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Kwon S, Choi Y, Kim ES, Lee KT, Bahn YS, Jung KW. Pleiotropic roles of LAMMER kinase, Lkh1 in stress responses and virulence of Cryptococcus neoformans. Front Cell Infect Microbiol 2024; 14:1369301. [PMID: 38774630 PMCID: PMC11106425 DOI: 10.3389/fcimb.2024.1369301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/27/2024] [Indexed: 05/24/2024] Open
Abstract
Dual-specificity LAMMER kinases are highly evolutionarily conserved in eukaryotes and play pivotal roles in diverse physiological processes, such as growth, differentiation, and stress responses. Although the functions of LAMMER kinase in fungal pathogens in pathogenicity and stress responses have been characterized, its role in Cryptococcus neoformans, a human fungal pathogen and a model yeast of basidiomycetes, remains elusive. In this study, we identified a LKH1 homologous gene and constructed a strain with a deleted LKH1 and a complemented strain. Similar to other fungi, the lkh1Δ mutant showed intrinsic growth defects. We observed that C. neoformans Lkh1 was involved in diverse stress responses, including oxidative stress and cell wall stress. Particularly, Lkh1 regulates DNA damage responses in Rad53-dependent and -independent manners. Furthermore, the absence of LKH1 reduced basidiospore formation. Our observations indicate that Lkh1 becomes hyperphosphorylated upon treatment with rapamycin, a TOR protein inhibitor. Notably, LKH1 deletion led to defects in melanin synthesis and capsule formation. Furthermore, we found that the deletion of LKH1 led to the avirulence of C. neoformans in a systemic cryptococcosis murine model. Taken together, Lkh1 is required for the stress response, sexual differentiation, and virulence of C. neoformans.
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Affiliation(s)
- Sunhak Kwon
- Advanced Radiation Technology Institute, Korea Atomic Energy Research Institute, Jeongeup, Jeonbuk, Republic of Korea
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul, Republic of Korea
| | - Yeseul Choi
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul, Republic of Korea
| | - Eui-Seong Kim
- Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Jeonbuk, Republic of Korea
| | - Kyung-Tae Lee
- Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Jeonbuk, Republic of Korea
| | - Yong-Sun Bahn
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul, Republic of Korea
| | - Kwang-Woo Jung
- Advanced Radiation Technology Institute, Korea Atomic Energy Research Institute, Jeongeup, Jeonbuk, Republic of Korea
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2
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De la Cerda-Vargas MF, Candelas-Rangel JA, Navarro-Dominguez P, Sandoval-Bonilla BA, Meza-Mata E, Muñoz-Hernandez MA, Segura-Lopez FK, Ramirez-Silva LH, Gonzalez-Martinez MDR, Delgado-Aguirre HA. Neurococcidiomycosis in children with hydrocephalus: assessment of functional outcome, quality of life and survival in relation to neuroimaging findings. Childs Nerv Syst 2024; 40:303-319. [PMID: 37819508 DOI: 10.1007/s00381-023-06166-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/24/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE Coccidioidal meningitis (CM) is an uncommon disease frequently misdiagnosed. Neuroimaging and mortality are not considered in detail in previous pediatric CM series. Our objective is to evaluate outcome of pediatric neurococcidiomycosis in relation to neuroimaging findings. METHODS We performed a prospective, observational, cross-sectional study in children with hydrocephalus and CM treated at Specialties Hospital in Torreon, Mexico (between 2015 and 2020). The outcome was evaluated by Hydrocephalus Outcome Questionnaire (HOQ) and the modified Rankin Scale (mRS). Follow-up was established at the first shunt surgery and survival since CM diagnosis confirmation. Neuroimaging was analyzed in relation to clinical data, outcome and survival. Kaplan-Meier analysis was performed with IBM-SPSS-25. RESULTS Ten pediatric cases with CM and hydrocephalus were reported. Aged 6-228 months, 60% were female. Mean number of surgeries was 4.3 SD ± 3 (range 1-15). Asymmetric hydrocephalus was the most common neuroimaging finding (70%), followed by cerebral vasculitis (20%) and isolated fourth ventricle (IFV) (20%). The mean HOQ overall score was 0.338 SD ± 0.35. A minimum follow-up of 18 months was reported. Mean survival was 13.9 SD ± 6.15 months (range 3-24). Poor survival was correlated with asymmetric hydrocephalus (p = 0.335), cerebral vasculitis (p = 0.176), IFV (p < 0.001), bacterial superinfection (p = 0.017), lower mRS scores at hospital discharge (p = 0.017) and during follow-up (p = 0.004). The mortality rate was 20%. CONCLUSIONS We report the largest series in Latin America of pediatric CM and hydrocephalus. Asymmetric hydrocephalus, IFV and cerebral vasculitis are complications that increase mortality and must be early diagnosed for a timely surgical and medical treatment. HOQ and mRS could be alternative scales to evaluate outcome in these patients. After a long follow-up (18 months), survival remained poor after diagnosis confirmation in our series.
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Affiliation(s)
- Maria F De la Cerda-Vargas
- Department of Neurosurgery and Neurotechnologie, Universitätsklinik Tübingen, Tübingen, Germany.
- Department of Neurosurgery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico.
| | - Jose A Candelas-Rangel
- Department of Neurosurgery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
- Department of Neurosrugery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
| | - Pedro Navarro-Dominguez
- Department of Neurosurgery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
| | - Bayron A Sandoval-Bonilla
- Associated Professor, Department of Neurosurgery, Specialties Hospital, Centro Médico Nacional (CMN) Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Elizabeth Meza-Mata
- Head of Anatomical Pathology Department, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
| | - Melisa A Muñoz-Hernandez
- Department of Health and Research, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreón, Coahuila, Mexico
| | - F K Segura-Lopez
- Department of Health and Research, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreón, Coahuila, Mexico
| | - Luis H Ramirez-Silva
- Department of Neurosurgery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
| | | | - Hector A Delgado-Aguirre
- Department of Transplants, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
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3
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Lanser DM, Bennett AB, Vu K, Gelli A. Macropinocytosis as a potential mechanism driving neurotropism of Cryptococcus neoformans. Front Cell Infect Microbiol 2023; 13:1331429. [PMID: 38149006 PMCID: PMC10750359 DOI: 10.3389/fcimb.2023.1331429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/27/2023] [Indexed: 12/28/2023] Open
Abstract
Cryptococcus neoformans can invade the central nervous system by crossing the blood-brain barrier via a transcellular mechanism that relies on multiple host factors. In this narrative, we review the evidence that a direct interplay between C. neoformans and brain endothelial cells forms the basis for invasion and transmigration across the brain endothelium. Adherence and internalization of C. neoformans is dependent on transmembrane proteins, including a hyaluronic acid receptor and an ephrin receptor tyrosine kinase. We consider the role of EphA2 in facilitating the invasion of the central nervous system by C. neoformans and highlight experimental evidence supporting macropinocytosis as a potential mechanism of internalization and transcytosis. How macropinocytosis might be conclusively demonstrated in the context of C. neoformans is also discussed.
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Affiliation(s)
| | | | | | - Angie Gelli
- Department of Pharmacology, School of Medicine, University of California, Davis, Davis, CA, United States
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4
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Ahmed MAEGES, Abbas HS, Kotakonda M. Fungal Diseases Caused by Serious Contamination of Pharmaceuticals and Medical Devices, and Rapid Fungal Detection Using Nano-Diagnostic Tools: A Critical Review. Curr Microbiol 2023; 81:10. [PMID: 37978091 PMCID: PMC10656328 DOI: 10.1007/s00284-023-03506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/27/2023] [Indexed: 11/19/2023]
Abstract
Fungal-contaminated compounded pharmaceuticals and medical devices pose a public health problem. This review aimed to provide an organized overview of the literature on that critical issue. Firstly, it was found that compounding pharmacies can produce drugs that are contaminated with fungi, leading to outbreaks of severe fungal diseases. Secondly, inadequate sterile compounding techniques or storage conditions, or exceeding the limit of a fungal count, can result in fungal contamination. Lastly, nanotools can be used to rapidly detect fungi, thus improving fungal diagnostic procedures. To achieve this goal, we have reviewed the published data on PubMed, the CDC, and FDA Web sites, and a literature search was undertaken to identify severe fungal infections associated with compounding pharmacies outside of hospitals, limited by the dates 2003 to 2021. The "Preferred Reporting Items for Critical Reviews" were followed in searching, including, and excluding papers. Fungal outbreaks have been documented due to contaminated pharmaceuticals and medical devices. In 2013, 55 people died from fungal meningitis caused by contaminated steroid injections containing methylprednisolone acetate. Additionally, in 2021, Aspergillus penicillioides contamination was reported in ChloraPrep drugs, which was attributed to the storage conditions that were conducive to the growth of this fungus. These incidents have resulted in severe infectious diseases, such as invasive mycoses, cornea infections, Endophthalmitis, and intestinal and gastric mycosis. By implementing preventive measures and policies, it is possible to avoid these outbreaks. Creating Nano-diagnostics presents a major challenge, where promptly diagnosing fungal infections is required to determine the proper corrective and preventive measures.
