Ophthalmic manifestations of infections with Cryptococcus neoformans in patients with the acquired immunodeficiency syndrome

The present study was undertaken to determine the nature and the prevalence of ophthalmic manifestations of infections with Cryptococcus neoformans in human immunodeficiency virus seropositive patients and to analyze whether the presence or absence of ocular signs is associated with improved survival. Eighty human immunodeficiency virus seropositive patients with cryptococcal infection were enrolled. We observed papilledema in 26 of the 80 patients (32.5%). Visual loss and abducens nerve palsy occurred in seven patients (9%). Only two patients (2.5%) had optic atrophy. Visual loss caused by optic nerve involvement was less frequent among the 62 patients treated with oral conazoles exclusively than among the 18 patients who had received amphotericin B or a combination of amphotericin B and conazoles. Actual invasion of the intraocular structures with Cryptococcus neoformans was an uncommon complication in our series. In addition to the ocular manifestations attributable to cryptococcal disease, human immunodeficiency virus-related retinopathy was present in nearly half of the patients. Cytomegalovirus retinitis was diagnosed in four patients (5%). The 26 patients (32.5%) with papilledema had a median survival of 182 days vs 160 days for the patients without papilledema. The median survival for 18 patients (22.5%) with cotton-wool spots was 102 days vs 186 days for those without cotton-wool spots. The differences between these subgroups were not statistically significant.

Cutaneous cryptococcosis in AIDS: successful treatment with itraconazole

A case of cutaneous cryptococcosis in a HIV-positive 46-year-old farmer is presented. The situation could be cured by applying itraconazole 400 mg day-1 for 45 days.

Cryptococcal peritonitis: report of a case developing during continuous ambulatory peritoneal dialysis and review of the literature

A patient developed cryptococcal peritonitis with systemic dissemination during continuous ambulatory peritoneal dialysis (CAPD). This case prompted a search of the literature for cases of cryptococcal peritonitis; 19 previously reported cases were identified. On the basis of their clinical characteristics, these cases were divided into two groups. Group 1 included 10 cases developing during CAPD. Treatment consisted of removal of the peritoneal dialysis catheter and administration of a short course of amphotericin B. Eight of the 10 cases had a benign course, and nine patients survived. Group 2 comprised 10 cases developing in patients with severe underlying illnesses, such as chronic liver disease, AIDS, systemic lupus erythematosus, and leukemia. Disseminated cryptococcosis was documented in eight of the nine patients in this group for whom relevant information was available. Seven patients died, some despite antifungal therapy. Cryptococcal disease may have protean manifestations and an insidious course. Accordingly, the diagnosis of cryptococcal peritonitis may well be delayed. An awareness of this entity may lead to earlier diagnosis and treatment and possibly to improved outcome.

Cutaneous cryptococcosis in a patient with cutaneous T cell lymphoma receiving therapy with photopheresis and methotrexate

Photopheresis is being used with increasing frequency as therapy for patients with neoplastic and dermatologic diseases and is being evaluated as therapy for patients with AIDS. We describe a patient with advanced cutaneous T cell lymphoma who developed pulmonary and cutaneous cryptococcosis after receiving therapy with photopheresis and biweekly methotrexate. We consider the potential roles of cutaneous T cell lymphoma, methotrexate, and photopheresis as predisposing factors in the development of serious cryptococcal infections.

[Findings of bile duct ultrasonography in 100 patients with AIDS in black Africa]

A systematic study of bile ducts by abdominal echotomography on 100 African patients affected by AIDS disease has showed 11 bile ducts abnormalities (7 alithiasic cholecystitis and 6 inflammatory cholangitis, associated in 2 cases). The patients studies showed several associated infections, particularly a pulmonary tuberculosis and/or extra-pulmonary. The etiology of bile ducts attack has not been formally specified: lack of Cryptosporidium at the stools parasitologic exam, but presence of several opportunistic germs, or no, in the several samples (blood, cerebrospinal fluid, stools, expectoration).

Possibility of in-hospital infection by Cryptococcus neoformans in patients with AIDS

The objective of the present work was to carry out a survey of soil samples taken from different areas of a hospital of infectious disease located in the city of Córdoba, where three AIDS patients were hospitalized during different periods in the same ward. The three of them returned with meningeal cryptococcosis between three or five months after having been discharged. Cryptococcus neoformans was isolated in 8/10 samples collected outside the hospital, near the pigeon house. The samples collected from the AIDS patients ward and its surroundings were negative. These findings suggest that the patients may have been infected by the fungus during their first stay in hospital.

