-1 and HIV-2. He responded to fluconazole, and was given itraconazole as secondary prophylaxis because of persistent low CD4 counts. To our knowledge this is the first patient with idiopathic CD4+ T lymphocytopenia associated with CNS cryptococcosis in Japan. CD4 counts should be part of the initial work up for patients with CNS cryptococcosis.

[Cryptococcal meningitis associated with chronic lymphocytic leukemia: a case report. Review of the literature]

INTRODUCTION

The authors report the occurrence of a cryptococcal meningitis in a patient treated by corticosteroids and polychemotherapy for a chronic lymphocytic leukemia.

EXEGESIS

A 63-year-old man with chronic lymphocytic leukemia was sent to hospital because of impaired condition with fever. Neurological disorders appeared. Cryptococcal meningitis was diagnosed. Under treatment, the outcome was favorable.

CONCLUSION

This paper highlights the feature of this infection most likely underestimated in HIV-seronegative patients and the need to a priori consider this diagnosis.

[Late cryptococcal meningitis after liver transplantation]

We report a case of cryptococcal meningitis, eight years after liver transplantation for primary biliary cirrhosis. Detection of the cryptococcal antigen in serum and cerebrospinal fluid appears to be essential for initial diagnosis and follow-up. Oral fluconazole treatment alone can be effective, when given for a very long period to prevent relapse.

[Cryptococcal meningitis following cryptococcal pneumonia in an immunocompetent]

Cryptococcal meningitis (CM) is common in the immunocompromised (especially due to AIDS), but also occurs in immunocompetent subjects. CM can complicate cryptococcal pneumonia (CP) not only in the immunocompromised but also in the immunocompetent. We describe a healthy 26-year-old man who developed a prolonged lung infection. Diagnosis of cryptococcal pneumonia was established from bronchoscopic washings. He recovered spontaneously, so no antifungal treatment was given. 4 months later he was admitted with cryptococcal meningitis and was treated successfully with amphotericin B. An extensive immunologic study revealed no abnormalities. Since CM can complicate cryptococcal pneumonia, it is recommended that patients with CP be followed, even if recovery is apparently complete.

Risk factors for cryptococcal meningitis in HIV-infected patients

To identify the risk factors for cryptococcal meningitis in patients with HIV disease we conducted a nested case-control study of 37 incident cases of cryptococcal meningitis and 74 controls, identified from a cohort of more than 2000 HIV-infected patients. Conditional logistic regression was used to study demographic and AIDS-related variables in addition to fluconazole and steroid use. No difference in demographic variables, HIV risk factors, or stage of AIDS was detected between cases and controls. Exposure to fluconazole for more than 90 days reduced the risk of cryptococcal meningitis by 82% (OR=0.18; 95% CI=0.04-0.85; p=0.03). We did not find a difference in steroid use between cases and controls for either the length or amount of steroid exposure (p=0.41). No difference in survival during follow-up in the clinic was observed by the log-rank test (p=0.74). Among the cases, a cryptococcal antigen was positive in more than 97% of the CSF or blood samples. CSF and blood cultures were positive in 81 and 44% of the samples, respectively. We conclude that demographic factors did not affect the risk of cryptococcal meningitis in an inner city United States population. While fluconazole use has a protective effect, steroid use was not associated with an increased risk of cryptococcal meningitis in HIV-infected patients.

[Chronic Cryptococcal meningitis with CSF oligoclonal IgG band in a patient with Claude syndrome]

We described a 61-year-old man who was diagnosed as having chronic cryptococcal meningitis, while he was hospitalized with Claude syndrome. The patient was admitted because of acute onset of gait disturbance. He had a tendency to fall down to his left side since he awoke in the morning of August 12, 1995. On admission, he was mentally alert, showing a right oculomotor nerve palsy, gaze-evoked horizontal nystagmus in the left eye on the left lateral gaze, and incoordination of the left upper and lower extremities. In addition, he fell to the left side on standing up with feet together and with eyes closed. He had mild wild-based gait with a tendency to fall down to the left on tandem gait. Babinski sign was present on the left side. He did not have fever, nor meningeal signs, nor sensory abnormalities. X-ray films of the chest showed multiple nodular shadows consistent with pneumoconiosis. Cranial X-ray computed tomography and magnetic resonance imaging revealed a small lesion in the paramedian area of the midbrain on the right, consistent with an infarct. Cerebral arteriography revealed a stenosis in the proximal portion of the right posterior cerebral artery. Cerebrospinal fluid (CSF) showed a moderate mononuclear cell predominant pleocytosis, a moderate elevation of total protein, slightly reduced glucose values. Although the culture and India ink preparation of CSF were negative for cryptococcus in repeated studies, its antigen was positive both in the serum and CSF. In addition, the CSF showed an oligoclonal IgG band which was predominantly K type. After the antigen of Cryptococcus neoformans was added to the CSF in vitro, the oligoclonal IgG band was absorbed completely. The patient was treated with fluconazole (FLCZ), which did not cause any improvement of the CSF abnormalities, so that FLCZ was replaced by 5-flucytosine (5-FC). Since the CSF abnormalities moderately improved with 5-FC, he was discharged on December 21, 1995. After the 5-FC was discontinued, the CSF results slowly worsened over several months without any signs and symptoms of meningitis. He was hospitalized again on October 28, 1996 for treatment with both 5-FC and amphotericin B. Although the CSF abnormalities improved markedly, the meningitis was not cured. After he was discharged on February 1, 1997, he was treated with both 5-FC and FLCZ. Although his CSF abnormalities worsened mildly, he remained afebrile without meningeal signs and symptoms and led an ordinary life. In our patient it remained undetermined whether the Claude syndrome was caused by arteriosclerotic infarction, or vasculitis due to cryptococcal meningitis, or both. Asymptomatic chronic cryptococcal meningitis as observed in our patients is unusual. In addition, this is the second case after Porter et al (1977) that the oligoclonal IgG band in CSF proved to be related to cryptococcal infection.

