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Cao C, Luo L, Hu Y, Huang T, Gao S, Ling C, He H, Guo Y. Nomogram to Predict the Outcome of Ventriculoperitoneal Shunt Among Patients with Non-HIV Cryptococcal Meningitis. World Neurosurg 2024:S1878-8750(24)00514-X. [PMID: 38552785 DOI: 10.1016/j.wneu.2024.03.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The ventriculoperitoneal (VP) shunt is widely acknowledged as a treatment option for managing intracranial hypertension resulting from non-human immunodeficiency virus (HIV) cryptococcal meningitis (CM). Nonetheless, there is currently no consensus on the appropriate surgical indications for this procedure. Therefore, it is crucial to conduct a preoperative evaluation of patient characteristics and predict the outcome of the VP shunt to guide clinical treatment effectively. METHODS A retrospective analysis was conducted on data from 85 patients with non-HIV CM who underwent VP shunt surgery at our hospital. The analysis involved studying demographic data, preoperative clinical manifestations, cerebrospinal fluid (CSF) characteristics, and surgical outcomes and comparisons between before and after surgery. A nomogram was developed and evaluated. RESULTS The therapy outcomes of 71 patients improved, whereas 14 cases had worse outcomes. Age, preoperative cryptococcus count, and preoperative CSF protein levels were found to influence the surgical outcome. The nomogram exhibited exceptional predictive performance (area under the curve = 0.896, 95% confidence interval: 0.8292-0.9635). Internal validation confirmed the nomogram's excellent predictive capabilities. Moreover, decision curve analysis demonstrated the nomogram's practical clinical utility. CONCLUSIONS The surgical outcome of VP shunt procedures patients with non-HIV CM was associated with age, preoperative cryptococcal count, and preoperative CSF protein levels. We developed a nomogram that can be used to predict surgical outcomes in patients with non-HIV CM.
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Affiliation(s)
- Cheng'an Cao
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Lun Luo
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuanjun Hu
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Tengchao Huang
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shuangqi Gao
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Cong Ling
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Haiyong He
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ying Guo
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China.
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Qu J, Lv X. Cryptococcal meningitis in apparently immunocompetent patients. Crit Rev Microbiol 2024; 50:76-86. [PMID: 36562731 DOI: 10.1080/1040841x.2022.2159786] [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] [Received: 10/06/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
Cryptococcal meningitis (CM) is an invasive fungal disease that currently poses a threat to human health worldwide, with high morbidity and mortality, particularly in immunocompromised patients. Although CM mainly occurs in HIV-positive patients and other immunocompromised patients, it is also increasingly seen in seemingly immunocompetent hosts. The clinical characteristics of CM between immunocompromised and immunocompetent populations are different. However, few studies have focussed on CM in immunocompetent individuals. This review summarizes the clinical characteristics of apparently immunocompetent CM patients in terms of aetiology, immune pathogenesis, clinical presentation, laboratory data, imaging findings, treatment strategies and prognosis. It is of great significance to further understand the disease characteristics of CM, explore new treatment strategies and improve the prognosis of CM in immunocompetent individuals.
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Affiliation(s)
- Junyan Qu
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoju Lv
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, China
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3
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Specht CA, Lam WC, Hester MM, Lourenco D, Levitz SM, Lodge JK, Upadhya R. Chitosan-Deficient Cryptococcus as Whole-Cell Vaccines. Methods Mol Biol 2024; 2775:393-410. [PMID: 38758333 DOI: 10.1007/978-1-0716-3722-7_27] [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] [Indexed: 05/18/2024]
Abstract
Creating a safe and effective vaccine against infection by the fungal pathogen Cryptococcus neoformans is an appealing option that complements the discovery of new small molecule antifungals. Recent animal studies have yielded promising results for a variety of vaccines that include live-attenuated and heat-killed whole-cell vaccines, as well as subunit vaccines formulated around recombinant proteins. Some of the recombinantly engineered cryptococcal mutants in the chitosan biosynthesis pathway are avirulent and very effective at conferring protective immunity. Mice vaccinated with these avirulent chitosan-deficient strains are protected from a lethal pulmonary infection with C. neoformans strain KN99. Heat-killed derivatives of the vaccination strains are likewise effective in a murine model of infection. The efficacy of these whole-cell vaccines, however, is dependent on a number of factors, including the inoculation dose, route of vaccination, frequency of vaccination, and the specific mouse strain used in the study. Here, we present detailed methods for identifying and optimizing various factors influencing vaccine potency and efficacy in various inbred mouse strains using a chitosan-deficient cda1Δcda2Δcda3Δ strain as a whole-cell vaccine candidate. This chapter describes the protocols for immunizing three different laboratory mouse strains with vaccination regimens that use intranasal, orotracheal, and subcutaneous vaccination routes after the animals were sedated using two different types of anesthesia.
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Affiliation(s)
- Charles A Specht
- Department of Medicine, The University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Woei C Lam
- Department of Molecular Microbiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Pfizer STL, Chesterfield, MO, USA
- Department of Molecular Microbiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Maureen M Hester
- Department of Medicine, The University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Diana Lourenco
- Department of Medicine, The University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Stuart M Levitz
- Department of Medicine, The University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Jennifer K Lodge
- Department of Molecular Microbiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, USA
| | - Rajendra Upadhya
- Department of Molecular Microbiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, USA.
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Kebabonye K, Jongman M, Loeto D, Moyo S, Choga W, Kasvosve I. Determining Potential Link between Environmental and Clinical Isolates of Cryptococcus neoformans/Cryptococcus gattii Species Complexes Using Phenotypic and Genotypic Characterisation. MYCOBIOLOGY 2023; 51:452-462. [PMID: 38179115 PMCID: PMC10763847 DOI: 10.1080/12298093.2023.2272380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 10/10/2023] [Indexed: 01/06/2024]
Abstract
Opportunistic infections due to Cryptococcus neoformans and C. gattii species complexes continue to rise unabated among HIV/AIDS patients, despite improved antifungal therapies. Here, we collected a total of 20 environmental and 25 presumptive clinical cryptococcal isolates from cerebrospinal fluid (CSF) samples of 175 patients enrolled in an ongoing clinical trial Ambition 1 Project (Botswana-Harvard Partnership). Identity confirmation of the isolates was done using MALDI-TOF MS and PCR. We describe the diversity of the isolates by PCR fingerprinting and sequencing (Oxford Nanopore Technology) of the intergenic spacer region. Mating types of the isolates were determined by amplification of the MAT locus. We report an unusual prevalence of 42.1% of C. neoformans x C. deneoformans hybrids Serotype AD (n = 16), followed by 39.5% of C. neoformans Serotype A (n = 15), 5.3% of C. deneoformans, Serotype D (n = 2), 7.9% of C. gattii (n = 3), and 5.3% of C. tetragattii (n = 2) in 38 representative isolates that have been characterized. Mating type-specific PCR performed on 38 representative environmental and clinical isolates revealed that 16 (42.1%) were MATa/MATα hybrids, 17 (44.7%) were MATα, and five (13.2%) possessed MATa mating type. We used conventional and NGS platforms to demonstrate a potential link between environmental and clinical isolates and lay a foundation to further describe mating patterns/history in Botswana.
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Affiliation(s)
- Kenosi Kebabonye
- School of Health Allied Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Mosimanegape Jongman
- Department of Biological Sciences, Faculty of Science, University of Botswana, Gaborone, Botswana
- Research Laboratory, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Daniel Loeto
- Department of Biological Sciences, Faculty of Science, University of Botswana, Gaborone, Botswana
| | - Sikhulile Moyo
- School of Health Allied Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
- Research Laboratory, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Medical Virology, Stellenbosch University, Cape Town, South Africa
- School of Health Systems of Public Health, University of Pretoria, Pretoria, South Africa
| | - Wonderful Choga
- Research Laboratory, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Ishmael Kasvosve
- School of Health Allied Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
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Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Yoon H, Nakouzi AS, Duong VA, Hung LQ, Binh TQ, Tung NLN, Day JN, Pirofski LA. Shared and unique antibody and B cell profiles in HIV-positive and HIV-negative individuals with cryptococcal meningoencephalitis. Med Mycol 2023; 61:myad102. [PMID: 37771088 PMCID: PMC10599321 DOI: 10.1093/mmy/myad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/07/2023] [Accepted: 09/27/2023] [Indexed: 09/30/2023] Open
Abstract
Host non-T cell markers to aid in the diagnosis of cryptococcal meningoencephalitis (CM) have not been identified. In this case-control study, we characterized antibody and B cell profiles in HIV-negative and HIV-positive Vietnamese individuals of the Kinh ethnicity recently diagnosed with CM and controls. The study included 60 HIV-negative with no known immunocompromising condition and 60 HIV-positive individuals, with 30 CM cases and 30 controls in each group. Participants were matched by age, sex, HIV serostatus, and CD4 count in the HIV-positive group. Plasma immunoglobulin (Ig) levels, including IgG1, IgG2, IgM, and IgA, Cryptococcus spp. glucuronoxylomannan (GXM)- and laminarin (branched ${\rm{\beta }}$-[1-3]-glucan)-binding IgG, IgM, IgA levels, and peripheral blood B cell subsets were measured. Logistic regression, principal component, and mediation analyses were conducted to assess associations between antibody, B cell levels, and CM. The results showed that GXM-IgG levels were higher and IgG1 and IgG2 were lower in CM cases than controls, regardless of HIV status. In HIV-negative individuals, IgG2 mediated an inverse association between CD19+CD27+CD43+CD5- (B-1b-like) cells and CM. In HIV-positive individuals, lower levels of IgA, laminarin-IgA, and CD19+CD27+IgM+IgD- (IgM+ memory B) cells were each associated with CM. The shared and distinct antibody and B cell profiles identified in HIV-negative and HIV-positive CM cases may inform the identification of non-T-cell markers of CM risk or unsuspected disease, particularly in HIV-negative individuals.
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Affiliation(s)
- Hyunah Yoon
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA
| | - Antonio S Nakouzi
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA
| | - Van Anh Duong
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City Q5, Vietnam
| | - Le Quoc Hung
- Department of Tropical Diseases, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tran Quang Binh
- Department of Tropical Diseases, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Le Nhu Tung
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Ho Chi Minh City Q5, Vietnam
| | - Jeremy N Day
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City Q5, Vietnam
- Department of Microbiology and Infection, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK
| | - Liise-anne Pirofski
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA
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7
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Naseem MA, Khan MA, Ali W, Danial Malik M, Aslam W. Cryptococcal Meningitis in an HIV-Negative Pulmonary Tuberculosis Patient: A Case Report. Cureus 2023; 15:e45900. [PMID: 37885511 PMCID: PMC10598787 DOI: 10.7759/cureus.45900] [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] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Cryptococcal meningitis represents a severe opportunistic fungal infection primarily observed in individuals with compromised immune systems. It frequently manifests in symptoms like headaches, vomiting, cranial nerve complications, and cognitive alterations. However, it's worth noting that up to 15% of cases may exhibit no discernible central nervous system-related symptoms. A 70-year-old male, previously diagnosed with pulmonary tuberculosis and undergoing treatment with anti-tubercular medications, was admitted due to changes in consciousness, sporadic low-grade fever, and cognitive impairment. An in-depth investigation revealed his HIV-negative and non-diabetic status, as well as his preserved immune competence. A plain CT head showed a communicating hydrocephalus and a lumbar puncture was positive for Cryptococcus neoformans. Treatment commenced with an induction regimen encompassing amphotericin and fluconazole, concurrently maintaining the anti-tubercular treatment course. The patient's condition displayed improvement, leading to a transition to a maintenance dosage of fluconazole. This case highlighted an extraordinary occurrence of Cryptococcal meningitis in an HIV-negative patient with no history of immunosuppressant use. Notably, Cryptococcal infection should be regarded as a primary consideration in patients afflicted by pulmonary tuberculosis who subsequently present with altered consciousness. The timely identification and proper management of such instances can substantially mitigate the risks of mortality and morbidity associated with this condition.
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Affiliation(s)
| | | | - Waqar Ali
- Internal Medicine, Central Park Medical College and Teaching Hospital, Lahore, PAK
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Kajeekul R, Mekawichai P, Chayakulkeeree M. Clinical Features of Cryptococcal Meningoencephalitis in HIV-Positive and -Negative Patients in a Resource-Limited Setting. J Fungi (Basel) 2023; 9:869. [PMID: 37754977 PMCID: PMC10532421 DOI: 10.3390/jof9090869] [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: 07/18/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
Cryptococcal meningoencephalitis is a systemic fungal infection in immunocompromised and immunocompetent individuals. This study investigated the clinical characteristics and factors associated with mortality in HIV-associated and non-HIV-associated cryptococcal meningoencephalitis in a resource-limited setting. This was a retrospective cohort study of patients with cryptococcal meningoencephalitis between January 2009 and December 2019 at a tertiary teaching hospital in Thailand. Overall, 1019 patients with cryptococcal meningoencephalitis were enrolled, and 923 (90.6%) were HIV-positive. The patients with HIV-associated cryptococcal meningoencephalitis were younger than the HIV-negative patients (37 versus 56 years, p < 0.01). The HIV-negative patients were more likely to have underlying conditions (52.1% versus 7.5%; p < 0.01), had a longer median duration of headaches prior to admission (14 days versus 6 days, p < 0.01), and were more likely to have an altered mental status at presentation (36.5% versus 18.6%, p < 0.01) and pulmonary involvement (15.6% versus 0.8%, p < 0.01). The HIV-positive patients had lower cerebrospinal fluid (CSF) white blood cell counts (4 versus 94 cells/mm3; p < 0.01), lower CSF protein (69 versus 157 mg/dL; p < 0.01), higher CSF glucose (38.8 versus 21 mg/dL; p < 0.01), and more frequent cryptococcemia (44.1% versus 20.5%; p < 0.01). The mortality rate was high but not significantly different between the two groups (30.2% versus 33.2%; p = 0.53). The HIV-positive patients with comorbidities, fever, an altered mental status at presentation, a CSF white blood cell count below 20 cell/mm3, fungemia, and positive CSF India ink were independently associated with 30-day mortality. In comparison, an altered mental status at presentation and fungemia were associated with 30-day mortality in HIV-negative patients. In conclusion, HIV-negative patients with cryptococcal meningoencephalitis had more extensive central nervous system inflammation, although the two groups' mortality rates were similar. Unfavorable prognostic factors included comorbidities, fever, an altered mental status at presentation, a low CSF white blood cell count, fungemia, and positive CSF India ink.
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Affiliation(s)
- Rattagan Kajeekul
- Department of Internal Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima 30000, Thailand;
| | - Pawut Mekawichai
- Department of Internal Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima 30000, Thailand;
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Stack M, Hiles J, Valinetz E, Gupta SK, Butt S, Schneider JG. Cryptococcal Meningitis in Young, Immunocompetent Patients: A Single-Center Retrospective Case Series and Review of the Literature. Open Forum Infect Dis 2023; 10:ofad420. [PMID: 37636518 PMCID: PMC10456216 DOI: 10.1093/ofid/ofad420] [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: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
Background Cryptococcal meningitis is an uncommon but serious infection with high mortality and morbidity. Classically described in immunocompromised patients, including those with solid organ transplants or HIV/AIDS, cryptococcosis has also been reported in young and otherwise healthy patients, albeit rarely. Methods We retrospectively searched for all cases of cryptococcal meningitis in young (≤50 years) and previously healthy patients with no known immunocompromising conditions from January 2015 to January 2022 at Indiana University Health (IU Health). Additionally, a PubMed literature review was performed with the keywords "cryptococcal meningitis" and "immunocompetent" from January 1988 to January 2022. Clinical courses, including outcomes and treatment regimens, were evaluated. Results We identified 4 local cases of cryptococcal meningitis in otherwise healthy patients age ≤50 years. Three cases were due to Cryptococcus neoformans, with 1 experiencing a postinfectious inflammatory response syndrome (PIIRS). The PubMed search identified 51 additional cases, with 32 (63%) being caused by Cryptococcus neoformans and 8 (17%) by Cryptococcus gattii. Of the 51 cases, only 2 resulted in death directly due to cryptococcosis. Fifteen (29%) had PIIRS, with steroid treatment documented in 11 of 15. Antifungal induction regimens and duration were varied but predominately consisted of amphotericin and flucytosine, with a mean induction duration of 5.0 weeks. Conclusions Cryptococcal meningitis in young, previously healthy patients is likely under-recognized. PIIRS (akin to immune reconstitution inflammatory syndrome observed in HIV/AIDS) with prolonged recovery should be of concern. Determining risk factors for cryptococcosis in these patients remains elusive.
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Affiliation(s)
- Matthew Stack
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jon Hiles
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Health, Indianapolis, Indiana, USA
| | - Ethan Valinetz
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samir K Gupta
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Saira Butt
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jack G Schneider
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Jackson KM, Ding M, Nielsen K. Importance of Clinical Isolates in Cryptococcus neoformans Research. J Fungi (Basel) 2023; 9:364. [PMID: 36983532 PMCID: PMC10056780 DOI: 10.3390/jof9030364] [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: 02/20/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023] Open
Abstract
The human pathogenic fungus Cryptococcus neoformans is a global health concern. Previous research in the field has focused on studies using reference strains to identify virulence factors, generate mutant libraries, define genomic structures, and perform functional studies. In this review, we discuss the benefits and drawbacks of using reference strains to study C. neoformans, describe how the study of clinical isolates has expanded our understanding of pathogenesis, and highlight how studies using clinical isolates can further develop our understanding of the host-pathogen interaction during C. neoformans infection.
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Affiliation(s)
| | | | - Kirsten Nielsen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455, USA
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Kaur H, Gupta P, Pilania R, Suri D, Singh S, Ghosh A, Rudramurthy SM. Trend of pediatric cryptococcosis in a tertiary care centre and review of literature. Indian J Med Microbiol 2022; 43:18-29. [PMID: 36464534 DOI: 10.1016/j.ijmmb.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/28/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE Cryptococcosis is one of the most significant systemic fungal infections worldwide. Epidemiological data for pediatric cryptococcosis is very limited. Therefore, we planned this study to determine the burden of cryptococcosis in the pediatric population at our tertiary care center and performed review of literature. MATERIAL AND METHODS In this retrospective study, all the patients less than 18 years of age were diagnosed with cryptococcosis, from January 2015-June 2021 were included. Demographic, clinical, and laboratory details of all the patients were noted. Furthermore, PubMed and MedLine databases were comprehensively searched for cases of pediatric cryptococcosis till June 2021. RESULTS Of the total 5420 samples from suspected cryptococcosis cases processed at mycology laboratory, a total of 21 episodes of cryptococcosis (0.39%) were identified in 15 pediatric patients. The majority of the patients were apparently immunocompetent (10/15). Central nervous system (CNS) cryptococcosis was the most common presentation, followed by disseminated disease. All the isolates were identified as Cryptococcus neoformans (formerly referred to as C. neoformans var grubii), except one that was identified as Papiliotrema laurentii (formerly referred to as Cryptococcus laurentii). A standard treatment regimen inclusive of induction and maintenance therapy was provided in only five patients. The literature review revealed a total of 125 studies describing 1134 cases, of which 76.4% are reported from outside Asia, the majority (65.7%) restricted to CNS with C. neoformans as the commonest species. The management profile divulged a significantly higher use of standard drug regimen in Asia as compared to the rest of the world. Mortality of 13.32% was noted worldwide. CONCLUSION To the best of our knowledge, this is the first clinico-epidemiological study of pediatric cryptococcosis from India and the largest retrospective study worldwide. The rising incidence among immunocompetent individuals, especially in Asia, is a matter of concern. Clinical suspicion and early diagnosis are the cornerstones for the management of cases.
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Affiliation(s)
- Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | | | - Rakesh Pilania
- Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anup Ghosh
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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12
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Ruma YN, Keniya MV, Monk BC. Exploring Cryptococcus neoformans CYP51 and Its Cognate Reductase as a Drug Target. J Fungi (Basel) 2022; 8:jof8121256. [PMID: 36547589 PMCID: PMC9785471 DOI: 10.3390/jof8121256] [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: 11/02/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Cryptococcus remains a leading cause of invasive fungal infections in immunocompromised people. Resistance to azole drugs has imposed a further challenge to the effective treatment of such infections. In this study, the functional expression of full-length hexahistidine-tagged Cryptococcus neoformans CYP51 (CnCYP51-6×His), with or without its cognate hexahistidine-tagged NADPH-cytochrome P450 reductase (CnCPR-6×His), in a Saccharomyces cerevisiae host system has been used to characterise these enzymes. The heterologous expression of CnCYP51-6×His complemented deletion of the host CYP51 and conferred increased susceptibility to both short-tailed and long-tailed azole drugs. In addition, co-expression of CnCPR-6×His decreased susceptibility 2- to 4-fold for short-tailed but not long-tailed azoles. Type 2 binding of azoles to CnCYP51-6×His and assay of NADPH cytochrome P450 reductase activity confirmed that the heterologously expressed CnCYP51 and CnCPR are functional. The constructs have potential as screening tools and use in structure-directed antifungal discovery.
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Affiliation(s)
- Yasmeen N. Ruma
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin 9016, New Zealand
| | - Mikhail V. Keniya
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin 9016, New Zealand
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, NJ 07110, USA
| | - Brian C. Monk
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin 9016, New Zealand
- Correspondence:
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13
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Howard-Jones AR, Sparks R, Pham D, Halliday C, Beardsley J, Chen SCA. Pulmonary Cryptococcosis. J Fungi (Basel) 2022; 8:1156. [PMID: 36354923 PMCID: PMC9696922 DOI: 10.3390/jof8111156] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 07/25/2023] Open
Abstract
Pulmonary cryptococcosis describes an invasive lung mycosis caused by Cryptococcus neoformans or Cryptococcus gattii complex. It is often a high-consequence disease in both immunocompromised and immunocompetent populations, and may be misdiagnosed as pulmonary malignancy, leading to a delay in therapy. Epidemiology follows that of cryptococcal meningoencephalitis, with C. gattii infection more common in certain geographic regions. Diagnostic tools include histopathology, microscopy and culture, and the detection of cryptococcal polysaccharide antigen or Cryptococcus-derived nucleic acids. All patients with lung cryptococcosis should have a lumbar puncture and cerebral imaging to exclude central nervous system disease. Radiology is key, both as an adjunct to laboratory testing and as the initial means of detection in asymptomatic patients or those with non-specific symptoms. Pulmonary cryptococcomas (single or multiple) may also be associated with disseminated disease and/or cryptococcal meningitis, requiring prolonged treatment regimens. Optimal management for severe disease requires extended induction (amphotericin B and flucytosine) and consolidation therapy (fluconazole) with close clinical monitoring. Susceptibility testing is of value for epidemiology and in regions where relatively high minimum inhibitory concentrations to azoles (particularly fluconazole) have been noted. Novel diagnostic tools and therapeutic agents promise to improve the detection and treatment of cryptococcosis, particularly in low-income settings where the disease burden is high.
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Affiliation(s)
- Annaleise R. Howard-Jones
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
| | - Rebecca Sparks
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - David Pham
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Catriona Halliday
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Justin Beardsley
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Sharon C.-A. Chen
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
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14
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Ngan NTT, Flower B, Day JN. Treatment of Cryptococcal Meningitis: How Have We Got Here and Where are We Going? Drugs 2022; 82:1237-1249. [PMID: 36112342 PMCID: PMC9483520 DOI: 10.1007/s40265-022-01757-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/26/2022]
Abstract
Cryptococcal meningitis is a devastating brain infection cause by encapsulated yeasts of the Cryptococcus genus. Exposure, through inhalation, is likely universal by adulthood, but symptomatic infection only occurs in a minority, in most cases, months or years after exposure. Disease has been described in almost all tissues, but it is the organism’s tropism for the central nervous system that results in the most devastating illness. While invasive disease can occur in the immunocompetent, the greatest burden by far is in immunocompromised individuals, particularly people living with human immunodeficiency virus (HIV), organ transplant recipients and those on glucocorticoid therapy or other immunosuppressive drugs. Clinical presentation is variable, but diagnosis is usually straightforward, with cerebrospinal fluid microscopy, culture, and antigen testing proving significantly more sensitive than diagnostic tests for other brain infections. Although disease incidence has reduced since the advent of effective HIV therapy, mortality when disease occurs remains extremely high, and has changed little in recent decades. This Therapy in Practice review is an update of a talk first given by JND at the European Congress on Clinical Microbiology and Infectious Diseases in 2019 in the Netherlands. The review contextualizes the most recently published World Health Organization (WHO) guidelines for the treatment of HIV-associated cryptococcal meningitis in terms of the data from large, randomized, controlled trials published between 1997 and 2022. We discuss the rationale for induction and maintenance therapy and the efficacy and undesirable effects of the current therapeutic armamentarium of amphotericin, flucytosine and fluconazole. We address recent research into repurposed drugs such as sertraline and tamoxifen, and potential future treatment options, including the novel antifungals fosmanogepix, efungumab and oteseconazole, and non-pharmaceutical solutions such as neurapheresis cerebrospinal fluid filtration.
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Affiliation(s)
- Nguyen Thi Thuy Ngan
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Barnaby Flower
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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15
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Abstract
Cryptococcosis is a disease caused by the pathogenic fungi Cryptococcus neoformans and Cryptococcus gattii, both environmental fungi that cause severe pneumonia and may even lead to cryptococcal meningoencephalitis. Although C. neoformans affects more fragile individuals, such as immunocompromised hosts through opportunistic infections, C. gattii causes a serious indiscriminate primary infection in immunocompetent individuals. Typically seen in tropical and subtropical environments, C. gattii has increased its endemic area over recent years, largely due to climatic factors that favor contagion in warmer climates. It is important to point out that not only C. gattii, but the Cryptococcus species complex produces a polysaccharidic capsule with immunomodulatory properties, enabling the pathogenic species of Cryptococccus to subvert the host immune response during the establishment of cryptococcosis, facilitating its dissemination in the infected organism. C. gattii causes a more severe and difficult-to-treat infection, with few antifungals eliciting an effective response during chronic treatment. Much of the immunopathology of this cryptococcosis is still poorly understood, with most studies focusing on cryptococcosis caused by the species C. neoformans. C. gattii became more important in the epidemiological scenario with the outbreaks in the Pacific Northwest of the United States, which resulted in phylogenetic studies of the virulent variant responsible for the severe infection in the region. Since then, the study of cryptococcosis caused by C. gattii has helped researchers understand the immunopathological aspects of different variants of this pathogen.
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16
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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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17
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de Oliveira L, Melhem MDSC, Buccheri R, Chagas OJ, Vidal JE, Diaz-Quijano FA. Early clinical and microbiological predictors of outcome in hospitalized patients with cryptococcal meningitis. BMC Infect Dis 2022; 22:138. [PMID: 35139801 PMCID: PMC8830130 DOI: 10.1186/s12879-022-07118-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cryptococcal meningitis causes high mortality in immunocompromised and immunocompetent patients. The objective of this study was to identify early predictors of clinical outcome, available at the first days of hospitalization, in patients with cryptococcal meningitis in a tertiary center in Brazil. Methods Ninety-six cases of cryptococcal meningitis with clinical, epidemiological and laboratory data, and identification and antifungal susceptibility of the strains were analyzed. Quantitative CSF yeast counts were performed by direct microscopic exam with a Fuchs-Rosenthal cell counting chamber using an institutional protocol. Univariable and multiple analyses using logistic regression were performed to identify predictors, available at the beginning of hospitalization, of in-hospital mortality. Moreover, we performed a secondary analysis for a composite outcome defined by hospital mortality and intensive care unit transfer. Results The species and the antifungal susceptibility were not associated with the outcomes evaluated. The variables significantly associated with the mortality were age (OR = 1.08, 95% CI 1.02–1.15), the cerebrospinal fluid (CSF) yeasts count (OR = 1.65, 95% CI 1.20–2.27), systemic arterial hypertension (OR = 22.63, 95% CI 1.64–312.91) and neurological impairment identified by computed tomography (OR = 41.73, 95% CI 3.10–561.65). At the secondary analysis, CSF yeast count was also associated with the composite outcome, in addition to the culture of Cryptococcus spp. from bloodstream and cerebral toxoplasmosis. The associations were consistent with survival models evaluated. Conclusions Age and CSF yeast count were independently associated with in-hospital mortality of patients with cryptococcal meningitis but Cryptococcus species identification and antifungal susceptibility were not associated with the outcomes. Quantitative CSF yeast counts used in this study can be evaluated and implemented in other low and middle-income settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07118-7.
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Affiliation(s)
- Lidiane de Oliveira
- Department of Epidemiology, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP, CEP 01246-904, Brazil.
| | - Marcia de Souza Carvalho Melhem
- Mycology Unit of Adolfo Lutz Institute, Public Health Reference Laboratory, Secretary of Health, Av. Dr.Arnaldo, 351, São Paulo, SP, CEP 05411-000, Brazil.,School of Medicine, Federal University of Mato Grosso do Sul, Bairro Universitário, Av. Costa e Silva, s/no, Campo Grande, MS, CEP 79070-900, Brazil
| | - Renata Buccheri
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil
| | - Oscar José Chagas
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil
| | - José Ernesto Vidal
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil.,Department of Infectious Diseases, Hospital das Clinicas, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 470, São Paulo, SP, CEP 01246-904, Brazil
| | - Fredi Alexander Diaz-Quijano
- Department of Epidemiology, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP, CEP 01246-904, Brazil
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18
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McCabe GA, McHugh JW, Goodwin T, Johnson DF, Fok A, Campbell TG. Ophthalmic manifestations of Cryptococcus gattii species complex: a case series and review of the literature. Int J Ophthalmol 2022; 15:119-127. [PMID: 35047366 DOI: 10.18240/ijo.2022.01.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 06/25/2021] [Indexed: 12/18/2022] Open
Abstract
AIM To report 4 cases of Cryptococcus gattii (C. gattii) species complex infection with diverse ophthalmic manifestations, and to review the literature to examine pathobiology of disease, classical ophthalmic presentations and outcomes, and treatment modalities for this emerging pathogen. METHODS Cases of C. gattii meningoencephalitis with ophthalmic manifestations were identified via chart review at two institutions in Australia and one institution in the mid-west region of the United States and are reported as a case series. Additionally, a MEDLINE literature review was conducted to identify all reported cases of C. gattii with ophthalmic manifestations from 1990-2020. Cases were reviewed and tabulated, together with our series of patients, in this report. RESULTS Four cases of C. gattii with ophthalmic manifestations are presented; three from Australia and one from the USA. A literature review identified a total of 331 cases of C. gattii with visual sequelae. The majority of cases occurred in immunocompetent individuals. Blurred vision and diplopia were the most common presenting symptoms, with papilloedema the most common sign, reported in 10%-50% of cases. Visual loss was reported in 10%-53% of cases, as compared to rates of visual loss of 1%-9% in C. neoformans infection. Elevated intracranial pressure, cerebrospinal fluid (CSF) fungal burden, and abnormal neurological exam at presentation correlated with poor visual outcomes. The mainstays of treatment are anti-fungal agents and aggressive management of intracranial hypertension with serial lumbar punctures. CSF diversion procedures should be considered for refractory cases. Acetazolamide and mannitol are associated with high complication rates, and adjuvant corticosteroids have demonstrated higher mortality rates; these treatments should be avoided. CONCLUSION Permanent visual loss represents a devastating yet potentially preventable sequelae of C. gattii infection. Intracranial hypertension needs to be recognised early and aggressively managed. Referral to an ophthalmologist/neuro-ophthalmologist in all cases of cryptococcal infection independent of visual symptoms at time of diagnosis is recommended.
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Affiliation(s)
- Grace A McCabe
- Department of Ophthalmology, the Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
| | - Jack W McHugh
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55902, USA
| | - Todd Goodwin
- James Cook University, Townsville, Queensland 4811, Australia.,NQ Eye Foundation, Townsville, Queensland 4811, Australia
| | - Douglas F Johnson
- Department of Infectious Disease, the Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
| | - Anthony Fok
- Department of Neurology, the Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
| | - Thomas G Campbell
- Department of Ophthalmology, the Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia.,NQ Eye Foundation, Townsville, Queensland 4811, Australia.,Centre for Eye Research Australia, East Melbourne, Victoria 3002, Australia.,Ophthalmology, Department of Surgery, the University of Melbourne, Melbourne, Victoria 3010, Australia
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19
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Ngan NTT, Thanh Hoang Le N, Vi Vi NN, Van NTT, Mai NTH, Van Anh D, Trieu PH, Lan NPH, Phu NH, Chau NVV, Lalloo DG, Hope W, Beardsley J, White NJ, Geskus R, Thwaites GE, Krysan D, Tai LTH, Kestelyn E, Binh TQ, Hung LQ, Tung NLN, Day JN. An open label randomized controlled trial of tamoxifen combined with amphotericin B and fluconazole for cryptococcal meningitis. eLife 2021; 10:68929. [PMID: 34581270 PMCID: PMC8547950 DOI: 10.7554/elife.68929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background Cryptococcal meningitis has high mortality. Flucytosine is a key treatment but is expensive and rarely available. The anticancer agent tamoxifen has synergistic anti-cryptococcal activity with amphotericin in vitro. It is off-patent, cheap, and widely available. We performed a trial to determine its therapeutic potential. Methods Open label randomized controlled trial. Participants received standard care - amphotericin combined with fluconazole for the first 2 weeks - or standard care plus tamoxifen 300 mg/day. The primary end point was Early Fungicidal Activity (EFA) - the rate of yeast clearance from cerebrospinal fluid (CSF). Trial registration https://clinicaltrials.gov/ct2/show/NCT03112031. Results Fifty patients were enrolled (median age 34 years, 35 male). Tamoxifen had no effect on EFA (-0.48log10 colony-forming units/mL/CSF control arm versus -0.49 tamoxifen arm, difference -0.005log10CFU/ml/day, 95% CI: -0.16, 0.15, p=0.95). Tamoxifen caused QTc prolongation. Conclusions High-dose tamoxifen does not increase the clearance rate of Cryptococcus from CSF. Novel, affordable therapies are needed. Funding The trial was funded through the Wellcome Trust Asia Programme Vietnam Core Grant 106680 and a Wellcome Trust Intermediate Fellowship to JND grant number WT097147MA.
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Affiliation(s)
- Nguyen Thi Thuy Ngan
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Viet Nam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | - Nguyen Ngo Vi Vi
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | | | - Duong Van Anh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Phan Hai Trieu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - William Hope
- Centre of Excellence in Infectious Disease Research, Institute of Translational Medicine, Liverpool University, Liverpool, United Kingdom
| | - Justin Beardsley
- The University of Sydney, Marie Bashir Institute, NSW, Camperdown, Australia.,Westmead Institute for Medical Research, Westmead, Australia
| | - Nicholas J White
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ronald Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Damian Krysan
- Department of Paediatrics and Microbiology/Immunology, Carver College of Medicine, University of Iowa, Iowa City, United States
| | | | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Tran Quang Binh
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | - Le Quoc Hung
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | | | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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20
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Tsai ST, Lin FY, Chen PS, Chiang HY, Kuo CC. Three-year mortality in cryptococcal meningitis: Hyperglycemia predict unfavorable outcome. PLoS One 2021; 16:e0251749. [PMID: 34048463 PMCID: PMC8162582 DOI: 10.1371/journal.pone.0251749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 05/02/2021] [Indexed: 11/18/2022] Open
Abstract
Existing evidence revealed grave prognosis for cryptococcal meningitis (CM), particularly its short-term mortality. However, its long-term survival and prognostic factors remained unknown. This study investigated 3-year mortality and analyzed its predictive factors in patients with CM. This retrospective cohort study with 83 cerebrospinal fluid culture-confirmed CM patients was conducted at China Medical University Hospital from 2003 to 2016. The 3-year mortality rate in patients with CM was 54% (45 deaths among 83 patients). Advanced age, human immunodeficiency virus (HIV) seronegative state, low Glasgow Coma Scale score on admission, decreased hemoglobin and hyperglycemia on diagnosis were associated with 3-year mortality. After multivariate adjustment in the Cox proportional hazard model, only severe hyperglycemia (serum glucose ≥200 mg/dL) on diagnosis could predict 3-year mortality.
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Affiliation(s)
- Sheng-Ta Tsai
- Department of Neurology, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Fu-Yu Lin
- Department of Neurology, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
- * E-mail:
| | - Pei-Shan Chen
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Chin-Chi Kuo
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
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21
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The interplay of phenotype and genotype in Cryptococcus neoformans disease. Biosci Rep 2021; 40:226594. [PMID: 33021310 PMCID: PMC7569153 DOI: 10.1042/bsr20190337] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 12/17/2022] Open
Abstract
Cryptococcus neoformans is an opportunistic fungal pathogen that causes life-threatening meningitis primarily in immunocompromised individuals. In order to survive and proliferate during infection, C. neoformans must adapt to a variety of stresses it encounters within the host. Patient outcome depends on the interaction between the pathogen and the host. Understanding the mechanisms that C. neoformans uses to facilitate adaptation to the host and promote pathogenesis is necessary to better predict disease severity and establish proper treatment. Several virulence phenotypes have been characterized in C. neoformans, but the field still lacks a complete understanding of how genotype and phenotype contribute to clinical outcome. Furthermore, while it is known that C. neoformans genotype impacts patient outcome, the mechanisms remain unknown. This lack of understanding may be due to the genetic heterogeneity of C. neoformans and the extensive phenotypic variation observed between and within isolates during infection. In this review, we summarize the current understanding of how the various genotypes and phenotypes observed in C. neoformans correlate with human disease progression in the context of patient outcome and recurrence. We also postulate the mechanisms underlying the genetic and phenotypic changes that occur in vivo to promote rapid adaptation in the host.
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22
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Paccoud O, Bougnoux ME, Desnos-Ollivier M, Varet B, Lortholary O, Lanternier F. Cryptococcus gattii in Patients with Lymphoid Neoplasms: An Illustration of Evolutive Host-Fungus Interactions. J Fungi (Basel) 2021; 7:212. [PMID: 33809570 PMCID: PMC8001097 DOI: 10.3390/jof7030212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 12/12/2022] Open
Abstract
Recent outbreaks of Cryptococcus gattii (CG) infections in North America have sparked renewed interest in the pathogenic potential of CG, and have underscored notable differences with Cryptococcus neoformans in terms of geographic distribution, pathogen virulence, and host susceptibility. While cases of CG are increasingly reported in patients with a wide variety of underlying conditions, only very few have been reported in patients with lymphoid neoplasms. Herein, we report a case of autochthonous CG meningitis in a patient receiving ibrutinib for chronic lymphocytic leukemia in France, and review available data on the clinical epidemiology of CG infections in patients with lymphoid neoplasms. We also summarise recent data on the host responses to CG infection, as well as the potential management pitfalls associated with its treatment in the haematological setting. The clinical epidemiology, clinical presentation, and course of disease during infections caused by CG involve complex interactions between environmental exposure to CG, infecting genotype, pathogen virulence factors, host susceptibility, and host immune responses. Future treatment guidelines should address the challenges associated with the management of antifungal treatments in the onco-haematological setting and the potential drug-drug interactions.
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Affiliation(s)
- Olivier Paccoud
- University of Paris, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), 75015 Paris, France; (O.P.); (O.L.)
| | - Marie-Elisabeth Bougnoux
- University of Paris, Department of Mycology, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), 75015 Paris, France;
| | - Marie Desnos-Ollivier
- Molecular Mycology Unit, Centre National de la Recherche Scientifique (CNRS), National Reference Center for Invasive Mycoses & Antifungals (NRCMA), Pasteur Institute, UMR2000, 75015 Paris, France;
| | - Bruno Varet
- University of Paris, Department of Hematology, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), 75015 Paris, France;
| | - Olivier Lortholary
- University of Paris, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), 75015 Paris, France; (O.P.); (O.L.)
- Molecular Mycology Unit, Centre National de la Recherche Scientifique (CNRS), National Reference Center for Invasive Mycoses & Antifungals (NRCMA), Pasteur Institute, UMR2000, 75015 Paris, France;
| | - Fanny Lanternier
- University of Paris, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), 75015 Paris, France; (O.P.); (O.L.)
- Molecular Mycology Unit, Centre National de la Recherche Scientifique (CNRS), National Reference Center for Invasive Mycoses & Antifungals (NRCMA), Pasteur Institute, UMR2000, 75015 Paris, France;
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Thanh LT, Toffaletti DL, Tenor JL, Giamberardino C, Sempowski GD, Asfaw Y, Phan HT, Van Duong A, Trinh NM, Thwaites GE, Ashton PM, Chau NVV, Baker SG, Perfect JR, Day JN. Assessing the virulence of Cryptococcus neoformans causing meningitis in HIV infected and uninfected patients in Vietnam. Med Mycol 2020; 58:1149-1161. [PMID: 32196550 PMCID: PMC7657091 DOI: 10.1093/mmy/myaa013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
We previously observed a substantial burden of cryptococcal meningitis in Vietnam atypically arising in individuals who are uninfected with human immunodeficiency virus (HIV). This disease was associated with a single genotype of Cryptococcus neoformans (sequence type [ST]5), which was significantly less common in HIV-infected individuals. Aiming to compare the phenotypic characteristics of ST5 and non-ST5 C. neoformans, we selected 30 representative Vietnamese isolates and compared their in vitro pathogenic potential and in vivo virulence. ST5 and non-ST5 organisms exhibited comparable characteristics with respect to in vitro virulence markers including melanin production, replication at 37°C, and growth in cerebrospinal fluid. However, the ST5 isolates had significantly increased variability in cellular and capsular sizing compared with non-ST5 organisms (P < .001). Counterintuitively, mice infected with ST5 isolates had significantly longer survival with lower fungal burdens at day 7 than non-ST5 isolates. Notably, ST5 isolates induced significantly greater initial inflammatory responses than non-ST5 strains, measured by TNF-α concentrations (P < .001). Despite being generally less virulent in the mouse model, we hypothesize that the significant within strain variation seen in ST5 isolates in the tested phenotypes may represent an evolutionary advantage enabling adaptation to novel niches including apparently immunocompetent human hosts.
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Affiliation(s)
- Lam Tuan Thanh
- Oxford University Clinical Research Unit, Wellcome Trust Asia Africa Programme, Ho Chi Minh City, Vietnam
| | - Dena L Toffaletti
- Division of Infectious Diseases, Department of Medicine and Department of Molecular Genetics and Microbiology, Duke University, North Carolina, USA
| | - Jennifer L Tenor
- Division of Infectious Diseases, Department of Medicine and Department of Molecular Genetics and Microbiology, Duke University, North Carolina, USA
| | - Charles Giamberardino
- Division of Infectious Diseases, Department of Medicine and Department of Molecular Genetics and Microbiology, Duke University, North Carolina, USA
| | - Gregory D Sempowski
- Duke Human Vaccine Institute and Regional Biocontainment Laboratory, Duke University, North Carolina, USA
| | - Yohannes Asfaw
- Division of Laboratory Animal Resources, Duke University, North Carolina, USA
| | - Hai Trieu Phan
- Oxford University Clinical Research Unit, Wellcome Trust Asia Africa Programme, Ho Chi Minh City, Vietnam
| | - Anh Van Duong
- Oxford University Clinical Research Unit, Wellcome Trust Asia Africa Programme, Ho Chi Minh City, Vietnam
| | - Nguyen Mai Trinh
- Oxford University Clinical Research Unit, Wellcome Trust Asia Africa Programme, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Wellcome Trust Asia Africa Programme, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philip M Ashton
- Oxford University Clinical Research Unit, Wellcome Trust Asia Africa Programme, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Stephen G Baker
- Cambridge Institute of Therapeutic immunology and Infectious Disease, Department of Medicine, University of Cambridge, Cambridge, UK
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine and Department of Molecular Genetics and Microbiology, Duke University, North Carolina, USA
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Wellcome Trust Asia Africa Programme, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Khan F, Khattab M, Qamar M, Al Maslamani M, Al Soub H, Deshmukh A. Cryptococcal meningitis in Qatar: A hospital based study from 2005-2015. IBNOSINA JOURNAL OF MEDICINE AND BIOMEDICAL SCIENCES 2020. [DOI: 10.4103/ijmbs.ijmbs_5_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Clinical and microbiological characteristics of cryptococcosis at an university hospital in China from 2013 to 2017. Braz J Infect Dis 2019; 24:7-12. [PMID: 31870760 PMCID: PMC9392018 DOI: 10.1016/j.bjid.2019.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 11/02/2019] [Accepted: 11/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background This study aims to explore the epidemiology, clinical profile and strain characteristics of cryptococcosis from 2013 to 2017 in a major teaching hospital in China. Methods Trends in antifungal drug susceptibility of 217 consecutive non-repetitive cryptococcal isolates collected from patients of an university hospital in China were analyzed between 2013 and 2017. Of those, 98 isolates were conserved for identification by internal transcribed spacer (ITS) sequencing and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) system. Multilocus sequence typing (MLST) was used to designate molecular types. Clinical characteristics of the 98 patients with cryptococcosis during the period of 2013–2017 were retrospectively evaluated. Results There was a trend for gradual increase in the MIC range of fluconazole was from 2013 to 2017. The conserved 98 clinical cryptococcal isolates included 97 C. neoformans and one C. gattii, and 90 (91.8%) isolates belonged to ST5 genotype VNI. Out of the 98 patients with cryptococcosis, 28 (28.6%) were HIV-infected and 32 (32.7%) had no underlying diseases. HIV-infected patients had higher mortality than HIV-uninfected patients (28.6% vs 14.3%, p = 0.147). Conclusions Most of the patients with cryptococcosis were not HIV-infected in this study, while patients with HIV had a higher mortality. Reduced susceptibility to fluconazole was observed among C. neoformans isolates, most of them belonged to ST5 genotype VNI having an impact on the effective dose of fluconazole.
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Hai TP, Van AD, Ngan NTT, Nhat LTH, Lan NPH, Vinh Chau NV, Thwaites GE, Krysan D, Day JN. The combination of tamoxifen with amphotericin B, but not with fluconazole, has synergistic activity against the majority of clinical isolates of Cryptococcus neoformans. Mycoses 2019; 62:818-825. [PMID: 31173410 PMCID: PMC6771715 DOI: 10.1111/myc.12955] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cryptococcal meningitis has fatality rates of 40%-70%, resulting in 200 000 deaths each year. The best outcomes are achieved with amphotericin combined with flucytosine but flucytosine is expensive and unavailable where most disease occurs. More effective and affordable treatments are needed. Tamoxifen, a selective oestrogen receptor modulator frequently indicated for breast cancer, has been found to have synergistic activity against the Cryptococcus neoformans type strain when combined with amphotericin or fluconazole. It is cheap, off-licence, widely available and well-tolerated, and thus a pragmatic potential treatment for cryptococcal disease. OBJECTIVES We wanted to determine the susceptibility of clinical isolates of C. neoformans to tamoxifen alone and in combination with other antifungals, to determine whether there is sufficient evidence of activity to justify a clinical trial. METHODS We used the CLSI broth microdilution protocol to test the susceptibility of 30 randomly selected clinical isolates of C. neoformans to tamoxifen, in dual combination with amphotericin, fluconazole or flucytosine, and in triple combination with amphotericin and fluconazole. Evidence of drug interactions was assessed using the fractional inhibitory concentration index. RESULTS The MIC50 and MIC90 of tamoxifen were 4 and 16 mg/L, respectively. The combination of tamoxifen and amphotericin suggested a synergistic interaction in 20 of 30 (67%) isolates. There was no interaction between tamoxifen and either fluconazole or flucytosine. Synergy was maintained in 3-Dimensional chequerboard testing. There was no evidence of antagonism. CONCLUSIONS Tamoxifen may be a useful addition to treatment with amphotericin and fluconazole for cryptococcal meningitis; a trial is justified.
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Affiliation(s)
- Trieu Phan Hai
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Anh Duong Van
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Nguyen Thi Thuy Ngan
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Cho Ray HospitalHo Chi Minh cityViet Nam
| | | | | | | | - Guy E. Thwaites
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Damian Krysan
- Department of Pediatrics and Microbiology/ImmunologyUniversity of IowaIowa CityIowaUSA
| | - Jeremy N. Day
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine, Nuffield Department of MedicineUniversity of OxfordOxfordUK
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Huang SH, Chuang YC, Lee YC, Hung CC, Sheng WH, Su JJ, Sun HY, Chen YC, Chang SC. Lumbar puncture for non-HIV-infected non-transplant patients with cryptococcosis: Should it be mandatory for all? PLoS One 2019; 14:e0221657. [PMID: 31437259 PMCID: PMC6705819 DOI: 10.1371/journal.pone.0221657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The indications for lumbar puncture in non-HIV-infected, non-transplant (NHNT) patients with cryptococcosis without meningeal signs need to be more fully defined. OBJECTIVES This study was designed to determine the optimal predictors of central nervous system (CNS) involvement in adult NHNT patients with cryptococcosis. METHODS The study population consisted of adult NHNT patients with culture-confirmed cryptococcosis who sought care at a university hospital in Taiwan from 2002 to 2016. We used a case-control method to identify the clinical characteristics and laboratory findings associated with CNS involvement in patients who underwent a diagnostic lumbar puncture. In the sensitivity analysis, we included additional control patients who did not undergo lumbar puncture, but were followed beyond 12 months without the development of CNS involvement in the absence of exposure to any fungicidal agents. RESULTS We entered 270 NHNT adult patients into the study during the 15-year period. CNS involvement was confirmed in 66 (71.0%) of 93 patients who underwent lumbar puncture. A multivariable analysis revealed that presence of neurological manifestations and elevated serum CRAG titers were independently associated with a 23.97-fold (95% confidence interval [CI], 4.37-182.23) and 1.53-fold (per 2-fold increment, 95% CI 1.26-1.92) increased odds ratio for CNS involvement, respectively. Headache and focal neurologic signs were independently associated with CNS involvement. A cut-off serum CRAG titer of ≥1:64 provided the highest diagnostic performance by Youden index (sensitivity 83% and specificity 65%). Similar findings were noted in the sensitivity analysis including 198 (73%) patients. CONCLUSION Lumbar puncture is indicated for NHNT patients with cryptococcosis who have neurologic manifestations or a serum CRAG titer of ≥1:64.
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Affiliation(s)
- Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chien Lee
- Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei, Taiwan
| | - Chien-Ching Hung
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen Jen Su
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail:
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan
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28
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Du W, Li H, Tian B, Sai S, Gao Y, Lan T, Meng Y, Ding C. Development of nose-to-brain delivery of ketoconazole by nanostructured lipid carriers against cryptococcal meningoencephalitis in mice. Colloids Surf B Biointerfaces 2019; 183:110446. [PMID: 31465938 DOI: 10.1016/j.colsurfb.2019.110446] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 07/25/2019] [Accepted: 08/18/2019] [Indexed: 11/26/2022]
Abstract
Cryptococcus neoformans-mediated meningoencephalitis is a critical infectious disorder of the human central nervous system. However, efficient treatment for the disease is limited due to the poor penetration across the blood brain barrier (BBB). Here, we develop a nose-to-brain drug delivery system utilizing nanostructured lipid carriers (NLCs). We demonstrated that fluorescent-dye-loaded NLCs efficiently uptake into the cytoplasm of encapsulated C. neoformans cells. In comparison with current antifungal drugs, the ketoconazole (keto)-NLCs show significantly increased antifungal activity against C. neoformans in vivo under various growth conditions. The NLCs show enhanced tissue colonization properties. Importantly, using animal imaging analyses, NLCs are able to enter brain tissues via the olfactory bulb region by intranasal administration, bypassing the BBB. In addition, NLCs maintain prolonged residence in tissues. In mouse brain tissue, keto-NLCs showed significantly enhanced antifungal activity when administered intranasally, drastically dampening the C. neoformans burden. Taken together, NLCs not only improve the ketoconazole penetration efficiency against capsulated C. neoformans cells, but also boost the efficacy of antifungal drugs. Most importantly, keto-NLCs significantly contribute to the treatment of cryptococcal meningoencephalitis in mice by bypassing the BBB via the olfactory system.
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Affiliation(s)
- Wei Du
- College of Life and Health Sciences, Northeastern University, Shenyang, Liaoning 110015, China
| | - Hailong Li
- College of Life and Health Sciences, Northeastern University, Shenyang, Liaoning 110015, China
| | - Baocheng Tian
- School of Medicine, Binzhou Medical University, Yantai, China
| | - Sixiang Sai
- School of Medicine, Binzhou Medical University, Yantai, China
| | - Yiru Gao
- College of Life and Health Sciences, Northeastern University, Shenyang, Liaoning 110015, China
| | - Tian Lan
- College of Life and Health Sciences, Northeastern University, Shenyang, Liaoning 110015, China
| | - Yang Meng
- College of Life and Health Sciences, Northeastern University, Shenyang, Liaoning 110015, China
| | - Chen Ding
- College of Life and Health Sciences, Northeastern University, Shenyang, Liaoning 110015, China.
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29
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Beardsley J, Sorrell TC, Chen SCA. Central Nervous System Cryptococcal Infections in Non-HIV Infected Patients. J Fungi (Basel) 2019; 5:jof5030071. [PMID: 31382367 PMCID: PMC6787755 DOI: 10.3390/jof5030071] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/22/2019] [Accepted: 07/29/2019] [Indexed: 12/27/2022] Open
Abstract
Central nervous system (CNS) cryptococcosis in non-HIV infected patients affects solid organ transplant (SOT) recipients, patients with malignancy, rheumatic disorders, other immunosuppressive conditions and immunocompetent hosts. More recently described risks include the use of newer biologicals and recreational intravenous drug use. Disease is caused by Cryptococcus neoformans and Cryptococcus gattii species complex; C. gattii is endemic in several geographic regions and has caused outbreaks in North America. Major virulence determinants are the polysaccharide capsule, melanin and several ‘invasins’. Cryptococcal plb1, laccase and urease are essential for dissemination from lung to CNS and crossing the blood–brain barrier. Meningo-encephalitis is common but intracerebral infection or hydrocephalus also occur, and are relatively frequent in C. gattii infection. Complications include neurologic deficits, raised intracranial pressure (ICP) and disseminated disease. Diagnosis relies on culture, phenotypic identification methods, and cryptococcal antigen detection. Molecular methods can assist. Preferred induction antifungal therapy is a lipid amphotericin B formulation (amphotericin B deoxycholate may be used in non-transplant patients) plus 5-flucytosine for 2–6 weeks depending on host type followed by consolidation/maintenance therapy with fluconazole for 12 months or longer. Control of raised ICP is essential. Clinicians should be vigilant for immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Justin Beardsley
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia
- Westmead Institute for Medical Research, Westmead, Sydney 2145, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital and the Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia.
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30
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Wang J, Hong JJ, Zhang PP, Yang MF, Yang Q, Qu TT. Cryptococcal pleuritis with pleural effusion as the only clinical presentation in a patient with hepatic cirrhosis: A case report and literature review. Medicine (Baltimore) 2019; 98:e16354. [PMID: 31305427 PMCID: PMC6641672 DOI: 10.1097/md.0000000000016354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Cryptococcosis is a significant life-threatening fungal infection in worldwide, mainly reported in immunocompromised patients. Pleural effusion presentation of cryptococcal infection as the only clinical presentation is rarely seen in pulmonary cryptococcosis, which may lead to be misdiagnosed, and the study on this subject will provide further insights. PATIENT CONCERNS A 64-year-old man was hospitalized in our department and diagnosed as hepatic B cirrhosis. A computed tomography (CT) of the thorax showed a massive right pleural effusion without pulmonary parenchymal abnormalities. He was started on empirical treatment for pleural tuberculosis (TB). However, during his hospitalization, a right pleural effusion developed and fever was not controlled. DIAGNOSES On day 14 admission, pleural fluid cultured positive for Cryptococcus neoformans. The C neoformans isolate belonged to ST5 and molecular type VNI (var. grubii). INTERVENTIONS The patient was diagnosed with cryptococcal pleuritis, then amphotericin B and fluconazole were administrated. OUTCOMES Finally, the patient was improved and discharged from our hospital. LESSONS Similar cases in cryptococcal pleuritis patients with pleural effusion as the only clinical presentation in the literature are also reviewed. Through literature review, we recommend that pleural effusion cryptococcal antigen test should be used to diagnose cryptococcal pleuritis to reduce misdiagnosis. The early administration of antifungal drug with activity to Cryptococcus seemed beneficial in preventing dissemination of cryptococcosis.
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Affiliation(s)
- Jie Wang
- Respiratory Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
| | - Jin-Jing Hong
- State Key Laboratory for Diagnosis and treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, and Infectious disease Department, The First People's Hospital of Wenling, Wenling
| | - Piao-Piao Zhang
- State Key Laboratory for Diagnosis and treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Mei-Fang Yang
- State Key Laboratory for Diagnosis and treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qing Yang
- State Key Laboratory for Diagnosis and treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ting-Ting Qu
- State Key Laboratory for Diagnosis and treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Thanh LT, Phan TH, Rattanavong S, Nguyen TM, Duong AV, Dacon C, Hoang TN, Nguyen LPH, Tran CTH, Davong V, Nguyen CVV, Thwaites GE, Boni MF, Dance D, Ashton PM, Day JN. Multilocus sequence typing of Cryptococcus neoformans var. grubii from Laos in a regional and global context. Med Mycol 2019; 57:557-565. [PMID: 30339200 PMCID: PMC6581559 DOI: 10.1093/mmy/myy105] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 12/21/2022] Open
Abstract
Cryptococcosis causes approximately 180 000 deaths each year in patients with human immunodeficiency virus (HIV). Patients with other forms of immunosuppression are also at risk, and disease is increasingly recognized in apparently immunocompetent individuals. Cryptococcus neoformans var. grubii, responsible for the majority of cases, is distributed globally. We used the consensus ISHAM Multilocus sequence typing (MLST) scheme to define the population structure of clinical C. neoformans var. grubii isolates from Laos (n = 81), which we placed into the global context using published MLST data from other countries (total N = 1047), including a reanalysis of 136 Vietnamese isolates previously reported. We observed a phylogeographical relationship in which the Laotian population was similar to its neighbor Thailand, being dominated (83%) by Sequence Types (ST) 4 and 6. This phylogeographical structure changed moving eastwards, with Vietnam's population consisting of an admixture of isolates dominated by the ST4/ST6 (35%) and ST5 (48%) lineages. The ST5 lineage is the predominant ST reported from China and East Asia, where it accounts for >90% of isolates. Analysis of genetic distance (Fst) between different populations of C. neoformans var. grubii supports this intermediate structure of the Vietnamese population. The pathogen and host diversity reported from Vietnam provide the strongest epidemiological evidence of the association between ST5 and HIV-uninfected patients. Regional anthropological genetic distances suggest diversity in the C. neoformans var. grubii population across Southeast Asia is driven by ecological rather than human host factors. Where the ST5 lineage is present, disease in HIV-uninfected patients is to be expected.
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Affiliation(s)
| | | | - Sayaphet Rattanavong
- Laos-Oxford-Mahosot Hospital Wellcome Trust Research Unit, Lao People's Democratic Republic
| | | | | | - Cherrelle Dacon
- Sir William Dunn School of Pathology, University of Oxford, UK
| | | | - Lan Phu Huong Nguyen
- Oxford University Clinical Research Unit, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Viengmon Davong
- Laos-Oxford-Mahosot Hospital Wellcome Trust Research Unit, Lao People's Democratic Republic
| | | | - Guy E Thwaites
- Oxford University Clinical Research Unit, Vietnam
- Nuffield Department of Medicine, Oxford University, UK
| | - Maciej F Boni
- Nuffield Department of Medicine, Oxford University, UK
- Department of Biology, Pennsylvania State University, USA
| | - David Dance
- Laos-Oxford-Mahosot Hospital Wellcome Trust Research Unit, Lao People's Democratic Republic
- Nuffield Department of Medicine, Oxford University, UK
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Jeremy N Day
- Oxford University Clinical Research Unit, Vietnam
- Nuffield Department of Medicine, Oxford University, UK
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32
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Ashton PM, Thanh LT, Trieu PH, Van Anh D, Trinh NM, Beardsley J, Kibengo F, Chierakul W, Dance DAB, Rattanavong S, Davong V, Hung LQ, Chau NVV, Tung NLN, Chan AK, