[Cryptococcosis during HIV infection]

A multi-arm, parallel, preclinical study investigating the potential benefits of acetazolamide, candesartan, and triciribine in combination with fluconazole for the treatment of cryptococcal meningoencephalitis

Cryptococcus neoformans, an opportunistic fungal pathogen, primarily infects immunodeficient patients frequently causing cryptococcal meningoencephalitis (CM). Increased intracranial pressure (ICP) is a serious complication responsible for increased morbidity and mortality in CM patients. Non-invasive pharmacological agents that mitigate ICP could be beneficial in treating CM patients. The objective of the study was to investigate the efficacy of acetazolamide (AZA), candesartan (CAN), and triciribine (TCBN), in combination with the antifungal fluconazole, on C. neoformans-induced endothelial, brain, and lung injury in an experimental mouse model of CM. Our study shows that C. neoformans increases the expression of brain endothelial cell (BEC) junction proteins Claudin-5 (Cldn5) and VE-Cadherin to induce pathological cell-barrier remodeling and gap formation associated with increased Akt and p38 MAPK activation. All three agents inhibited C. neoformans-induced endothelial gap formation, only CAN and TCBN significantly reduced C. neoformans-induced Cldn5 expression, and only TCBN was effective in inhibiting Akt and p38MAPK. Interestingly, although C. neoformans did not cause brain or lung edema in mice, it induced lung and brain injuries, which were significantly reversed by AZA, CAN, or TCBN. Our study provides novel insights into the direct effects of C. neoformans on BECs in vitro, and the potential benefits of using AZA, CAN, or TCBN in the management of CM patients.

The management and outcome of cryptococcosis in patients with different immune statuses and treatment protocols: A multicenter real-world study in Jiangsu Province - China

OBJECTIVE

The incidence of cryptococcosis is increasing in non-immunocompromised patients. However, the evidence on proper management is inadequate in this population. We conducted this multi-center real-world study in pulmonary cryptococcosis patients with different immune statuses, so as to provide practical evidence for optimized clinical management of cryptococcosis, especially for mild-to-moderate immunodeficient diseases patients.

METHODS

This is a prospective observational study. The clinical data of patients with proven cryptococcosis were collected and analyzed from 7 tertiary teaching hospitals in Jiangsu Province, China from January, 2013 to December, 2018. Proven cases include pulmonary cryptococcosis, cryptococcal meningitis, cryptococcemia and cutaneous cryptococcosis. Patients were followed up over 24 months. According to their immune status, patients with cryptococcosis were divided into three groups, namely immunocompetent group (IC), mild-to-moderate immunodeficient diseases group (MID), severe immunodeficient diseases group (SID). Meanwhile, pulmonary crypotococcosis (PC) and extrapulmonary crypotococcosis (EPC) were also classified and analyzed.

RESULTS

255 proven cases of cryptococcosis were enrolled. Finally, 220 cases completed the follow-up. 143 proven cases (65.0%) were immunocompetent (IC), 41 cases (18.6%) were MID, and 36 cases (16.4%) were SID. 174 cases (79.1%) were PC and 46 cases (20.9%) were EPC. The mortality was significantly higher in SID and MID patients [47.2% (SID) vs. 12.2% (MID) vs. 0.0% (IC), p<0.001]. The mortality was also significantly higher in EPC patients [45.7% vs. 0.6% (PC), p<0.001]. Patients with alternative initial antifungal treatment had higher mortality than patients with guideline recommended initial treatment [23.1% vs. 9.5%, p=0.041]. In MID group, the mortality of receiving alternative initial antifungal treatment was significantly higher than recommended initial treatment [2/3 vs. 3/34(8.8%), p=0.043]. In pulmonary cryptococcosis patients with MID, the mortality was very similar to IC group [0.0% vs. 0.0% (IC)], lower than SID group [0.0% vs. 11.1% (SID), p=0.555]. However, in extrapulmonary cryptococcosis patients with MID, the mortality was significantly higher than that in IC [62.5% vs. 0.0% (IC)], and similar to SID patients [62.5% vs. 59.3% (SID)].

CONCLUSION

The immune status exert a significant influence on the management and prognosis of cryptococcosis patients. The mortality of cryptococcosis patients with MID is higher than that of immunocompetent patients. For MID patients with pure pulmonary cryptococcosis, it is acceptable to take the treatment recommended as IC patients. For the MID patients with extrapulmonary cryptococcosis, the mortality is high and the initial treatment should follow the regimen for SID patients. Following the recommended treatment regimen in the IDSA guideline can reduce mortality in patients with cryptococcosis. Starting on alternative initial antifungal treatment may bring worse outcomes.

Neuromeningeal cryptoccocosis revealing IgA-λ multiple myeloma

Cryptococcosis is an opportunistic fungal infection that is commonly associated with an immune-compromised state. Cases of cryptococcosis have rarely been reported in patients with multiple myeloma (MM). However, cryptococcosis as a presenting symptom of MM has never been reported. We presented here a case of neuromeningeal cryptococcosis in a patient without underlying diseases, who has revealed IgA-λ MM. Early detection and treatment of cryptococcosis are essential to reduce morbidity.