Cryptococcal meningitis and intracranial tuberculoma in a patient with Waldenstrom's macroglobulinemia treated with fludarabine

We report a patient with Waldenstrom's Macroglobulinemia who presented with cryptococcal meningitis followed by an intracranial tuberculoma during the 18 months period after termination of cytotoxic therapy with Fludarabine. Opportunistic infections due to intracellular organisms are extremely rare in the course of this malignancy and we review the predisposing factors of these infectious entities.

Cryptococcal meningitis following a thrombotic microangiopathy in an unrelated donor bone marrow transplant recipient

In patients undergoing bone marrow transplantation cryptococcosis is rarely encountered. We report a fatal case of Cryptococcus meningitis in a 12-year-old girl with acute lymphoblastic leukemia (ALL) in second remission who had a transplant from a human leukocyte antigen (HLA)-identical unrelated bone marrow donor. The conditioning regimen was thiotepa, cyclophosphamide, and total body irradiation (TBI); graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A, methotrexate, and antilymphocyte globulin (ALG). The patient experienced stage III GVHD responsive to high-dose corticosteroids. On day +54 a thrombotic microangiopathy occurred. On day +64 neurological status worsened; a brain computed tomographic (CT) scan showed hyperdense lesions suggesting fungal infection. Detection of cryptococcal antigen by latex agglutination was positive but India ink stain and culture were negative. Despite treatment with amphotericin B, 5-flucytosine, and granulocyte-macrophage colony-stimulating factor, the patient died 13 days after the diagnosis.

Infection caused by Cryptococcus neoformans var. gattii serotype B in an AIDS patient in India

Cryptococcus neoformans is an opportunistic pathogen infecting AIDS patients. However, infection caused by C. neoformans var. gattii in AIDS patients is reportedly rare. We report herein the first culture proven C. neoformans var. gattii serotype B infection in an AIDS patient in India.

[Neuromeningeal cryptococcosis and alcoholic cirrhosis]

Cryptococcal infections are usually described in immunosuppressed patients, but have also been described in patients with cirrhosis. We report a case of cryptococcal meningitis in a 62 year old man with Child class C alcoholic cirrhosis. Clinical signs associated mental confusion and discrete meningeal stiffness without fever. Diagnosis was confirmed by lumbar puncture which identified specific antigens and isolated Cryptococcus on Sabouraud medium. In patients with cirrhosis, cryptococcal meningitis infection should be considered in cases of isolated and unexplained mental confusion.

Cryptococcal meningitis after liver transplantation

We present our experience with 10 liver transplant recipients in whom cryptococcal meningitis developed after liver transplantation. Disease developed a median period of 3.5 months (range, 2-36 months) after transplantation and patients were diagnosed a median period of 9 days (range, 2-90 days) after initial symptoms. Headache, fever, and mental status changes were the most frequent clinical presentations, while meningismus was found in only 30% of patients. Cerebrospinal fluid analysis was diagnostic in all cases. All patients were treated with amphotericin B and flucytosine. Immunosuppression was either decreased or discontinued during therapy. Five patients died, four as a direct result of cryptococcal infection and one as a result of chronic rejection. Three patients had long-term survival without any sequelae. One long-term survivor suffered blindness consequent to the disease. We conclude that cryptococcal meningitis is a rare complication in liver transplant recipients (0.25%), and has a high mortality rate (50%). Early recognition, combination antifungal therapy, and decrease or discontinuation of immunosuppression are important for cure. No relapse has been seen in surviving patients.