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Affiliation(s)
- Mohamed Abd El-Gawad El-Sayed Ahmed
- Department of Microbiology and Immunology, Faculty of Pharmaceutical Science and Drug Manufacturing, Misr University for Science and Technology, Cairo, 6th of October City, Egypt
| | - Heba S Abbas
- Department of Microbiology and Immunology, Faculty of Pharmaceutical Science and Drug Manufacturing, Misr University for Science and Technology, Cairo, 6th of October City, Egypt.
- Microbiology Department, Egyptian Drug Authority, Previously National Organization for Drug Control and Research, Giza, Egypt.
| | - Muddukrishnaiah Kotakonda
- Department of Pharmaceutics, Jamia Salafiya Pharmacy College, Pulikkal, Malappuram District, Kerala, India
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Shen J, Lackey E, Shah S. Neurosarcoidosis: Diagnostic Challenges and Mimics A Review. Curr Allergy Asthma Rep 2023; 23:399-410. [PMID: 37256482 PMCID: PMC10230477 DOI: 10.1007/s11882-023-01092-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE OF REVIEW Neurosarcoidosis is a rare manifestation of sarcoidosis that is challenging to diagnose. Biopsy confirmation of granulomas is not sufficient, as other granulomatous diseases can present similarly. This review is intended to guide the clinician in identifying key conditions to exclude prior to concluding a diagnosis of neurosarcoidosis. RECENT FINDINGS Although new biomarkers are being studied, there are no reliable tests for neurosarcoidosis. Advances in serum testing and imaging have improved the diagnosis for key mimics of neurosarcoidosis in certain clinical scenarios, but biopsy remains an important method of differentiation. Key mimics of neurosarcoidosis in all cases include infections (tuberculosis, fungal), autoimmune disease (vasculitis, IgG4-related disease), and lymphoma. As neurosarcoidosis can affect any part of the nervous system, patients should have a unique differential diagnosis tailored to their clinical presentation. Although biopsy can assist with excluding mimics, diagnosis is ultimately clinical.
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Affiliation(s)
- Jeffrey Shen
- Duke Department of Medicine, Division of Rheumatology and Immunology, Duke University, 40 Duke Medicine Cir Clinic 1J, Durham, NC, 27710, USA.
| | - Elijah Lackey
- Duke Department of Neurology, Duke University, 40 Duke Medicine Cir Clinic 1L, Durham, NC, 27701, USA
| | - Suma Shah
- Duke Department of Neurology, Duke University, 40 Duke Medicine Cir Clinic 1L, Durham, NC, 27701, USA
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Conn BN, Wozniak KL. Innate Pulmonary Phagocytes and Their Interactions with Pathogenic Cryptococcus Species. J Fungi (Basel) 2023; 9:617. [PMID: 37367553 PMCID: PMC10299524 DOI: 10.3390/jof9060617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Cryptococcus neoformans is an opportunistic fungal pathogen that causes over 180,000 annual deaths in HIV/AIDS patients. Innate phagocytes in the lungs, such as dendritic cells (DCs) and macrophages, are the first cells to interact with the pathogen. Neutrophils, another innate phagocyte, are recruited to the lungs during cryptococcal infection. These innate cells are involved in early detection of C. neoformans, as well as the removal and clearance of cryptococcal infections. However, C. neoformans has developed ways to interfere with these processes, allowing for the evasion of the host's innate immune system. Additionally, the innate immune cells have the ability to aid in cryptococcal pathogenesis. This review discusses recent literature on the interactions of innate pulmonary phagocytes with C. neoformans.
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Affiliation(s)
| | - Karen L. Wozniak
- Department of Microbiology and Molecular Genetics, Oklahoma State University, 307 Life Science East, Stillwater, OK 74078, USA;
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7
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Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Clinical Studies to Animal Experiments. Microorganisms 2022; 10:microorganisms10122419. [PMID: 36557672 PMCID: PMC9780901 DOI: 10.3390/microorganisms10122419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Cryptococcus neoformans is an encapsulated pathogenic fungus that initially infects the lung but can migrate to the central nervous system (CNS), resulting in meningoencephalitis. The organism causes the CNS infection primarily in immunocompromised individuals including HIV/AIDS patients, but also, rarely, in immunocompetent individuals. In HIV/AIDS patients, limited inflammation in the CNS, due to impaired cellular immunity, cannot efficiently clear a C. neoformans infection. Antiretroviral therapy (ART) can rapidly restore cellular immunity in HIV/AIDS patients. Paradoxically, ART induces an exaggerated inflammatory response, termed immune reconstitution inflammatory syndrome (IRIS), in some HIV/AIDS patients co-infected with C. neoformans. A similar excessive inflammation, referred to as post-infectious inflammatory response syndrome (PIIRS), is also frequently seen in previously healthy individuals suffering from cryptococcal meningoencephalitis. Cryptococcal IRIS and PIIRS are life-threatening complications that kill up to one-third of affected people. In this review, we summarize the inflammatory responses in the CNS during HIV-associated cryptococcal meningoencephalitis. We overview the current understanding of cryptococcal IRIS developed in HIV/AIDS patients and cryptococcal PIIRS occurring in HIV-uninfected individuals. We also describe currently available animal models that closely mimic aspects of cryptococcal IRIS observed in HIV/AIDS patients.
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8
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Cryptococcus neoformans Infection in the Central Nervous System: The Battle between Host and Pathogen. J Fungi (Basel) 2022; 8:jof8101069. [PMID: 36294634 PMCID: PMC9605252 DOI: 10.3390/jof8101069] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/28/2022] [Accepted: 10/07/2022] [Indexed: 11/17/2022] Open
Abstract
Cryptococcus neoformans (C. neoformans) is a pathogenic fungus with a global distribution. Humans become infected by inhaling the fungus from the environment, and the fungus initially colonizes the lungs. If the immune system fails to contain C. neoformans in the lungs, the fungus can disseminate to the blood and invade the central nervous system, resulting in fatal meningoencephalitis particularly in immunocompromised individuals including HIV/AIDS patients. Following brain invasion, C. neoformans will encounter host defenses involving resident as well as recruited immune cells in the brain. To overcome host defenses, C. neoformans possesses multiple virulence factors capable of modulating immune responses. The outcome of the interactions between the host and C. neoformans will determine the disease progression. In this review, we describe the current understanding of how C. neoformans migrates to the brain across the blood–brain barrier, and how the host immune system responds to the invading organism in the brain. We will also discuss the virulence factors that C. neoformans uses to modulate host immune responses.
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9
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Fatal cryptococcal meningitis in a non-HIV patient. Int J Health Sci (Qassim) 2022. [DOI: 10.53730/ijhs.v6ns1.6010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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10
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Shinjyo N, Kagaya W, Pekna M. Interaction Between the Complement System and Infectious Agents - A Potential Mechanistic Link to Neurodegeneration and Dementia. Front Cell Neurosci 2021; 15:710390. [PMID: 34408631 PMCID: PMC8365172 DOI: 10.3389/fncel.2021.710390] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/09/2021] [Indexed: 12/24/2022] Open
Abstract
As part of the innate immune system, complement plays a critical role in the elimination of pathogens and mobilization of cellular immune responses. In the central nervous system (CNS), many complement proteins are locally produced and regulate nervous system development and physiological processes such as neural plasticity. However, aberrant complement activation has been implicated in neurodegeneration, including Alzheimer’s disease. There is a growing list of pathogens that have been shown to interact with the complement system in the brain but the short- and long-term consequences of infection-induced complement activation for neuronal functioning are largely elusive. Available evidence suggests that the infection-induced complement activation could be protective or harmful, depending on the context. Here we summarize how various infectious agents, including bacteria (e.g., Streptococcus spp.), viruses (e.g., HIV and measles virus), fungi (e.g., Candida spp.), parasites (e.g., Toxoplasma gondii and Plasmodium spp.), and prion proteins activate and manipulate the complement system in the CNS. We also discuss the potential mechanisms by which the interaction between the infectious agents and the complement system can play a role in neurodegeneration and dementia.
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Affiliation(s)
- Noriko Shinjyo
- Laboratory of Immune Homeostasis, WPI Immunology Frontier Research Center, Osaka University, Osaka, Japan.,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Wataru Kagaya
- Department of Parasitology and Research Center for Infectious Disease Sciences, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Marcela Pekna
- Laboratory of Regenerative Neuroimmunology, Center for Brain Repair, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
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11
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Bourbeau K, Gupta S, Wang S. Candida albicans meningitis in AIDS patient: A case report and literature review. IDCases 2021; 25:e01216. [PMID: 34285874 PMCID: PMC8273402 DOI: 10.1016/j.idcr.2021.e01216] [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: 05/06/2021] [Revised: 07/02/2021] [Accepted: 07/02/2021] [Indexed: 11/23/2022] Open
Abstract
Candida albicans is found to be part of the normal flora in human skin, oral, and respiratory tract, and is known to be an opportunistic infection in immunocompromised populations; rarely is it a cause of meningitis. This case of a patient with Acquired Immune Deficiency Syndrome (AIDS) and Candida albicans meningitis illustrates the subtle symptoms and insidious onset of fungal meningitis. This case and review of literature identify the importance of early identification and therapy.
