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Romani L, Williamson PR, Di Cesare S, Di Matteo G, De Luca M, Carsetti R, Figà-Talamanca L, Cancrini C, Rossi P, Finocchi A. Cryptococcal Meningitis and Post-Infectious Inflammatory Response Syndrome in a Patient With X-Linked Hyper IgM Syndrome: A Case Report and Review of the Literature. Front Immunol 2021; 12:708837. [PMID: 34335625 PMCID: PMC8320724 DOI: 10.3389/fimmu.2021.708837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/25/2021] [Indexed: 12/27/2022] Open
Abstract
The hyper IgM syndromes are a rare group of primary immunodeficiency. The X-linked Hyper IgM syndrome (HIGM), due to a gene defect in CD40L, is the commonest variant; it is characterized by an increased susceptibility to a narrow spectrum of opportunistic infection. A few cases of HIGM patients with Cryptococcal meningoencephalitis (CM) have been described in the literature. Herein we report the case of a young male diagnosed in infancy with HIGM who developed CM complicated by a post-infectious inflammatory response syndrome (PIIRS), despite regular immunoglobulin replacement therapy and appropriate antimicrobial prophylaxis. The patient was admitted because of a headache and CM was diagnosed through detection of Cryptococcus neoformans in the cerebrospinal fluid. Despite the antifungal therapy resulting to negative CSF culture, the patient exhibited persistent headaches and developed diplopia. An analysis of inflammatory cytokines on CSF, as well as the brain MRI, suggested a diagnosis of PIIRS. Therefore, a prolonged corticosteroids therapy was started obtaining a complete resolution of symptoms without any relapse.
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Affiliation(s)
- Lorenza Romani
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Peter Richard Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institutes of Health, Bethesda, MD, United States
| | - Silvia Di Cesare
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Gigliola Di Matteo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Maia De Luca
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Rita Carsetti
- B Cell Physiopathology Unit, Immunology Research Area, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Figà-Talamanca
- Neuroradiology Unit, Imaging Department, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Caterina Cancrini
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paolo Rossi
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Finocchi
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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Hu Z, Xu C, Liu D, Meng F, Chi Y, Chen W. Pulmonary cryptococcal immune reconstitution syndrome in a person living with HIV: a case report. Int J STD AIDS 2020; 31:280-284. [PMID: 32000585 DOI: 10.1177/0956462419893545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cryptococcal immune reconstitution inflammatory syndrome (C-IRIS) in human immunodeficiency virus (HIV)-1 infection manifests as a clinical worsening or new presentation of cryptococcal disease after initiating antiretroviral therapy (ART). C-IRIS involving the respiratory system has been scarcely reported. Here, we report a case of pulmonary C-IRIS in a person living with HIV after initiating ART, characterized by an exacerbation of a pulmonary nodule and new occurrence of pleural effusions, which responded well to corticosteroid treatment.
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Affiliation(s)
- Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Chuanjun Xu
- Department of Radiology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Duxian Liu
- Department of Pathology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Fanqing Meng
- Department of Pathology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yun Chi
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wei Chen
- Clinical Research Center, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
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Cryptococcal Lymphadenitis in an HIV-Infected Patient: A Rare Manifestation of Immune Reconstitution Inflammatory Syndrome. Diseases 2018; 6:diseases6030070. [PMID: 30060547 PMCID: PMC6164892 DOI: 10.3390/diseases6030070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 11/16/2022] Open
Abstract
Cryptococcosis is a fungal infection that is typically associated with acquired immunodeficiency syndrome (AIDS). The advent of highly active antiretroviral therapy has decreased the frequency of this infection, but has led to the emergence of atypical cases of immune reconstitution inflammatory syndrome (IRIS). Here, we describe the case of a 40-year-old man who was diagnosed with HIV infection and cryptococcal meningitis. He was successfully treated with antifungals and then started antiretroviral therapy. The patient returned to the hospital 15 months later complaining of fever, pain, and neck swelling. A computed tomography (CT) scan revealed a conglomerate of necrotic lymph nodes in the supraclavicular region. He underwent biopsy and histology showed granulomatous inflammation with fungal elements, consistent with Cryptococcus. He tested positive for serum cryptococcal antigen. The patient was treated with liposomal amphotericin and flucytosine. After induction therapy, he was re-started on fluconazole. The final fungal cultures were negative. We attributed our patient's clinical presentation to "paradoxical" IRIS, which was associated with his previously treated cryptococcosis. Near resolution of the supraclavicular mass was noted at the 3-month follow-up.