Cryptococcal meningitis in a child with hyperimmunoglobulin E syndrome

A 13-year-old boy with hyperimmunoglobulin E (hyper-IgE) syndrome presented with headache, blurred vision, photophobia and bilateral papilledema due to cryptococcal meningitis. Treatment with amphotericin B, and S-fluorocytosine for several weeks and repeated lumbar punctures did not reduce the intracranial pressure, and a myeloperitoneal shunt was performed. The child was maintained on fluconazole for an additional six months. Patients with hyper-IgE syndrome are at increased risk of opportunistic fungal infections such as cryptococcal meningitis.

[A case report: cryptococcal meningitis and fluconazole therapy]

An 18-year-old female was given prednisolone and azathioprine for treatment of systemic lups erythematosus. She was admitted to Fukuoka University Hospital because of headache and vomiting. Examinations revealed she was suffering from cryptococcal meningitis. Fluconazole (FLCZ) 400 mg a day was administrated for therapy. Her general condition improved and the serum level of cryptococcal antigen decreased one month after therapy. This therapy resulted in abatement of subjected symptoms and sterilization of the cerebral spinal fluid. This case suggested that therapy with FLCZ alone is useful for patients with cryptococcal meningitis, therefore the standard therapy with amphotericin B (AMPH) or the combination.

Olfactory pathways in three patients with cryptococcal meningitis and acquired immune deficiency syndrome

The olfactory mucosa, bulbs and tracts were examined for the presence of Cryptococcus neoformans in 3 patients with the acquired immune deficiency syndrome (AIDS) and cryptococcal meningitis. Two of them had antibodies against HIV-1 and one had positive serology for HIV-2. Cryptococci were seen in the subarachnoid space around olfactory tracts and bulbs and in the submucosal olfactory nerve fascicles. In one case, olfactory nerve fascicles from the lamina propria were also affected. Olfactory epithelium and respiratory mucosa were not involved. We suggest that Cryptococcus reached the olfactory nerve fascicles through the olfactory pathways for cerebrospinal fluid drainage which might serve as a source of latent cryptococcal infection.

A T cell-independent protective host response against Cryptococcus neoformans expressed at the primary site of infection in the lung

T cell-independent host resistance expressed against a primary lung infection with Cryptococcus neoformans was investigated. Following intratracheal inoculation of the yeast, BALB/cBy scid/scid mice or CD4+ plus CD8+ T cell-depleted BALB/cBy mice developed a primary lung infection that remained stable for several weeks before progressing and disseminating to kill the host. By contrast, normal BALB/cBy hosts resolved the infection after 4 to 8 weeks. Thy+ CD4- CD8- cells were found to accumulate in the pulmonary alveoli of infected scid/scid or normal mice. Depletion of these cells caused the infection to progress more rapidly and resulted 4 weeks later in a 30- to 70-fold increase in yeast numbers in the lungs and dissemination to extrapulmonary sites. Cytofluorometric studies revealed that the Thy+ CD4- CD8- cells responsible were negative for the CD3 T cell marker. A small percentage of these Thy+ CD3- cells expressed asialo-Gm1, but treatment with asialo-Gm1 antibody did not have the same infection-enhancing effect as Thy-1 monoclonal antibody treatment. Further experiments revealed that Thy-1 monoclonal antibody treatment had no effect on the establishment of infectious foci in the brain or liver following intravenous inoculation of the yeast. The data point to the existence of an early resistance mechanism for which Thy+ CD3- CD4- CD8- cells are essential. This mechanism of host defense, while insufficient for complete protection, may be capable of delaying the development of cryptococcal meningoencephalitis by restricting the growth of the yeast at primary sites of infection in the lungs, even in immunodeficient mice.

[Clinical and pharmacokinetic observations on fluconazole in the management of cryptococcal meningitis]

The above study was intended to evaluate certain pharmacokinetic properties as well as the pharmacological activity of fluconazole in patients with cryptococcal meningitis. The results obtained show satisfactory bioavailability of the drug in the cerebrospinal fluid and marked reduction of the number of fungi found in the liquor.

[A case of cryptococcal meningitis in an HTLV-1 carrier]

We report a case of 73-year-old male HTLV-I carrier with cryptococcal meningitis. The patient, who was born in Taiwan, has raised golden pheasants for ten years and bantams for five years. Antibody to HIV was negative. Flow cytometric study of the peripheral lymphocytes showed reduced CD4+CD45RA+ (naive cells) and increased CD4+CD45RO+ (memory cells), CD3+CD25+ and CD3+ HLA-DR(DR)+ cells. Lymphocyte responses to phytohemagglutinin and concanavalin A were depressed. Cerebrospinal fluid (CSF) cells and serum and CSF antigen to cryptococcal neoformans were decreased by therapy with fluconazole and flucytosine. Although the naive, memory and CD3+DR+ cell abnormalities showed no change, the CD45RA/CD45RO ratio and CD3+CD25+ level tended to improve. Opportunistic infections such as cryptococcal meningitis may be induced by severe decreases in naive cells and increases in memory cells in HTLV-I carriers.