Disseminated Cryptococcus neoformans infection and Crohn's disease in an immunocompetent patient

Absence of measurable quantities of Candida auris and Cryptococcus spp. in the gut microbiota of Ghanaian individuals with and without HIV infection as confirmed by applying multiple real-time PCR assays

Introduction. Fungal infections are relevant health risks for individuals with acquired immunodeficiency in the resource-limited tropics, but available surveillance data are scarce. For Candida auris and Cryptococcus spp., the evolution from environmental reservoirs to human pathogens causing life-threatening diseases is currently discussed as a public health concern in the context of climate change and limited treatment options.Gap statement. Uncovering the gastrointestinal tract as an epidemiological niche of fungi emerging from the environment into individuals for whom fungal infections are not diagnosed.Aim. To contribute to data on the local epidemiology of C. auris and Cryptococcus spp. in Western African Ghana by analysing gastrointestinal samples of Ghanaian individuals.Methodology. Four real-time PCR assays targeting C. auris and five real-time PCR assays targeting Cryptococcus spp. were applied with stool samples of 875 non-age-stratified Ghanaian HIV patients and 30 Ghanaian control individuals without known HIV infection. Also, 664 samples from Ghanaian children under 2 years of age were investigated. The true abundance of the target micro-organism was considered as unlikely in the case of one or fewer positive signals, likely in the case of two to three positive signals and highly likely in the case of four or more positive signals per sample in the real-time PCR assays.Results. The combined application of sensitive, target-specific real-time PCR assays indicates that neither C. auris, Cryptococcus neoformans complex nor Cryptococcus gattii complex were part of the gut microbiota of Ghanaian individuals with or without HIV infection.Conclusion. Despite the significant disease burden from these pathogens in immunosuppressed Ghanaian individuals, detection from gastrointestinal samples was unlikely, which should be taken into account when discussing screening strategies for these fungi of public health concern. In contrast, the detection of these fungi from such samples should not routinely be considered as commensal colonization flora.

Updated immunomodulatory roles of gut flora and microRNAs in inflammatory bowel diseases

Inflammatory bowel disease is a heterogeneous intestinal inflammatory disorder, including ulcerative colitis (UC) and Crohn's disease (CD). Existing studies have shown that the pathogenesis of IBD is closely related to the host's genetic susceptibility, intestinal flora disturbance and mucosal immune abnormalities, etc. It is generally believed that there are complicated interactions between host immunity and intestinal microflora/microRNAs during the occurrence and progression of IBD. Intestinal flora is mainly composed of bacteria, fungi, viruses and helminths. These commensals are highly implicated in the maintenance of intestinal microenvironment homeostasis alone or in combination. MiRNA is an endogenous non-coding small RNA with a length of 20 to 22 nucleotides, which can perform a variety of biological functions by silencing or activating target genes through complementary pairing bonds. A large quantity of miRNAs are involved in intestinal inflammation, mucosal barrier integrity, autophagy, vesicle transportation and other small RNA alterations in IBD circumstance. In this review, the immunomodulatory roles of gut flora and microRNAs are updated in the occurrence and progression of IBD. Meanwhile, the gut flora and microRNA targeted therapeutic strategies as well as other immunomodulatory approaches including TNF-α monoclonal antibodies are also emphasized in the treatment of IBD.

Pulmonary cryptococcosis after immunomodulator treatment in patients with Crohn’s disease: Three case reports

BACKGROUND

Corticosteroids and anti-tumor necrosis factor α mAbs are widely used to treat Crohn's disease (CD). However, one disadvantage of this treatment is impairment of normal immune function, leading to an increased risk of infection. Cryptococcus infection is an opportunistic infection that occurs mainly in immunocompromised patients and poses a significant diagnostic challenge in patients with CD.

CASE SUMMARY

Here, we report three cases of pulmonary cryptococcosis in patients with CD after receiving immunomodulatory treatment. The patients presented with no or mild respiratory symptoms. Chest computed tomography scans revealed pulmonary nodules in the unilateral or bilateral lobes. Diagnoses were made using pathological examination and metagenomic sequencing. The patients were treated with fluconazole 400 mg once daily for 1 to 6 mo, and symptoms were resolved. Literature searches were conducted in PubMed, Web of Science, and Embase to retrieve previously reported cases and summarize patient characteristics.