The Emericellipsins A-E from an Alkalophilic Fungus Emericellopsis alkalina Show Potent Activity against Multidrug-Resistant Pathogenic Fungi

Novel antimicrobial peptides with antifungal and cytotoxic activity were derived from the alkalophilic fungus Emericellopsis alkalina VKPM F1428. We previously reported that this strain produced emericellipsin A (EmiA), which has strong antifungal and cytotoxic properties. Further analyses of the metabolites obtained under a special alkaline medium resulted in the isolation of four new homologous (Emi B-E). In this work, we report the complete primary structure and detailed biological activity for the newly synthesized nonribosomal antimicrobial peptides called emericellipsins B-E. The inhibitory activity of themajor compound, EmiA, against drug-resistant pathogenic fungi was similar to that of amphotericin B (AmpB). At the same time, EmiA had no hemolytic activity towards human erythrocytes. In addition, EmiA demonstrated low cytotoxic activity towards the normal HPF line, but possessed cancer selectivity to the K-562 and HCT-116 cell lines. Emericillipsins from the alkalophilic fungus Emericellopsis alkaline are promising treatment alternatives to licensed antifungal drugs for invasive mycosis therapy, especially for multidrug-resistant aspergillosis and cryptococcosis.

Clinical and microbiological characteristics of cryptococcosis at an university hospital in China from 2013 to 2017

Background

This study aims to explore the epidemiology, clinical profile and strain characteristics of cryptococcosis from 2013 to 2017 in a major teaching hospital in China.

Methods

Trends in antifungal drug susceptibility of 217 consecutive non-repetitive cryptococcal isolates collected from patients of an university hospital in China were analyzed between 2013 and 2017. Of those, 98 isolates were conserved for identification by internal transcribed spacer (ITS) sequencing and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) system. Multilocus sequence typing (MLST) was used to designate molecular types. Clinical characteristics of the 98 patients with cryptococcosis during the period of 2013–2017 were retrospectively evaluated.

Results

There was a trend for gradual increase in the MIC range of fluconazole was from 2013 to 2017. The conserved 98 clinical cryptococcal isolates included 97 C. neoformans and one C. gattii, and 90 (91.8%) isolates belonged to ST5 genotype VNI. Out of the 98 patients with cryptococcosis, 28 (28.6%) were HIV-infected and 32 (32.7%) had no underlying diseases. HIV-infected patients had higher mortality than HIV-uninfected patients (28.6% vs 14.3%, p = 0.147).

Conclusions

Most of the patients with cryptococcosis were not HIV-infected in this study, while patients with HIV had a higher mortality. Reduced susceptibility to fluconazole was observed among C. neoformans isolates, most of them belonged to ST5 genotype VNI having an impact on the effective dose of fluconazole.

The life-threatening eruption in HIV and immunosuppression

Immunosuppressed patients frequently have skin diseases of mild to moderate intensity. Diagnosis as well as treatment should be performed early to avoid important complications for these patients. Skin eruptions are among these problems. Life-threatening eruptions in HIV and other types of immunosuppression range from acute retroviral syndrome to drug eruptions; immune reconstitution inflammatory syndrome; infection by virus, protozoan, bacteria, or fungi; inflammatory and immune dermatoses; and neoplasia. All of these are discussed in this group of patients.

Cryptococcal pleuritis with pleural effusion as the only clinical presentation in a patient with hepatic cirrhosis: A case report and literature review

RATIONALE

Cryptococcosis is a significant life-threatening fungal infection in worldwide, mainly reported in immunocompromised patients. Pleural effusion presentation of cryptococcal infection as the only clinical presentation is rarely seen in pulmonary cryptococcosis, which may lead to be misdiagnosed, and the study on this subject will provide further insights.

PATIENT CONCERNS

A 64-year-old man was hospitalized in our department and diagnosed as hepatic B cirrhosis. A computed tomography (CT) of the thorax showed a massive right pleural effusion without pulmonary parenchymal abnormalities. He was started on empirical treatment for pleural tuberculosis (TB). However, during his hospitalization, a right pleural effusion developed and fever was not controlled.

DIAGNOSES

On day 14 admission, pleural fluid cultured positive for Cryptococcus neoformans. The C neoformans isolate belonged to ST5 and molecular type VNI (var. grubii).

INTERVENTIONS

The patient was diagnosed with cryptococcal pleuritis, then amphotericin B and fluconazole were administrated.

OUTCOMES

Finally, the patient was improved and discharged from our hospital.

LESSONS

Similar cases in cryptococcal pleuritis patients with pleural effusion as the only clinical presentation in the literature are also reviewed. Through literature review, we recommend that pleural effusion cryptococcal antigen test should be used to diagnose cryptococcal pleuritis to reduce misdiagnosis. The early administration of antifungal drug with activity to Cryptococcus seemed beneficial in preventing dissemination of cryptococcosis.

Invasive fungal infection by Cryptococcus neoformans var. grubii with bone marrow and meningeal involvement in a HIV-infected patient: a case report

Background

Cryptococcosis is a common opportunistic infection in patients infected by Human Immunodeficiency Virus (HIV) and is the second leading cause of mortality in Acquired Immunodeficiency Syndrome (AIDS) patients worldwide. The most frequent presentation of cryptococcal infection is subacute meningitis, especially in patients with a CD4+ T Lymphocytes count below 100 cells/μL. However, in severely immunosuppressed individuals Cryptococcus neoformans can infect virtually any human organ, including the bone marrow, which is a rare presentation of cryptococcosis.

Case presentation

A 45-year-old HIV-infected male patient with a CD4+ T lymphocyte count of 26 cells/μL who presented to the emergency department with fever and pancytopenia. Throughout the diagnostic evaluation, the bone marrow aspirate culture yielded encapsulated yeasts in budding, identified as Cryptococcus sp. The bone marrow biopsy revealed a hypocellularity for age and absence of fibrosis. It was observed presence of loosely formed granuloma composed of multinucleated giant cells encompassing rounded yeast like organisms stained with mucicarmine, compatible with Cryptococcus sp. Then, the patient underwent a lumbar puncture to investigate meningitis, although he had no neurological symptoms and neurological examination was normal. The cerebrospinal fluid culture yielded Cryptococcus sp. The species and genotype identification step showed the infection was caused by Cryptococcus neoformans var. grubii (genotype VNI). The patient was initially treated with amphotericin B deoxycholate plus fluconazole for disseminated cryptococcosis, according to guideline recommendations. However, the patient developed acute kidney injury and the treatment was switched for fluconazole monotherapy. The symptoms disappeared completely with recovery of white blood cells and platelets counts. Cerebrospinal fluid cultures for fungi at one and two-weeks of treatment were negative.

Conclusions

Bone marrow infection caused by Cryptococcus neoformans is a rare presentation of cryptococcosis. The cryptococcal infection should be included for differential diagnosis in HIV-infected patients with fever and cytopenias, especially when CD4+ T lymphocytes count is below 100 cells/μL.

Antifungal activity study of the monoterpene thymol against Cryptococcus neoformans

Cryptococcus neoformans is a yeast fungus, which causes cryptococcosis, triggered by basidiospore inhalation and consequent dissemination to the central nervous system. In this study, we analyzed the antifungal action of thymol against 10 clinical strains of C. neoformans and analyzed the interaction of this monoterpene with sterols. The MICs of thymol ranged from 20 to 51 μg/ml, while the MFC values varied between 40 and 101 μg/ml. For the strains ICB-2601 and LM-39, in the presence of ergosterol, the MIC of thymol was 64 μg/ml, and in the presence of cholesterol, its MIC was 32 μg/ml. Based on the results, thymol presents antifungal action and seems to interact with ergosterol, but not with cholesterol. Complementary studies are needed to analyze its full effects.

[Neuromeningeal cryptococcosis in patients infected with HIV at Agadir regional hospital, (Souss-Massa, Morocco)]

INTRODUCTION

Neuromeningeal cryptococcosis (NMC) is a severe and fatal opportunistic infection. Lethality is frequent in the absence of treatment, especially in the presence of HIV co-infection.

OBJECTIVE

To determine the prevalence, epidemiological, clinical, biological and therapeutic aspects as well as the evolution of NMC for patients infected with HIV.

PATIENTS AND METHODS

This is a retrospective study of 40 cases of neuromeningeal cryptococcosis diagnosed in HIV-infected patients. Data are collected for 7 years (from January 2010 to December 2016) in the registers of the parasitology laboratory and the infectious diseases department at the regional hospital center in Agadir.

RESULTS

A reduction in the prevalence of neuromeningeal cryptococcosis in HIV-infected patients was noted from 2010 to 2016 (3.66% to 0.83%). The overall prevalence of NMC was 1.53%. The mean age was 37±10 years old, with 90% of patients aged less than 45 years. The main clinical symptomatology was headache (75%). The main cytochemical abnormalities of cerebrospinal fluid analysis were hyperproteinorachy (60%), hypoglycorachy (63%) and lymphocytosis (50%). The mean CD4 cell count was 47/mm³. Patients were initially treated with amphotericin B, relayed with fluconazole. The overall lethality was 35%.

CONCLUSION

Neuromeningeal cryptococcosis is a serious opportunistic infection in patients HIV-infected, and the lethality rate remains unacceptable. Fighting NMC in HIV+ patients requires early diagnosis, increased access to antiretrovirals, rapid introduction of appropriate treatment and the prescription of effective systemic antifungals.