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Affiliation(s)
- K Bourbeau
- Arrowhead Regional Medical Center, Colton, United States
| | - S Gupta
- Arrowhead Regional Medical Center, Colton, United States
| | - S Wang
- Arrowhead Regional Medical Center, Colton, United States
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12
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Onken AM, VanderLaan PA, Rosenbaum MW. Critical values in cytology. J Am Soc Cytopathol 2021; 10:341-348. [PMID: 34034996 DOI: 10.1016/j.jasc.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/30/2022]
Abstract
The timely reporting of critical values, or values that may be life-threatening if immediate action is not taken, is essential to patient care and safety. Although some guidelines exist for critical diagnoses in cytology, not all laboratories have a specific list of diagnoses that should be considered critical, and the very existence of cytology "critical values" has been called into question. Here we propose a pragmatic system for determining cytology critical values and report our laboratory's critical value list, formulated based on a review of the medical literature regarding clinical urgency and other institutions' cytology critical value lists.
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Affiliation(s)
- Allison M Onken
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthew W Rosenbaum
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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Chen Y, Li C, Sun D, Strickland AB, Liu G, Shi M. Quantitative analysis reveals internalisation of Cryptococcus neoformans by brain endothelial cells in vivo. Cell Microbiol 2021; 23:e13330. [PMID: 33745221 DOI: 10.1111/cmi.13330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 12/12/2022]
Abstract
Migration of Cryptococcus neoformans from the blood to the brain parenchyma is crucial to cause fatal meningoencephalitis. Although mechanisms involved in brain migration of C. neoformans have been widely studied in vitro, less is known about how the fungus crosses the blood-brain barrier (BBB) in vivo. This is in part because of the lack of an approach to quantitatively analyse the dynamics of fungal transmigration into the brain across the BBB in vivo. In this study, we report a novel approach to quantitatively analyse the interactions between C. neoformans and brain endothelial cells in a mouse model using flow cytometry. Using this system, we show that C. neoformans was internalised by brain endothelial cells in vivo and that mice infected with acapsular or heat-killed C. neoformans yeast cells displayed a lower frequency of brain endothelial cells containing the yeast cell compared to mice infected with wild-type or viable yeast cells, respectively. We further demonstrate that brain endothelial cells were invaded by serotype A strain (H99 strain) at a higher rate compared to serotype D strain (52D strain). Our experiments established that internalisation of C. neoformans by brain endothelial cells occurred in vivo and offered a powerful approach to quantitatively analyse fungal migration into the brain.
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Affiliation(s)
- Yanli Chen
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, USA
| | - Chang Li
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, USA
| | - Donglei Sun
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, USA
| | - Ashley B Strickland
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, USA
| | - Gongguan Liu
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, USA
| | - Meiqing Shi
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, USA
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14
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Nathan CL, Emmert BE, Nelson E, Berger JR. CNS fungal infections: A review. J Neurol Sci 2021; 422:117325. [PMID: 33516057 DOI: 10.1016/j.jns.2021.117325] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/23/2020] [Accepted: 01/19/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Cody L Nathan
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian E Emmert
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ernest Nelson
- Departments of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Berger
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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15
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Tahir M, Peseski AM, Jordan SJ. Case Report: Candida dubliniensis as a Cause of Chronic Meningitis. Front Neurol 2020; 11:601242. [PMID: 33363510 PMCID: PMC7752766 DOI: 10.3389/fneur.2020.601242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Candida dubliniensis is closely related to Candida albicans and rarely isolated in clinical specimens. C. dubliniensis is increasingly recognized as a pathogen in immunocompromised hosts. We present the third known case of Candida dubliniensis meningitis in a young immunocompetent host. Case Presentation: A 27-year-old female with a history of intravenous heroin use and chronic hepatitis C presented with a 10-month history of headaches and progressive bilateral vision loss. On physical examination, visual acuity was 20/20 in her right eye and grade II papilledema was noted. Examination of her left eye revealed complete loss of vision and grade IV papilledema. An MRI with and without contrast revealed increased leptomeningeal enhancement involving the posterior fossa and spinal cord. After multiple lumbar punctures, cerebrospinal fluid fungal cultures grew Candida dubliniensis. The patient was successfully treated with a combination of liposomal amphotericin and fluconazole for 6 weeks with complete resolution of her CNS symptoms, with the exception of irreversible vision loss. Conclusion: We report a case of chronic meningitis due to Candida dubliniensis in an immunocompetent woman with hepatitis C and a history of intravenous heroin use. Additional studies are needed to confirm risk factors for Candida dubliniensis colonization, which likely predisposes individuals to invasive candidiasis.
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Affiliation(s)
- Madiha Tahir
- The University of Vermont Health Network-Champlain Valley Physicians Hospital, Plattsburgh, NY, United States
| | - Andrew M Peseski
- Division of Internal Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Stephen J Jordan
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
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16
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A Case Report. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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Efficacy of Cerebrospinal Fluid Beta-d-Glucan Diagnostic Testing for Fungal Meningitis: a Systematic Review. J Clin Microbiol 2020; 58:JCM.02094-19. [PMID: 31996446 DOI: 10.1128/jcm.02094-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/25/2020] [Indexed: 12/15/2022] Open
Abstract
Several case reports and cohort studies have examined the use of (1,3)-beta-d-glucan measurement with cerebrospinal fluid to diagnose fungal meningitis. This systematic review aims to characterize the evidence regarding cerebrospinal fluid (1,3)-beta-d-glucan measurement to detect fungal meningitis. We searched PubMed for (1,3)-beta-d-glucan and each of several distinct fungi, cerebrospinal fluid, and meningitis. Summary data including diagnostic performance (where applicable) were recorded. A total of 939 records were examined via a PubMed search. One hundred eighteen records remained after duplicates were removed, and 104 records were excluded, as they did not examine cerebrospinal fluid, included animals, or focused on nonfungal infections. Fourteen studies were included in this systematic review. A variety of fungi, including species of Candida, Aspergillus, Exserohilum, Cryptococcus, Histoplasma, and Coccidioides, were studied, although most were case reports. Diagnostic accuracy was examined in 5 studies. Cerebrospinal fluid (CSF) (1,3)-beta-d-glucan measurement showed >95% sensitivity in the corticosteroid injection-related outbreak of Exserohilum rostratum One study in Histoplasma meningitis found 53% (53/87) sensitivity and 87% (133/153) specificity, while another study of Cryptococcus meningitis found 89% (69/78) sensitivity and 85% (33/39) specificity. CSF (1,3)-beta-d-glucan testing may be useful, primarily as a nonspecific marker of fungal meningitis. Although the FDA black box warning states that Cryptococcus spp. do not make (1,3)-beta-d-glucan, the current evidence shows that (1,3)-beta-d-glucan is detectable in cryptococcal meningitis. Organism-specific testing should be used in conjunction with (1,3)-beta-d-glucan measurement.
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18
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Sun D, Zhang M, Sun P, Liu G, Strickland AB, Chen Y, Fu Y, Yosri M, Shi M. VCAM1/VLA4 interaction mediates Ly6Clow monocyte recruitment to the brain in a TNFR signaling dependent manner during fungal infection. PLoS Pathog 2020; 16:e1008361. [PMID: 32101593 PMCID: PMC7062284 DOI: 10.1371/journal.ppat.1008361] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 03/09/2020] [Accepted: 01/28/2020] [Indexed: 12/17/2022] Open
Abstract
Monocytes exist in two major populations, termed Ly6Chi and Ly6Clow monocytes. Compared to Ly6Chi monocytes, less is known about Ly6Clow monocyte recruitment and mechanisms involved in the recruitment of this subset. Furthermore, the role of Ly6Clow monocytes during infections is largely unknown. Here, using intravital microscopy, we demonstrate that Ly6Clow monocytes are predominantly recruited to the brain vasculature following intravenous infection with Cryptococcus neoformans, a fungal pathogen causing meningoencephalitis. The recruitment depends primarily on the interaction of VCAM1 expressed on the brain endothelium with VLA4 expressed on Ly6Clow monocytes. Furthermore, TNFR signaling is essential for the recruitment through enhancing VLA4 expression on Ly6Clow monocytes. Interestingly, the recruited Ly6Clow monocytes internalized C. neoformans and carried the organism while crawling on and adhering to the luminal wall of brain vasculature and migrating to the brain parenchyma. Our study reveals a substantial recruitment of Ly6Clow monocytes to the brain and highlights important properties of this subset during infection. Monocytes are white blood cells, circulating in the bloodstream and playing important roles during infections. There are two subsets of monocytes in mice: Ly6Chi and Ly6Clow monocytes. In contrast to the recruitment of Ly6Chi monocytes shown in other infection models, we observed the predominant recruitment of Ly6Clow monocytes to the brain post-capillary venules during intravenous infection with C. neoformans, a fungal pathogen causing brain infection. The recruitment is mainly mediated by the interaction of VCAM1 and VLA4, which are expressed on the brain endothelium and monocytes, respectively. We further demonstrate that TNFR signaling plays an essential role during Ly6Clow monocyte recruitment through enhancing VLA4 expression on monocytes. We also observed that Ly6Clow monocytes internalize C. neoformans and, together with the ingested organism, crawl along the luminal wall of brain vasculatures and migrate to the brain parenchyma. Thus, VCAM1/VLA4 interaction mediates Ly6Clow monocyte recruitment to the brain in a TNFR signaling dependent manner during fungal infection.