Mediator release in cerebrospinal fluid of human immunodeficiency virus-positive patients with central nervous system involvement

In this study we evaluated the release of some mediators of inflammatory reactions such as histamine (H), leukotriene B4 (LTB4), leukotriene C4 (LTC4) and prostaglandin D2 (PGD2) in the cerebrospinal fluid (CSF) of 15 patients with acquired immunodeficiency syndrome (AIDS), eight with opportunistic infections of the central nervous system (CNS) and seven without HIV-related neurological pathology, and of 25 HIV-negative control subjects with other neurological diseases. The cerebrospinal LTB4 level was increased in all the AIDS patients (mean 348 pg/ml); the control group revealed normal levels of LTB4 in the CSF (mean 63.2 pg/ml). The PGD2 level in the HIV-positive (mean 264 pg/ml) patients was higher than of the control subjects (mean 50 pg/ml), while low LTC4 levels were found both in the HIV-positive and control groups. We did not find any significant concentration of H in the CSF of either the HIV-positive or the control subjects. These findings may be due to the presence of chronic HIV infection or to the opportunistic infections of the CNS that so often occur in the latest stages of the disease.

[Cryptococcosis in a female patient with angioimmunoblastic lymphadenopathy and dysproteinemia]

A case of a 72-year-old woman affected by angioimmunoblastic lymphadenopathy with dysproteinemia is described. She was admitted to the hospital for serious cutaneous lesions and dementia. The patient had been treated with corticosteroids for the previous two years. Cryptococcosis was diagnosed by cutaneous biopsy. Antimycotic therapy together with corticosteroid withdrawal cured the cutaneous lesions and improved her psychiatric symptoms.

Cryptococcal disease presenting as cellulitis

Three immunocompromised patients presented with cellulitis as the primary manifestation of cryptococcal disease. Two were recipients of cadaveric renal transplants who were receiving immunosuppressive drug therapy. The other patient had profound lymphopenia and severe hypoalbuminemia due to intestinal lymphangiectasia. All had failed to respond to empiric therapy for presumed bacterial cellulitis before results of skin biopsy or aspiration were available for the correct diagnosis to be made. With administration of systemic antifungal therapy, two patients survived. Although other forms of cryptococcal involvement of the skin are not rare, cellulitis is seldom considered to be a cutaneous manifestation of the disease. Our cases and a review of the English-language literature indicate that Cryptococcus neoformans must be included in the differential diagnosis of cellulitis in immunocompromised patients and that the presence of cryptococcal cellulitis suggests disseminated cryptococcal disease. Prompt diagnosis and treatment may dramatically reduce mortality.

Cryptococcal pleural effusion in an HTLV-I carrier with Waldenstroem's macroglobulinemia

A 70-year-old woman with Waldenstroem's macroglobulinemia developed bilateral pleural effusions due to Cryptococcus neoformans. She was found to be a carrier of HTLV-I. It is speculated that the opportunistic infection occurred as the result of an impaired cellular immunity secondary to HTLV-I infection.

Cryptococcal peritonitis in a CAPD patient

A 50-year-old diabetic woman with end-stage renal disease, who had been on continuous ambulatory peritoneal dialysis for 8 months, developed peritonitis caused by Cryptococcus neoformans var. neoformans. The patient was completely asymptomatic and infection was confirmed by detection of budding yeast cells in Gram-stained smears of turbid peritoneal fluid. The infection was cleared after intravenous fluconazole with delayed removal of the catheter. Fluconazole may be a suitable alternative drug in treating cryptococcal peritonitis.

AIDS-related CNS cryptococcosis: radiologic-pathologic correlation

PURPOSE

This study evaluates the effectiveness of cranial CT and MR in detecting autopsy findings of AIDS-related CNS cryptococcosis.

METHODS

Final imaging studies compared with pathology were CT in eight patients (five with contrast) and MR in five patients (all with Gd-DTPA).

RESULTS

Neither modality effectively identified cryptococcal meningitis. Punctate hyperintensities were seen in all patients with MR and corresponded pathologically to both perivascular spaces dilated by cryptococcal infection and cryptococcomas. Pathologically, cryptococcomas were more common than dilated perivascular spaces. MR detected more cryptococcomas than did CT, but both modalities underestimated the number of lesions seen at autopsy. Contrast enhancement of cryptococcomas and cryptococcal meningitis was uncommon.

CONCLUSIONS

CNS cryptococcosis was more effectively demonstrated by MR than by CT, but both modalities underestimated the pathologic extent of the disease. Cryptococcal lesion contrast enhancement was unusual possibly because of the immunocompromised state of our patients and the unique characteristics of the organism itself.

Fungal disease in HIV-infected persons: cryptococcosis, histoplasmosis, and coccidioidomycosis

The AIDS epidemic has profoundly influenced the expression of deep-seated fungal disease in this country over the past 10 years. Previously an uncommon etiology of life threatening disease, deep-seated fungal infections with Cryptococcus neoformans, Histoplasma capsulatum, and Coccidioides immitis accounted for nearly 3000 AIDS index diagnoses in 1990. As the epidemic matures, symptomatic HIV infection can be expected to rise in areas of endemic fungal infection resulting in further recognition of systemic fungal disease. Although amphotericin B and 5-flucytosine remain the initial treatments of choice for AIDS-associated deep fungal infection, clinical trials evaluating the new triazoles offer hope for more effective prophylaxis and treatment in the future.

Cutaneous cryptococcosis as the first symptom of a disseminated cryptococcosis in a patient with lymphogranulomatosis X

A 63-year-old patient, known to have suffered from lymphogranulomatosis X for 4 years is reported, in whom a cutaneous cryptococcosis appeared as first sign of a disseminated cryptococcosis. Despite systemic therapy with amphotericin B, the patient died after a period of 2 months. Differential diagnosis of skin tumours of immunosuppressed patients includes rare skin mycoses, and both histological and mycological examinations should be performed.

[Neurological complication of human immunodeficiency virus infection]

Neurological complications may occur even before immunosuppression is clinically observed, and can thus reveal HIV infection. Aseptic meningitis, subacute encephalitis, vacuolar myelopathy, inflammatory myopathy, and different types of polyneuropathies seem to be associated with HIV, but their pathogenesis has only recently begun to be understood. These complications must be distinguished from opportunistic infections and from intra-cerebral tumors with which they often coexist. The Sixth International Conference on AIDS in San Francisco has defined the extent and limits of our present knowledge, and has given new directions for research in this last, but not least important chapter of modern neurology.

Cryptococcal optic neuropathy in the acquired immune deficiency syndrome

Cryptococcus neoformans infection occurs frequently in patients with the acquired immune deficiency syndrome (AIDS). Cryptococcal meningitis can result in optic neuropathy. Improvement in afferent visual system dysfunction has not been documented. We report three patients with AIDS who developed either unilateral (1) or bilateral (2) afferent visual system dysfunction. The bilaterally affected patients had visual field deficits compatible with chiasmal involvement. All patients had improvement in their vision following appropriate treatment with amphotericin B. Reactivation of cryptococcal infection was heralded by neuro-ophthalmic manifestations in two patients, in spite of maintenance therapy. Despite the poor overall prognosis, AIDS patients with presumed cryptococcal optic neuropathy can benefit from optimal therapy.

[AIDS and the central nervous system: correlations between clinical, radiological and anatomo-pathological aspects. A critical review of 40 personal cases]

The authors review the cases of 40 patients with AIDS who died in 1989, in order to establish the relationships between clinical picture, neuroradiological features and neuropathological findings. Neurological involvement was present in over 75% of the patients, with HIV-related encephalopathy and toxoplasmosis as the most frequent diseases (52.5% and 20.0%). With regard to the cases of AIDS dementia complex (ADC) the authors observed a good correlation between the severity of the clinical manifestations, central nervous system atrophy as observed on computed tomography scan and pathological findings. The survival of AIDS patients with ADC was higher when compared to patients without ADC, suggesting the time-relationship of ADC. AS in the case of toxoplasma encephalitis, a strong relationship between radiological and pathological findings was observed. The presence of toxoplasma encephalitis in patients with radiologic features of healed lesions confirms the need for life-long prophylaxis.