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Meya DB, Manabe YC, Boulware DR, Janoff EN. The immunopathogenesis of cryptococcal immune reconstitution inflammatory syndrome: understanding a conundrum. Curr Opin Infect Dis 2016; 29:10-22. [PMID: 26658650 PMCID: PMC4689618 DOI: 10.1097/qco.0000000000000224] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Cryptococcal meningitis causes significant mortality among HIV-infected patients, despite antifungal therapy and use of antiretroviral therapy (ART). In patients with cryptococcal meningitis, ART is often complicated by immune reconstitution inflammatory syndrome (IRIS), manifesting as unmasking of previously unrecognized subclinical infection (unmasking CM-IRIS) or paradoxical worsening of symptoms in the central nervous system after prior improvement with antifungal therapy (paradoxical CM-IRIS). We review our current understanding of the pathogenesis of this phenomenon, focusing on unifying innate and adaptive immune mechanisms leading to the development of this often fatal syndrome. RECENT FINDINGS We propose that HIV-associated CD4 T-cell depletion, chemokine-driven trafficking of monocytes into cerebrospinal fluid in response to cryptococcal meningitis, and poor localized innate cytokine responses lead to inadequate cryptococcal killing and clearance of the fungus. Subsequent ART-associated recovery of T-cell signaling and restored cytokine responses, characterized by IFN-γ production, triggers an inflammatory response. The inflammatory response triggered by ART is dysregulated because of impaired homeostatic and regulatory mechanisms, culminating in the development of CM-IRIS. SUMMARY Despite our incomplete understanding of the immunopathogenesis of CM-IRIS, emerging data exploring innate and adaptive immune responses could be exploited to predict, prevent and manage CM-IRIS and associated morbid consequences.
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Affiliation(s)
- David B Meya
- Infectious Disease Institute, Makerere University, Uganda
- Dept of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, USA
- School of Medicine, College of Health Sciences, Makerere University
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - David R Boulware
- Dept of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, USA
| | - Edward N Janoff
- Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado Denver, Aurora, Colorado, USA; Denver Veterans Affairs Medical Center, Denver, CO
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Katchanov J, Branding G, Jefferys L, Arastéh K, Stocker H, Siebert E. Neuroimaging of HIV-associated cryptococcal meningitis: comparison of magnetic resonance imaging findings in patients with and without immune reconstitution. Int J STD AIDS 2015; 27:110-7. [PMID: 25693580 DOI: 10.1177/0956462415574633] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 02/01/2015] [Indexed: 11/16/2022]
Abstract
To determine the frequency, imaging characteristics, neuroanatomical distribution and dynamics of magnetic resonance imaging findings in HIV-associated cryptococcal meningitis in immunocompromised patients we compared patients without antiretroviral therapy with patients undergoing immune reconstitution. Neuroimaging and clinical data of 21 consecutive patients presenting to a German HIV centre in a 10-year period between 2005 and 2014 were reviewed. We identified eight patients with magnetic resonance imaging findings related to cryptococcal disease: five patients without antiretroviral therapy and three patients receiving effective antiretroviral therapy resulting in immune reconstitution. The pattern of magnetic resonance imaging manifestations was different in the two groups. In patients not on antiretroviral therapy, pseudocysts (n = 3) and lacunar ischaemic lesions (n = 2) were detected. Contrast-enhancing focal leptomeningeal and/or parenchymal lesions were found in all patients under immune reconstitution (n = 3). Magnetic resonance imaging lesions suggestive of leptomeningitis or meningoencephalitis were detected in all patients with a recurrence of cryptococcal meningitis under immune reconstitution, which differs from the classical magnetic resonance imaging findings in patients without antiretroviral therapy. In antiretroviral therapy-treated patients with past medical history of cryptococcal meningitis, detection of contrast-enhancing focal meningeal and/or parenchymal lesions should prompt further investigations for a recurrence of cryptococcal meningitis under immune reconstitution.
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Affiliation(s)
- Juri Katchanov
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin, Germany
| | - Gordian Branding
- Department of Radiology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Laura Jefferys
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin, Germany
| | - Keikawus Arastéh
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin, Germany
| | - Hartmut Stocker
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Campus Charité Mitte, Charité, Berlin, Germany
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