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Affiliation(s)
- Donglei Sun
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
| | - Mingshun Zhang
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
| | - Peng Sun
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
| | - Gongguan Liu
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
| | - Ashley B. Strickland
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
| | - Yanli Chen
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
| | - Yong Fu
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
| | - Mohammed Yosri
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
- The Regional Center for Mycology and Biotechnology, Al-Azhar University, Cairo, Egypt
| | - Meiqing Shi
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, Maryland, United States of America
- * E-mail:
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19
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Fungal dissemination is limited by liver macrophage filtration of the blood. Nat Commun 2019; 10:4566. [PMID: 31594939 PMCID: PMC6783440 DOI: 10.1038/s41467-019-12381-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 08/16/2019] [Indexed: 12/14/2022] Open
Abstract
Fungal dissemination into the bloodstream is a critical step leading to invasive fungal infections. Here, using intravital imaging, we show that Kupffer cells (KCs) in the liver have a prominent function in the capture of circulating Cryptococcus neoformans and Candida albicans, thereby reducing fungal dissemination to target organs. Complement C3 but not C5, and complement receptor CRIg but not CR3, are involved in capture of C. neoformans. Internalization of C. neoformans by KCs is subsequently mediated by multiple receptors, including CR3, CRIg, and scavenger receptors, which work synergistically along with C5aR signaling. Following phagocytosis, the growth of C. neoformans is inhibited by KCs in an IFN-γ independent manner. Thus, the liver filters disseminating fungi from circulation via KCs, providing a mechanistic explanation for the enhanced risk of cryptococcosis among individuals with liver diseases, and suggesting a therapeutic strategy to prevent fungal dissemination through enhancing KC functions. Patients with liver diseases are at increased risk of fungal infections. Here the authors show that Kupffer cells are critical for the filtration of fungi out of the blood and thereby for liver-mediated protection against disseminating fungal infection.
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20
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Smilnak GJ, Charalambous LT, Cutshaw D, Premji AM, Giamberardino CD, Ballard CG, Bartuska AP, Ejikeme TU, Sheng H, Verbick LZ, Hedstrom BA, Pagadala PC, McCabe AR, Perfect JR, Lad SP. Novel Treatment of Cryptococcal Meningitis via Neurapheresis Therapy. J Infect Dis 2019; 218:1147-1154. [PMID: 29788431 DOI: 10.1093/infdis/jiy286] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/11/2018] [Indexed: 11/14/2022] Open
Abstract
Cryptococcal meningitis (CM) has emerged as the most common life-threatening fungal meningitis worldwide. Current management involves a sequential, longitudinal regimen of antifungals; despite a significant improvement in survival compared with uniform mortality without treatment, this drug paradigm has not led to a consistent cure. Neurapheresis therapy, extracorporeal filtration of yeasts from cerebrospinal fluid (CSF) in infected hosts, is presented here as a novel, one-time therapy for CM. In vitro filtration of CSF through this platform yielded a 5-log reduction in concentration of the yeast and a 1-log reduction in its polysaccharide antigen over 24 hours. Additionally, an analogous closed-loop system achieved 97% clearance of yeasts from the subarachnoid space in a rabbit model over 4-6 hours. This is the first publication demonstrating the direct ability to rapidly clear, both in vitro and in vivo, the otherwise slowly removed fungal pathogen that directly contributes to the morbidity and mortality seen in CM.
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Affiliation(s)
- Gordon J Smilnak
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Lefko T Charalambous
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Drew Cutshaw
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Alykhan M Premji
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Charles D Giamberardino
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Christi G Ballard
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew P Bartuska
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Tiffany U Ejikeme
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Huaxin Sheng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | | | | | - Promila C Pagadala
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | | | - John R Perfect
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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21
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Stott KE, Hope W. Pharmacokinetics–pharmacodynamics of antifungal agents in the central nervous system. Expert Opin Drug Metab Toxicol 2018; 14:803-815. [DOI: 10.1080/17425255.2018.1492551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Katharine E Stott
- Antimicrobial Pharmacodynamics and Therapeutics Laboratory, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics Laboratory, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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22
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Charalambous LT, Premji A, Tybout C, Hunt A, Cutshaw D, Elsamadicy AA, Yang S, Xie J, Giamberardino C, Pagadala P, Perfect JR, Lad SP. Prevalence, healthcare resource utilization and overall burden of fungal meningitis in the United States. J Med Microbiol 2018; 67:215-227. [PMID: 29244019 PMCID: PMC6557145 DOI: 10.1099/jmm.0.000656] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/23/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Previous epidemiological and cost studies of fungal meningitis have largely focused on single pathogens, leading to a poor understanding of the disease in general. We studied the largest and most diverse group of fungal meningitis patients to date, over the longest follow-up period, to examine the broad impact on resource utilization within the United States. METHODOLOGY The Truven Health Analytics MarketScan database was used to identify patients with a fungal meningitis diagnosis in the United States between 2000 and 2012. Patients with a primary diagnosis of cryptococcal, Coccidioides, Histoplasma, or Candida meningitis were included in the analysis. Data concerning healthcare resource utilization, prevalence and length of stay were collected for up to 5 years following the original diagnosis. RESULTS Cryptococcal meningitis was the most prevalent type of fungal meningitis (70.1 % of cases over the duration of the study), followed by coccidioidomycosis (16.4 %), histoplasmosis (6.0 %) and candidiasis (7.6 %). Cryptococcal meningitis and candidiasis patients accrued the largest average charges ($103 236 and $103 803, respectively) and spent the most time in the hospital on average (70.6 and 79 days). Coccidioidomycosis and histoplasmosis patients also accrued substantial charges and time in the hospital ($82 439, 48.1 days; $78 609, 49.8 days, respectively). CONCLUSION Our study characterizes the largest longitudinal cohort of fungal meningitis in the United States. Importantly, the health economic impact and long-term morbidity from these infections are quantified and reviewed. The healthcare resource utilization of fungal meningitis patients in the United States is substantial.
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Affiliation(s)
| | - Alykhan Premji
- Department of Neurosurgery, Duke University Medical Center, NC, USA
| | - Caroline Tybout
- Department of Neurosurgery, Duke University Medical Center, NC, USA
| | - Anastasia Hunt
- Department of Neurosurgery, Duke University Medical Center, NC, USA
| | - Drew Cutshaw
- Department of Neurosurgery, Duke University Medical Center, NC, USA
| | | | - Siyun Yang
- Department of Biostatistics, Duke University, NC, USA
| | - Jichun Xie
- Department of Biostatistics, Duke University, NC, USA
| | | | - Promila Pagadala
- Department of Neurosurgery, Duke University Medical Center, NC, USA
| | - John R. Perfect
- Division of Infectious Diseases, Duke University Medical Center, NC, USA
| | - Shivanand P. Lad
- Department of Neurosurgery, Duke University Medical Center, NC, USA
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23
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Shah H, Honeybul S, Tang S, Arthur I, McLaren S, Boan P. Mould meningitis associated with intravenous drug use. Med Mycol Case Rep 2018; 20:18-20. [PMID: 30148056 PMCID: PMC6105917 DOI: 10.1016/j.mmcr.2018.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 12/27/2017] [Accepted: 01/09/2018] [Indexed: 10/31/2022] Open
Abstract
Fungal meningitis is most commonly causes by Cryptococcus species and dimorphic fungi. We present a rare case of mould meningitis, ventriculitis and subependymal nodules in an immunocompetent patient, having likely seeded the meninges and ventricular system through intravenous drug use. The causative mould remains undetermined. The case highlights the poor sensitivity of CSF culture and the need to consider surgical biopsy where there is diagnostic difficulty and fungal infection is being considered.
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Affiliation(s)
- Hassan Shah
- Department of Rehabilitation Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Stephanie Tang
- Department of Rehabilitation Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Ian Arthur
- PathWest Laboratory Medicine WA, Department of Microbiology, QEII Medical Centre, Perth, Western Australia, Australia
| | - Sally McLaren
- PathWest Laboratory Medicine WA, Department of Anatomical Pathology, QEII Medical Centre, Perth, Western Australia, Australia
| | - Peter Boan
- Departments of Infectious Diseases and Microbiology, Fiona Stanley Hospital and PathWest Laboratory Medicine WA, Perth, Western Australia, Australia
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24
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Xu S, Shinohara ML. Tissue-Resident Macrophages in Fungal Infections. Front Immunol 2017; 8:1798. [PMID: 29312319 PMCID: PMC5732976 DOI: 10.3389/fimmu.2017.01798] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/30/2017] [Indexed: 12/24/2022] Open
Abstract
Invasive fungal infections result in high morbidity and mortality. Host organs targeted by fungal pathogens vary depending on the route of infection and fungal species encountered. Cryptococcus neoformans infects the respiratory tract and disseminates throughout the central nervous system. Candida albicans infects mucosal tissues and the skin, and systemic Candida infection in rodents has a tropism to the kidney. Aspergillus fumigatus reaches distal areas of the lung once inhaled by the host. Across different tissues in naïve hosts, tissue-resident macrophages (TRMs) are one of the most populous cells of the innate immune system. Although they function to maintain homeostasis in a tissue-specific manner during steady state, TRMs may function as the first line of defense against invading pathogens and may regulate host immune responses. Thus, in any organs, TRMs are uniquely positioned and specifically programmed to function. This article reviews the current understanding of the roles of TRMs during major fungal infections.
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Affiliation(s)
- Shengjie Xu
- Department of Immunology, Duke University School of Medicine, Durham, NC, United States
| | - Mari L Shinohara
- Department of Immunology, Duke University School of Medicine, Durham, NC, United States.,Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, United States
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25
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Martínez-Girón R, Martínez-Torre C. Millipore™ filter debris mimicking fungal organisms in CSF cytology. Diagn Cytopathol 2017; 45:545-546. [PMID: 28371530 DOI: 10.1002/dc.23717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/20/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Rafael Martínez-Girón
- CFGS Anatomic Pathology and Cytology, Institute of Piedras, Blancas, Asturias, 33450, Spain
| | - Cristina Martínez-Torre
- Faculty of Pharmacy, University of Salamanca., Campus Miguel de Unamuno, Salamanca, 33007, Spain
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26
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Abstract
Infections of the nervous system are an important and challenging aspect of clinical neurology. Immediate correct diagnosis enables to introduce effective therapy, in conditions that without diagnosis may leave the patient with severe neurological incapacitation and sometimes even death. The cerebrospinal fluid (CSF) is a mirror that reflects nervous system pathology and can promote early diagnosis and therapy. The present chapter focuses on the CSF findings in neuro-infections, mainly viral and bacterial. Opening pressure, protein and glucose levels, presence of cells and type of the cellular reaction should be monitored. Other tests can also shed light on the causative agent: serology, culture, staining, molecular techniques such as polymerase chain reaction. Specific examination such as panbacterial and panfungal examinations should be examined when relevant. Our chapter is a guide-text that combines clinical presentation and course with CSF findings as a usuaful tool in diagnosis of neuroinfections.
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Affiliation(s)
- Felix Benninger
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Israel Steiner
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
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27
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Dorsett M, Liang SY. Diagnosis and Treatment of Central Nervous System Infections in the Emergency Department. Emerg Med Clin North Am 2016; 34:917-942. [PMID: 27741995 PMCID: PMC5082707 DOI: 10.1016/j.emc.2016.06.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Central nervous system (CNS) infections, including meningitis, encephalitis, and brain abscess, are rare but time-sensitive emergency department (ED) diagnoses. Patients with CNS infection can present to the ED with nonspecific signs and symptoms, including headache, fever, altered mental status, and behavioral changes. Neuroimaging and CSF fluid analysis can appear benign early in the course of disease. Delaying therapy negatively impacts outcomes, particularly with bacterial meningitis and herpes simplex virus encephalitis. Therefore, diagnosis of CNS infection requires vigilance and a high index of suspicion based on the history and physical examination, which must be confirmed with appropriate imaging and laboratory evaluation.
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Affiliation(s)
- Maia Dorsett
- Division of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8072, St. Louis, Missouri 64110, USA
| | - Stephen Y. Liang
- Division of Emergency Medicine, Division of Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8051, St. Louis, Missouri 63110, USA
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28
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Shi M, Mody CH. Fungal Infection in the Brain: What We Learned from Intravital Imaging. Front Immunol 2016; 7:292. [PMID: 27532000 PMCID: PMC4969284 DOI: 10.3389/fimmu.2016.00292] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/19/2016] [Indexed: 11/13/2022] Open
Abstract
Approximately 1.2 billion people suffer from fungal diseases worldwide. Arguably, the most serious manifestation occurs when pathogenic fungi infect the brain, often causing fatal meningoencephalitis. For most fungi, infection occurs via the vascular route. The organism must first be arrested in the brain microvasculature and transmigrate into the brain parenchyma across the blood–brain barrier. As a result, host immune cells are recruited into the brain to contain the fungi. However, it remains poorly understood how fungi traffic to, and migrate into the brain and how immune cells interact with invading fungi in the brain. A new era of intravital fluorescence microscopy has begun to provide insights. We are able to employ this powerful approach to study dynamic interactions of disseminating fungi with brain endothelial cells as well as resident and recruited immune cells during the brain infection. In this review, with a focus on Cryptococcus neoformans, we will provide an overview of the application of intravital imaging in fungal infections in the brain, discuss recent findings and speculate on possible future research directions.
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Affiliation(s)
- Meiqing Shi
- Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland , College Park, MD , USA
| | - Christopher H Mody
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada; Department of Internal Medicine, University of Calgary, Calgary, AB, Canada
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29
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Sun D, Zhang M, Liu G, Wu H, Li C, Zhou H, Zhang X, Shi M. Intravascular clearance of disseminating Cryptococcus neoformans in the brain can be improved by enhancing neutrophil recruitment in mice. Eur J Immunol 2016; 46:1704-14. [PMID: 27109176 DOI: 10.1002/eji.201546239] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 03/06/2016] [Accepted: 04/18/2016] [Indexed: 12/23/2022]
Abstract
Extrapulmonary dissemination of Cryptococcus neoformans (C. neoformans) is one of the most critical steps in the development of meningoencephalitis. Here, we report that clearance of the disseminating C. neoformans occurs within the brain microvasculature. Interestingly, the efficiency of the intravascular clearance in the brain is reduced compared to that in the lung. Intravascular clearance is mainly mediated by neutrophils, and complement C5a receptor signaling is crucial for mediating neutrophil recruitment in the vasculature. C. neoformans stimulated actin polymerization of neutrophils is critically involved in their recruitment to the lung, which is associated with the unique vascular structure detected in the lung. The relatively lower efficiency of fungal clearance in the brain vasculature correlates with less efficient recruitment of neutrophils. Accordingly, intravascular clearance of C. neoformans in the brain could be remarkably improved by increasing the recruitment of neutrophils. We conclude that neutrophils have the ability to eliminate C. neoformans arrested in the vasculature. However, insufficient recruitment of neutrophils limited the optimal clearance of this microorganism in the brain. These results imply that a therapeutic strategy aimed at enhancing the accumulation of neutrophils could help prevent cryptococcal meningoencephalitis.
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Affiliation(s)
- Donglei Sun
- Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, MD, USA
| | - Mingshun Zhang
- Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, MD, USA.,Department of Immunology, Nanjing Medical University, Nanjing, China
| | - Gongguan Liu
- Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, MD, USA
| | - Hui Wu
- Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, MD, USA
| | - Chang Li
- Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, MD, USA
| | - Hong Zhou
- Department of Immunology, Nanjing Medical University, Nanjing, China
| | - Xiquan Zhang
- Department of Animal Genetics, Breeding and Reproduction, South China Agricultural University, Guangzhou, China
| | - Meiqing Shi
- Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, MD, USA
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30
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Ventriculitis due to infection with Rhizopus arrhizus. Med Mycol Case Rep 2015; 10:18-20. [PMID: 26862476 PMCID: PMC4706622 DOI: 10.1016/j.mmcr.2015.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/09/2015] [Accepted: 12/11/2015] [Indexed: 01/24/2023] Open
Abstract
A 52-year-old heart–lung transplant patient presented to the emergency department with acute onset of neurologic symptoms. MRI showed ballooning of the left ventricle, midline shift and contrast enhancement in the anterior horn of the left ventricle. Ventricle neuroendoscopy revealed whitish, floccose aerial structures within the left ventricle. Brain biopsy cultures grew Rhizopus arrhizus. Therapy with liposomale amphotericin B and posaconazole was performed. Except for hemianopsia and deficits in minute motor activity, the patient completely recovered.
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31
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Zhang M, Sun D, Liu G, Wu H, Zhou H, Shi M. Real-time in vivo imaging reveals the ability of neutrophils to remove Cryptococcus neoformans directly from the brain vasculature. J Leukoc Biol 2015; 99:467-73. [PMID: 26428677 DOI: 10.1189/jlb.4ab0715-281r] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/21/2015] [Indexed: 11/24/2022] Open
Abstract
Although neutrophils are typically the first immune cells attracted to an infection site, little is known about how neutrophils dynamically interact with invading pathogens in vivo. Here, with the use of intravital microscopy, we demonstrate that neutrophils migrate to the arrested Cryptococcus neoformans, a leading agent to cause meningoencephalitis, in the brain microvasculature. Following interactions with C. neoformans, neutrophils were seen to internalize the organism and then circulate back into the bloodstream, resulting in a direct removal of the organism from the endothelial surface before its transmigration into the brain parenchyma. C. neoformans infection led to enhanced expression of adhesion molecules macrophage 1 antigen on neutrophils and ICAM-1 on brain endothelial cells. Depletion of neutrophils enhanced the brain fungal burden. Complement C3 was critically involved in the recognition of C. neoformans by neutrophils and subsequent clearance of the organism from the brain. Together, our finding of the direct removal of C. neoformans by neutrophils from its arrested site may represent a novel mechanism of host defense in the brain, in addition to the known, direct killing of microorganisms at the infection sites. These data are the first to characterize directly the dynamic interactions of leukocytes with a microbe in the brain of a living animal.
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Affiliation(s)
- Mingshun Zhang
- *Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, Maryland, USA; and Department of Immunology, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Donglei Sun
- *Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, Maryland, USA; and Department of Immunology, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Gongguan Liu
- *Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, Maryland, USA; and Department of Immunology, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hui Wu
- *Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, Maryland, USA; and Department of Immunology, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hong Zhou
- *Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, Maryland, USA; and Department of Immunology, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Meiqing Shi
- *Division of Immunology, Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, Maryland, USA; and Department of Immunology, Nanjing Medical University, Nanjing, Jiangsu, China
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Zhong Y, Li M, Liu J, Zhang W, Peng F. Cryptococcal meningitis in Chinese patients with systemic lupus erythematosus. Clin Neurol Neurosurg 2015; 131:59-63. [PMID: 25704191 DOI: 10.1016/j.clineuro.2015.01.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 01/08/2015] [Accepted: 01/23/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) is a chronic immunologic disorder that can affect multiple organ systems and makes the patient susceptible to infection. Cryptococcal meningitis (CM) is a rare but often fatal complication of SLE. DESIGN In this study, 6 patients with CM were identified among 631 patients with SLE. The demographic, clinical, laboratory profiles, serological features and outcomes of these 6 SLE patients with CM were retrospectively analyzed. RESULTS The mean age of these patients was 24.1 years (range 12-42) at the time of SLE diagnosis, and 27.1 years (range 14-42) at the time of Cryptococcus neoformans infection, with mean disease duration of 37 months (range 3-72). Four patients had active SLE. All patients were receiving glucocorticoids therapy (mean prednisone dose of 20.5 (5.0-36.0) mg/day) at the onset of infection. Five patients had received other immunosuppressive drugs. The most common presentations of CM were headache and fever and 4 of the 6 patients were normal on physical examination. The cerebrospinal fluid (CSF) indices (protein and glucose) were normal in 4 cases, whereas they were mildly abnormal in the other 2 patients. White counts in the CSF ranged from 8 to 240 cells/mm. C. neoformans were isolated from CSF of 4 patients. The isolation of crytococci from extraneural sites, including blood and lungs, was found in 2 patients. Results of the head computed tomography scan were unremarkable in 5 of the patients. The infection was completely resolved in 5 patients, and it was resolved with serious sequelae in one patient. CONCLUSIONS In conclusion, the key to a rapid diagnosis of CM in patients with SLE is to maintain a high degree of awareness which will help avoid delays in treatment. This is mainly due to the fact that the clinical presentation and laboratory results from routine hematological, biochemical and CSF analyses of CM in patients with SLE are mostly non-specific.
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Affiliation(s)
- Yuhua Zhong
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, No. 600, Tianhe Road, Guangzhou, Guangdong 510630, China
| | - Min Li
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, No. 600, Tianhe Road, Guangzhou, Guangdong 510630, China
| | - Jia Liu
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, No. 600, Tianhe Road, Guangzhou, Guangdong 510630, China
| | - Weixi Zhang
- Department of Neurology, The First Affiliated Hospital Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, Guangdong 510080, China
| | - Fuhua Peng
- Multiple Sclerosis Center, Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, No. 600, Tianhe Road, Guangzhou, Guangdong 510630, China.
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Infektionen. NEUROINTENSIV 2015. [PMCID: PMC7175474 DOI: 10.1007/978-3-662-46500-4_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In diesem Kapitel werden zunächst die für die Neurointensivmedizin wesentlichen bakteriellen Infektionen (Meningitis, spinale und Hirnabszesse, Spondylodiszitis, septisch-embolische Herdenzephalitis) abgehandelt, die trotz gezielt eingesetzter Antibiotika und neurochirurgischer Therapieoptionen noch mit einer erheblichen Morbidität und Mortalität behaftet sind. Besonderheiten wie neurovaskuläre Komplikationen, die Tuberkulose des Nervensystems, Neuroborreliose, Neurosyphilis und opportunistische Infektionen bei Immunsuppressionszuständen finden hierbei besondere Berücksichtigung. Der zweite Teil dieses Kapitels behandelt akute und chronische Virusinfektionen des ZNS sowie in einem gesonderten Abschnitt die HIVInfektion und HIV-assoziierte Krankheitsbilder sowie Parasitosen und Pilzinfektionen, die in Industrieländern seit Einführung der HAART bei HIV zwar eher seltener, aber mit zunehmender Globalisierung auch in unseren Breiten immer noch anzutreffen sind.
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Moudgal V, Singal B, Kauffman CA, Brodkey JA, Malani AN, Olmsted RN, Kasotakis MJ, Koch SR, Kaakaji R, Nyaku M, Neelakanta A, Valenstein P, Winter S, Otto M, Jagarlamudi R, Kerr L, Czerwinski J, Vandenberg D, Sutton SR, Murphy H, Halasyamani LK. Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections. Open Forum Infect Dis 2014; 1:ofu022. [PMID: 25734095 PMCID: PMC4324199 DOI: 10.1093/ofid/ofu022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone. METHODS Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports. RESULTS Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection. CONCLUSIONS We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.
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Affiliation(s)
| | | | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Medical School , Ann Arbor, Michigan
| | | | | | | | | | | | - Rami Kaakaji
- Saint Joseph Mercy Hospital , Ann Arbor, Michigan
| | - Mawuli Nyaku
- Centers for Disease Control and Prevention , Atlanta, Georgia
| | | | | | | | - Michael Otto
- Saint Joseph Mercy Hospital , Ann Arbor, Michigan
| | | | - Lisa Kerr
- Saint Joseph Mercy Hospital , Ann Arbor, Michigan
| | | | | | | | - Holly Murphy
- Saint Joseph Mercy Hospital , Ann Arbor, Michigan
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Zhong YH, Tan F, Li M, Liu J, Wang X, Yuan Y, Zhong XF, Peng FH. Comparisons of presentations and outcomes of cryptococcal meningitis between patients with and without hepatitis B virus infection. Int J Infect Dis 2014; 20:31-6. [DOI: 10.1016/j.ijid.2013.11.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/14/2013] [Accepted: 11/23/2013] [Indexed: 01/21/2023] Open
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Matsumura M, Kawamura R, Inoue R, Yamada K, Kawano M, Yamagishi M. Concurrent presentation of cryptococcal meningoencephalitis and systemic lupus erythematosus. Mod Rheumatol 2014. [DOI: 10.3109/s10165-010-0383-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Masami Matsumura
- Research Center for Medical Education, Kanazawa University Graduate School of Medicine,
Takara-machi 13-1, Kanazawa, Ishikawa 920-8641, Japan
| | - Rika Kawamura
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine,
Kanazawa, Japan
| | - Ryo Inoue
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine,
Kanazawa, Japan
| | - Kazunori Yamada
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine,
Kanazawa, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine,
Kanazawa, Japan
| | - Masakazu Yamagishi
- Division of Cardiology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine,
Kanazawa, Japan
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Abstract
The epidemiology of invasive fungal infections in immunocompromised patients is rapidly changing. Several of the fungi have worldwide distribution. However, some have specific geographical distribution. Sinocranial aspergillosis, mostly described from countries with temperate climates, occurs mostly in otherwise immunocompetent individuals Most of the systemic fungal pathogens have been associated with central nervous system (CNS) involvement. The major advances in CNS fungal infections are in the pathobiology, new diagnostic tools, and new therapies. In spite of these developments, there is still considerable delay in the diagnosis of CNS fungal infection. CNS fungal infections are associated with considerable morbidity and mortality. To achieve good outcomes early diagnosis and early institution of appropriate therapies are the key issues.
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Affiliation(s)
- J M K Murthy
- Continental Institute of Neurosciences & Rehabilitation, Continental Hospitals, IT & Financial District, Gachibowli, Hyderabad, India.
| | - C Sundaram
- Department of Pathology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, India
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Tyler KL, Johnson ECB, Cantu DS, Haller BL. A 20-year-old woman with headache and transient numbness. Neurohospitalist 2013; 3:101-10. [PMID: 23983894 DOI: 10.1177/1941874412473118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kenneth L Tyler
- Department of Neurology, University of Colorado-Denver, Denver, CO, USA
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Abstract
Central nervous system (CNS) infections—i.e., infections involving the brain (cerebrum and cerebellum), spinal cord, optic nerves, and their covering membranes—are medical emergencies that are associated with substantial morbidity, mortality, or long-term sequelae that may have catastrophic implications for the quality of life of affected individuals. Acute CNS infections that warrant neurointensive care (ICU) admission fall broadly into three categories—meningitis, encephalitis, and abscesses—and generally result from blood-borne spread of the respective microorganisms. Other causes of CNS infections include head trauma resulting in fractures at the base of the skull or the cribriform plate that can lead to an opening between the CNS and the sinuses, mastoid, the middle ear, or the nasopharynx. Extrinsic contamination of the CNS can occur intraoperatively during neurosurgical procedures. Also, implanted medical devices or adjunct hardware (e.g., shunts, ventriculostomies, or external drainage tubes) and congenital malformations (e.g., spina bifida or sinus tracts) can become colonized and serve as sources or foci of infection. Viruses, such as rabies, herpes simplex virus, or polioviruses, can spread to the CNS via intraneural pathways resulting in encephalitis. If infection occurs at sites (e.g., middle ear or mastoid) contiguous with the CNS, infection may spread directly into the CNS causing brain abscesses; alternatively, the organism may reach the CNS indirectly via venous drainage or the sheaths of cranial and spinal nerves. Abscesses also may become localized in the subdural or epidural spaces. Meningitis results if bacteria spread directly from an abscess to the subarachnoid space. CNS abscesses may be a result of pyogenic meningitis or from septic emboli associated with endocarditis, lung abscess, or other serious purulent infections. Breaches of the blood–brain barrier (BBB) can result in CNS infections. Causes of such breaches include damage (e.g., microhemorrhage or necrosis of surrounding tissue) to the BBB; mechanical obstruction of microvessels by parasitized red blood cells, leukocytes, or platelets; overproduction of cytokines that degrade tight junction proteins; or microbe-specific interactions with the BBB that facilitate transcellular passage of the microorganism. The microorganisms that cause CNS infections include a wide range of bacteria, mycobacteria, yeasts, fungi, viruses, spirochaetes (e.g., neurosyphilis), and parasites (e.g., cerebral malaria and strongyloidiasis). The clinical picture of the various infections can be nonspecific or characterized by distinct, recognizable clinical syndromes. At some juncture, individuals with severe acute CNS infections require critical care management that warrants neuro-ICU admission. The implications for CNS infections are serious and complex and include the increased human and material resources necessary to manage very sick patients, the difficulties in triaging patients with vague or mild symptoms, and ascertaining the precise cause and degree of CNS involvement at the time of admission to the neuro-ICU. This chapter addresses a wide range of severe CNS infections that are better managed in the neuro-ICU. Topics covered include the medical epidemiology of the respective CNS infection; discussions of the relevant neuroanatomy and blood supply (essential for understanding the pathogenesis of CNS infections) and pathophysiology; symptoms and signs; diagnostic procedures, including essential neuroimaging studies; therapeutic options, including empirical therapy where indicated; and the perennial issue of the utility and effectiveness of steroid therapy for certain CNS infections. Finally, therapeutic options and alternatives are discussed, including the choices of antimicrobial agents best able to cross the BBB, supportive therapy, and prognosis.
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Affiliation(s)
- A Joseph Layon
- Pulmonary and Critical Care Medicine, Geisinger Health System, Danville, Pennsylvania USA
| | - Andrea Gabrielli
- Departments of Anesthesiology & Surgery, University of Florida College of Medicine, Gainesville, Florida USA
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40
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Detection of fungal DNA in human body fluids and tissues during a multistate outbreak of fungal meningitis and other infections. EUKARYOTIC CELL 2013; 12:677-83. [PMID: 23457192 DOI: 10.1128/ec.00046-13] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Exserohilum rostratum was the major cause of an outbreak of fungal infections linked to injections of contaminated methylprednisolone acetate. Because almost 14,000 persons were exposed to product that was possibly contaminated with multiple fungal pathogens, there was unprecedented need for a rapid throughput diagnostic test that could detect both E. rostratum and other unusual agents of fungal infection. Here we report development of a novel PCR test that allowed for rapid and specific detection of fungal DNA in cerebrospinal fluid (CSF), other body fluids and tissues of infected individuals. The test relied on direct purification of free-circulating fungal DNA from fluids and subsequent PCR amplification and sequencing. Using this method, we detected Exserohilum rostratum DNA in 123 samples from 114 case-patients (28% of 413 case-patients for whom 627 samples were available), and Cladosporium DNA in one sample from one case-patient. PCR with novel Exserohilum-specific ITS-2 region primers detected 25 case-patients with samples that were negative using broad-range ITS primers. Compared to fungal culture, this molecular test was more sensitive: of 139 case-patients with an identical specimen tested by culture and PCR, E. rostratum was recovered in culture from 19 (14%), but detected by PCR in 41 (29%), showing a diagnostic sensitivity of 29% for PCR compared to 14% for culture in this patient group. The ability to rapidly confirm the etiologic role of E. rostratum in these infections provided an important contribution in the public health response to this outbreak.
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Shi M, Colarusso P, Calaruso P, Mody CH. Real-time in vivo imaging of fungal migration to the central nervous system. Cell Microbiol 2012; 14:1819-27. [PMID: 22966777 DOI: 10.1111/cmi.12027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 08/26/2012] [Accepted: 08/29/2012] [Indexed: 01/18/2023]
Abstract
Recent technical advances have afforded valuable new insights into the pathogenesis of fungal infections in the central nervous system (CNS), which continue to cause devastating complications, particularly in immunocompromised individuals. To cause CNS mycosis, organisms such as Cryptococcus neoformans become blood borne and progress through a series of pathogenic checkpoints that culminate in fungal replication in the brain. Critical steps include fungal arrest in the vasculature of the brain, interaction and signalling of the fungal and endothelial cells leading to transmigration with subsequent parenchymal invasion and fungal replication in the CNS. Previous studies that made use of in vitro and ex vivo approaches contributed greatly to our understanding of brain invasion by fungi. However, the knowledge gained from previous studies relied on in vitro models that did not account for vascular haemodynamics. For this reason, more refined approaches that model blood flow and vascular anatomy are required, andultimately studying fungal invasion and dissemination in vivo. Indeed, in vivo imaging (also known as intravital imaging) has emerged as a valuable technique to probe host-pathogen interactions. In this review, with a focus on C. neoformans, we will provide an overview of the applications of the prior techniques and recent advances, their strengths and limitations in characterizing the migration of fungi into the brain, and unanswered questions that may provide new directions for research.
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Affiliation(s)
- Meiqing Shi
- Virginia-Maryland Regional College of Veterinary Medicine, University of Maryland, College Park, MD 20742, USA
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Nigam C, Gahlot R, Kumar V, Chakravarty J, Tilak R. Central Nervous System Cryptococcosis among a Cohort of HIV Infected Patients from a University Hospital of North India. J Clin Diagn Res 2012; 6:1385-7. [PMID: 23205353 PMCID: PMC3471506 DOI: 10.7860/jcdr/2012/4158.2365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 06/28/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cryptococcus neoformans is a ubiquitous encapsulated yeast that causes significant infections which range from asymptomatic pulmonary colonization to the life threatening meningoencephalitis, especially in immunocompromised individuals. Cryptococcal meningitis is one of the AIDS-defining illnesses. Recent data have indicated that, the incidence of the cryptococcal infection is high in developing countries like India. We conducted this study to find out the incidence of cryptococcosis in this area. MATERIAL AND METHODS The Cerebrospinal Fluid (CSF) specimens were collected from known HIV positive cases that had a clinical diagnosis of meningitis and they were processed by standard microbiological procedures. The cryptococcal isolates were identified by microscopy, their cultural characteristics, sugar assimilation and by the hydrolysis of urea. RESULTS The incidence of cryptococcal meningitis was 12.9%. All the strains were susceptible to amphotericin B, fluconazole, itraconazole and voriconazole. CONCLUSION The cryptococcal infection should be suspected in all cases of meningitis, especially among HIV infected persons. An early diagnosis and treatment may alter the prognosis of these patients and hence, an examination of the CSF for cryptococcosis should be considered in all the HIV infected persons who have the symptoms of meningitis.
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Affiliation(s)
- Chaitanya Nigam
- Service Senior Resident, Department of Microbiology, IMS, BHU, Varanasi, India
| | - Rupam Gahlot
- Junior Resident, Department of Microbiology, IMS, BHU, Varanasi, India
| | - Vikas Kumar
- Service Senior Resident, Department of Microbiology, IMS, BHU, Varanasi, India
| | - Jaya Chakravarty
- Assistant Professor, Department of Medicine, IMS, BHU, Varanasi, India
| | - Ragini Tilak
- Associate Professor, Department of Microbiology, IMS, BHU, Varanasi, India
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43
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Ramireddy S, Wanger A, Ostrosky L. An instructive case of CNS histoplasmosis in an immunocompetent host. Med Mycol Case Rep 2012; 1:69-71. [PMID: 24371742 DOI: 10.1016/j.mmcr.2012.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 07/25/2012] [Accepted: 08/12/2012] [Indexed: 11/30/2022] Open
Abstract
Histoplasma capsulatum is a dimorphic endemic fungus which infects both immunocompetent and immunocompromised hosts. Isolated CNS histoplasmosis is a rare presentation with increased risk in individuals with impaired cellular immunity, however not all patients with this condition are immunocompromised. We report a case of isolated CNS histoplasmosis in an otherwise healthy immunocompetent patient who was initially treated with Liposomal Amphotericin B followed by oral Voriconazole and later Itraconazole with significant improvement in clinical status.
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Affiliation(s)
- Sweeya Ramireddy
- Division of Infectious Diseases, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 2.112, Houston, Texas 77030, USA
| | - Audrey Wanger
- Division of Infectious Diseases, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 2.112, Houston, Texas 77030, USA
| | - Luis Ostrosky
- Division of Infectious Diseases, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 2.112, Houston, Texas 77030, USA
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44
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Abstract
In cases of central nervous system infection, it is crucial for the neuroradiologist to provide an accurate differential diagnosis of the possible pathogens involved so that treating physicians can be aided in the choice of empiric therapy. This approach requires the radiologist to be aware of local epidemiology and have knowledge of infectious agents that are endemic to their area of practice. This article reviews and discusses the changing epidemiology of pathogens most often observed in meningitis, brain abscess, epidural abscess, postoperative infections, and human immunodeficiency virus infection.
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45
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Steiner I, Schmutzhard E, Sellner J, Chaudhuri A, Kennedy PGE. EFNS-ENS guidelines for the use of PCR technology for the diagnosis of infections of the nervous system. Eur J Neurol 2012; 19:1278-91. [DOI: 10.1111/j.1468-1331.2012.03808.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Accepted: 06/12/2012] [Indexed: 11/30/2022]
Affiliation(s)
- I. Steiner
- Department of Neurology; Rabin Medical Center; Petach Tikva Israel
| | - E. Schmutzhard
- Department of Neurology; Medical University Innsbruck; Innsbruck Austria
| | - J. Sellner
- Department of Neurology; Klinikum rechts der Isar; Technische Universität München; München Germany
- Neurologische Abteilung; Krankenhaus Hietzing mit Neurologischem Zentrum Rosenhügel; Vienna Austria
| | - A. Chaudhuri
- Clinical Neurosciences; Queen's Hospital; Romford UK
| | - P. G. E. Kennedy
- Department of Neurology; Southern General Hospital; Institute of Neurological Sciences; Glasgow University; Glasgow UK
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46
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Chen Y, Liu L. Modern methods for delivery of drugs across the blood-brain barrier. Adv Drug Deliv Rev 2012; 64:640-65. [PMID: 22154620 DOI: 10.1016/j.addr.2011.11.010] [Citation(s) in RCA: 601] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2011] [Revised: 11/21/2011] [Accepted: 11/21/2011] [Indexed: 02/07/2023]
Abstract
The blood-brain barrier (BBB) is a highly regulated and efficient barrier that provides a sanctuary to the brain. It is designed to regulate brain homeostasis and to permit selective transport of molecules that are essential for brain function. Unfortunately, drug transport to the brain is hampered by this almost impermeable, highly selective and well coordinated barrier. With progress in molecular biology, the BBB is better understood, particularly under different pathological conditions. This review will discuss the barrier issue from a biological and pathological perspective to provide a better insight to the challenges and opportunities associated with the BBB. Modern methods which can take advantage of these opportunities will be reviewed. Applications of nanotechnology in drug transport, receptor-mediated targeting and transport, and finally cell-mediated drug transport will also be covered in the review. The challenge of delivering an effective therapy to the brain is formidable; solutions will likely involve concerted multidisciplinary approaches that take into account BBB biology as well as the unique features associated with the pathological condition to be treated.
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Affiliation(s)
- Yan Chen
- School of Pharmacy, CHIRI, WABRI, Curtin University, Perth, Western Australia, Australia.
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47
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Xiao A, Jiang S, Liu Y, Deng K, You C. Invasive intracranial aspergillosis spread by the pterygopalatine fossa in an immunocompetent patient. Braz J Infect Dis 2012. [DOI: 10.1016/s1413-8670(12)70305-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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48
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Abstract
Fungal meningitis is a serious disease caused by a fungal infection of the central nervous system (CNS) mostly in individuals with immune system deficiencies. Fungal meningitis is often fatal without proper treatment, and the mortality rate remains unacceptably high even with antifungal drug interventions. Currently, cryptococcal meningitis is the most common fungal meningitis in HIV-1/AIDS, and its disease mechanism has been extensively studied. The key steps for fungi to infect brain and cause meningitis after establishment of local infection are the dissemination of fungal cells to the bloodstream and invasion through the blood brain barrier to reach the CNS. In this review, we use cryptococcal CNS infection as an example to describe the current molecular understanding of fungal meningitis, including the establishment of the infection, dissemination, and brain invasion. Host and microbial factors that contribute to these infection steps are also discussed.
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Affiliation(s)
- Tong-Bao Liu
- The Public Health Research Institute, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA
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49
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Hu X, Li JH, Lan L, Wu FF, Zhang EP, Song ZM, Huang HC, Luo FJ, Pan CW, Tan F. In vitro study of the effects of Angiostrongylus cantonensis larvae extracts on apoptosis and dysfunction in the blood-brain barrier (BBB). PLoS One 2012; 7:e32161. [PMID: 22393387 PMCID: PMC3290544 DOI: 10.1371/journal.pone.0032161] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 01/21/2012] [Indexed: 12/18/2022] Open
Abstract
It has been hypothesized that blood-brain barrier (BBB) dysfunction in Angiostrongylus cantonensis infection might be due to the apoptosis of the hosts' BBB cells. Here, we evaluated this hypothesis through several methods, all based on an in vitro mouse BBB model consisting of primary culture brain microvascular endothelial cells (BMECs) and brain astrocytic cells (BACs). In the present study, a four-hour percolation and HRP permeability experiment showed that A. cantonensis larvae extracts can increase the permeability of the BBB. Apoptosis among BMECs and BACs after exposure to larvae extracts was monitored by TUNEL and annexin-V-FITC/PI double staining. A. cantonensis larvae extracts were found to induce apoptosis in both BMECs and BACs. For this reason, we concluded that the induction of apoptosis might participate in the BBB dysfunction observed during angiostrongyliasis. Improved fundamental understanding of how A. cantonensis induces apoptosis may lead to new approaches to the treatment or prevention of this parasitic disease.
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Affiliation(s)
- Xin Hu
- School of Medical Laboratory Science and School of Life Science, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Jiang-Hui Li
- Institution of Health and Environment, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Lan Lan
- Department of Parasitology, School of Basic Medical Sciences, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Fei-Fei Wu
- Department of Parasitology, School of Basic Medical Sciences, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Er-Peng Zhang
- Department of Parasitology, School of Basic Medical Sciences, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Zeng-Mei Song
- Department of Parasitology, School of Basic Medical Sciences, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Hui-Cong Huang
- Department of Parasitology, School of Basic Medical Sciences, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Fang-Jun Luo
- Department of Clinical Laboratory, Zhuji People's Hospital, Zhuji, Zhejiang, People's Republic of China
| | - Chang-Wang Pan
- Department of Parasitology, School of Basic Medical Sciences, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Feng Tan
- Department of Parasitology, School of Basic Medical Sciences, Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
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Agarwal R, Kalita J, Marak RSK, Misra UK. Spectrum of fungal infection in a neurology tertiary care center in India. Neurol Sci 2012; 33:1305-10. [DOI: 10.1007/s10072-012-0932-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 01/03/2012] [Indexed: 10/14/2022]
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