CONCLUSION

The incidence of cryptococcus infection has increased along with immunomodulator use. Clinical vigilance is required for early identification and standardized treatment.

Fatal cryptococcal meningitis in a non-HIV patient

Cryptococcal infections (Cryptococcosis) are fatal fungal infections typically caused by Cryptococcus neoformans, a saprophyte frequently found in soil contaminated with  pigeon droppings and frequently seen in immunocompromised (specifically HIV Positive) individuals. Now a day’s awareness is emerging on cryptococcal disease among non-immunocompromised patients also. We present a case of Cryptococcus meningitis (CM) in a patient with cardiopulmonary arrest. A 55 year old male patient came with history of headache and fever with neck rigidity since last 3 months. The patient was admitted as a case of CM based on clinical findings and radiological features. Investigations were done to rule out other disorders of the immune system. He was treated with Amphotericine B (IV) and Fluconazole orally for 2 weeks. Culture of CSF was done which showed presence of Cryptococcus neoformans. It is concluded from the findings that Cryptococcus may also affect non-HIV patients regardless to their immune system.

Cryptococcal infection of the colon in a patient without concurrent human immunodeficiency infection: a case report and literature review

Cryptococcosis is a fungal infection that is rarely reported in patients without human immunodeficiency virus (HIV) infection, especially when the central nervous system (CNS) or pulmonary system is not involved. We report a case of isolated colonic cryptococcosis without disseminated disease in a 64-year-old immunocompetent woman without HIV infection who presented with chronic diarrhea and no episodes of fever or weight loss. The diagnosis was based on histopathology examination. Furthermore, we performed a literature review showing that few reports have been published so far and in the case of colonic cryptococcal infection, the prognosis is favorable among HIV-uninfected patients.

Colonic cryptococcosis as a rare presentation in HIV infection: a case report and review of the literature

Colonic cryptococcal infection is unusual in people living with HIV (PLWH) and even more so without concomitant neurological compromise. Published case reports describe diarrhea and other intestinal manifestations that are often confused with systemic tuberculosis infection. We describe an Peruvian woman living with HIV on antiretroviral therapy who presented hypotensive with a 6-month history of fever and epigastric pain, in addition to episodes of sporadic diarrhea. Due to the suspicion of systemic tuberculosis, antituberculosis treatment was started. Days later, without clinical improvement, colonoscopy revealed ulcers in the transverse colon. Histopathological examination of biopsied tissue was compatible with Cryptococcus spp. She received antifungal therapy with amphotericin B and fluconazole. Despite the treatment, the patient died six days later from multiple organ failure.

Gastrointestinal Cryptococcosis Associated with Intestinal Lymphangiectasia

Intestinal lymphangiectasia is a pathological dilation of enteric lymphatic vessels resulting in lymph leakage to the intestinal lumen. This chronic lymph leakage leads to a state of immunosuppression secondary to the loss of humoral and cellular components of the immune system and represents a potential risk factor for opportunistic infections. We report a case of protein-losing enteropathy in a seemingly immunocompetent patient. An intestinal histopathological study revealed the unusual association of lymphangiectasia and intestinal cryptococcosis. Although cryptococcal infection is common in immunocompromised patients, intestinal involvement is rarely reported. We found no reports on the association of intestinal cryptococcosis in patients with lymphangiectasia. This case report is the first to describe intestinal cryptococcosis associated with intestinal lymphangiectasia.

Disseminated cryptococcosis in Crohn's disease: a case report

BACKGROUND

Gastrointestinal (GI) cryptococcosis is rarely reported. Most cases were diagnosed during evaluation of comorbid conditions, incidental findings, or postmortem. Here, we present a case of Crohn's disease with gastrointestinal cryptococcosis that resembled exacerbation of Crohn's disease.

CASE PRESENTATION

A 64-year-old woman with Crohn's disease (CD) was referred to Siriraj Hospital due to worsening of abdominal pain and watery diarrhea for 2 weeks. The dose of immunosuppressive agents was increased for presumed exacerbation of CD. Pathologic examination of tissue obtained from polypoid mass at ileocecal valve and multiple clean-based ulcers at cecum revealed active ileitis and colitis with multiple round shape organisms with capsule, which was compatible with Cryptococcus species. Disseminated cryptococcosis was diagnosed due to gastrointestinal involvement and presumed pulmonary involvement regarding the presence of an oval-shaped cavitary lesion on chest X-ray and computed tomography of the lung. Patient was successfully treated with amphotericin B followed by fluconazole with satisfactory result.

CONCLUSION

Early diagnosis of gastrointestinal cryptococcosis in Crohn's disease is difficult due to the lack of specific symptoms and sign or mimicking an exacerbation of Crohn's disease. Seeking for other site of involvement in disseminated cryptococcosis including lung or central nervous system as well as detection of serum cryptococcal antigen would be helpful for early diagnosis and management.

Disseminated Cryptococcal Disease in Non-HIV, Nontransplant Patient

Disseminated cryptococcal infection carries a high risk of morbidity and mortality. Typical patients include HIV individuals with advanced immunosuppression or solid organ or hematopoietic transplant recipients. We report a case of disseminated cryptococcal disease in a 72-year-old male who was immunocompromised with chronic lymphocytic leukemia and ongoing chemotherapy. The patient presented with a subacute history of constitutional symptoms and headache after he received five cycles of FCR chemotherapy (fludarabine/cyclophosphamide/rituximab). Diagnosis of disseminated cryptococcal disease was made based on fungemia in peripheral blood cultures with subsequent involvement of the brain, lungs, and eyes. Treatment was started with liposomal amphotericin, flucytosine, and fluconazole as induction. He was discharged after 4 weeks of hospitalization on high dose fluconazole for consolidation for 2 months, followed by maintenance therapy.

Autoimmunity and the microbiome: T-cell receptor mimicry of "self" and microbial antigens mediates self tolerance in holobionts: The concepts of "holoimmunity" (TcR-mediated tolerance for the holobiont) and "holoautoimmunity" (loss of tolerance for the holobiont) are introduced

I propose a T-cell receptor (TcR)-based mechanism by which immunity mediates both "genetic self" and "microbial self" thereby, connecting microbiome disease with autoimmunity. The hypothesis is based on simple principles. First, TcR are selected to avoid strong cross-reactivity with "self," resulting in selection for a TcR repertoire mimicking "genetic self." Second, evolution has selected for a "microbial self" that mimics "genetic self" so as to share tolerance. In consequence, our TcR repertoire also mimics microbiome antigenicity, providing a novel mechanism for modulating tolerance to it. Also, the microbiome mimics the TcR repertoire, acting as a secondary immune system. I call this TcR-microbiome mimicry "holoimmunity" to denote immune tolerance to the "holobiont self." Logically, microbiome-host mimicry means that autoimmunity directed at host antigens will also attack components of the microbiome, and conversely, an immunological attack on the microbiome may cross-react with host antigens producing "holoautoimmunity."

The experience of a referral centre and literature overview of GIST and carcinoid tumours in inflammatory bowel diseases

Patients suffering from Inflammatory Bowel Diseases (IBD) are at increased risk of developing cancers of the gastrointestinal tract (GI). Adenocarcinomas are the most commonly observed GI tumours in IBD, and occur through an in inflammation-driven pathway. A trend toward reduced risk of bowel cancers has been observed in IBD in recent years, presumably related to improved medical treatments. However, some cancers may be independent from active inflammation, probably originating from altered interactions between the extremely active immune system of IBD patients and environmental factors. Data concerning gastrointestinal stromal tumours (GIST) and carcinoids tumours (CaT) of the GI in IBD patients are scanty. We report our experience with these rare cancers, and provide the readers with an overview on the topic, focussing on distinguishing and peculiar features of GIST and CaT of the GI in IBD compared with other cancer types and with general population, and address the treatment of such challenging conditions. Available data do not support an increased risk of GIST in IBD patients, but GI CaT may be more commonly observed in Crohn's disease. However, the presentation of GIST and GI CaT is protean and does not seem to be associated with disease activity in the involved GI segment in IBD. Conversely, some evidences suggest a potential role of inflammation in sustaining GI CaT in IBD. Increased awareness, longer duration of disease, and improved diagnostic modalities should also be considered when evaluating the increasing trend of CaT in CD patients. Treatment of GIST and CaT is not dissimilar from that of non-IBD patients, but prompt suspicion and diagnosis are crucial to achieve optimal outcomes.

Hormonal contraceptives and venous thromboembolism: Are inflammatory bowel disease patients at increased risk? A retrospective study on a prospective database

Recent studies showed an increased risk of venous thromboembolism (VTE) in patients receiving oral hormonal contraceptives. Inflammatory bowel diseases (IBD) often affect young patients and represent a pro-coagulant condition. This could result from active inflammation, but a potential role for genetic and molecular factors has been suggested. Hormonal contraceptives have also been associated with increased risk of VTE and the risk may be greater in IBD patients that already are in a pro-coagulant status, but no definitive data are available in this population. The purpose of our study was to seek for differences of the risk of VTE in IBD patients receiving hormonal contraceptives compared with controls. This is a retrospective study. We interrogated a prospectively maintained database of IBD patients observed at our outpatient clinic between 2000 and 2014. All female patients managed conservatively, with no active disease, who were taking oral hormone contraceptives in the study period, were included. Patients observed for other-than-IBD conditions at our Unit and at the Unit of Gynaecology and Obstetrics, receiving contraceptives, served as controls (ratio 1:2). Patients with cancer, those receiving hormonal therapy, and those with known genetic predisposition to VTE were excluded. We included 146 six IBD patients and 290 controls. One patient in each group developed VTE. Overall, the incidence of VTE associated with oral contraceptives was 0.5%. IBD was associated with increased risk of VTE (OR 1.9, 95% CI 0.12-32.12, p > 0.99). Active smokers since 10 years (17.2%) had higher risks of VTE (OR 8.6, 95% CI 1.16-19.25, p = 0.03). Our data show that patients with IBD in remission are not at higher risk of VTE due to oral oestrogen-containing contraceptives compared with non-IBD controls. Smokers are at increased risk, irrespective of the baseline disease.

Predictors of Venous Thromboembolism after Colorectal Surgery in a Single Unit

BACKGROUND

Patients undergoing colorectal surgery are at risk of developing venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). Knowing predictors of VTE could help preventing this life-threatening complication.

METHODS

We collected data of patients undergoing colorectal surgery at our Unit between 2009 and 2014. Baseline characteristics, type of surgery, and postoperative complications were gathered. A univariate regression analysis was performed with symptomatic VTE as outcome. Pre-, intra- and postoperative clinical factors were separately tested. All variables significantly associated with VTE occurring within three months from the discharge were entered in the final multivariate regression model.

RESULTS

A total of 476 patients were included. Symptomatic VTE occurred in 13 patients (2.7%). Six (46.1%) occurred after hospital discharge. Preoperative variables associated with VTE were: advanced age at surgery (OR 2.3, 95%CI 1.8-5.6), smoking (OR 1.7, 95%CI 1.2-2.5), inflammatory bowel diseases (OR 2.1, 95%CI 1.5-4.3), advanced pelvic malignancies (OR 2.4, 95%CI 2.0-4.2), and obesity (OR 1.5, 95%CI 1.1-2.1). Prolonged pelvic manipulation (OR 1.8, 95%CI 1.1-4.3) and steep Trendelenburg position (OR 2.4, 95%CI 1.9-5.0) were intraoperative predictors of VTE, while stockings significantly reduced the risk (OR 0.8, 95%CI 0.4-0.9). Late mobilization (OR 2.5, 95%CI 2.0-4.6) and septic complications (OR 1.4, 95%CI 1.2-3.7) were postoperative predictors of VTE, whereas anticoagulants administered for at least 3 weeks after discharge were associated with lower VTE risk (OR 0.5, 95%CI 0.2-0.8).

CONCLUSIONS

We observed several modifiable predictors of VTE. Patients with ≥2 risk factors undergoing colorectal surgery could benefit from a more intensive VTE preventive pathway.

Restorative proctocolectomy with ileal pouch-anal anastomosis is safe and effective in selected very elderly patients suffering from ulcerative colitis

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis is the mainstay treatment for intractable or refractory ulcerative colitis (UC). Safety and effectiveness of RP in elderly patients are debated. Our aim was to compare surgical outcomes and function of patients undergoing RP over 80-year-of-age with those of younger controls. We retrospectively gathered data of patients receiving RP for UC aged >80 years between January 1990 and December 2012. A control group of younger patients was established for comparison (1:3 ratio). Functional outcomes and satisfaction with surgery 6 and 12 months after ileostomy closure were collected. Ten patients >80-year-old were included (median age 87.5, range 84-90 years). All patients had at least one comorbidity (mean 2.1 ± 1) and were receiving medications for concomitant diseases. Half of them received a 3-stage procedure. Neither death nor major perioperative complications were observed. One patient (10%) required readmission for dehydration 2 weeks after RP with loop-ileostomy. Thirty younger patients (median age 34.3, range 25-52 years) served as controls. All patients had their ileostomy closed within 3 months from RP. At 6 month follow-up, elderly patients had more nocturnal seepage, antidiarrhoeals intake, and a trend toward more frequent day-time incontinence. At 12-month follow-up differences were less apparent. Only nocturnal seepage was higher in elderly. All patients retained their pouch and would have undergone surgery again. RP is feasible in selected advanced age patients, and functional results are comparable to younger patients.

Preventive NPWT over closed incisions in general surgery: does age matter?

Surgical site events (SSE), including surgical wound complications and surgical site infections, are a major concern in patients undergoing general surgery operations. These increase the costs of care, and can lead to prolonged hospital stay and need for further treatments, ultimately resulting in poor quality of life. Negative pressure wound therapy (NPWT) has been recently reported as a preventive strategy to avoid SSE, but little is known on the topic, and particularly in geriatric population. Our primary aim was to assess the efficacy of NPWT by means of a pocket device (PICO, Smith & Nephew, London, UK) in preventing SSE compared with conventional dressings in patients undergoing surgery with primary wound closure for breast and for colorectal diseases in our Unit. Our secondary aims were to assess the efficacy and safety of PICO in elderly patients, and to seek for differences between breast and abdominal results. All consecutive patients undergoing breast and colorectal surgery in our Unit between September 2012 and May 2014 were prospectively enrolled in this open label controlled study. Breast patients receiving NPWT were assigned to group B1, those receiving conventional dressings were assigned to group B2. Colorectal patients were assigned to group C1 (NPWT) and C2 (conventional dressings) in similar fashion. Each group included 25 patients, and at least 10 (40%) patients aged over 65 years to allow sub-analyses. NPWT significantly reduced SSE in both breast and colorectal patients compared with controls. No significant differences were observed according to age. Similar benefits were observed in breast and colorectal patients. Our results suggest that PICO is an effective tool to prevent SSE in patients undergoing general surgery, irrespective of age. Its use is recommended in frail, elderly patients at risk of SSE.

Fatigue in inflammatory bowel diseases: relationship with age and disease activity

A higher rate of patients suffering from inflammatory bowel diseases (IBD) are reported to experience the symptom of fatigue compared with general population. Fatigue can impair quality of life of IBD patients by limiting their daily functioning. However, this problem is poorly understood and addressed. Our aim was to investigate the impact of fatigue in IBD patients compared with controls, and to seek for relation between age and disease activity. IBD patients aged between 16 and 75 years observed at our Unit from June 2011 through June 2012 were evaluated for fatigue. Patients were asked to fill the fatigue impact scale (FIS) questionnaire. A cohort of age- and sex-matched patients observed for other-than-IBD diseases were prospectively enrolled to act as controls. Patients diagnosed with malignancies were excluded from evaluation. Each group included 16 patients, of whom half aged over 65 years. Fatigue was more severe in IBD patients than in controls (p = 0.02), irrespective of age and disease activity. IBD patients with moderate to severe disease activity showed worse fatigue compared with controls at any age (p < 0.0001). Young IBD patients with low disease activity showed a trend toward worse FIS score when compared with old IBD counterparts (p = 0.06). IBD significantly impacted on fatigue in our series. Considering IBD patients in remission, younger patients may experience worse fatigue. Further studies are needed to explore the effects of fatigue on quality of life and the potential of appropriate intervention strategies.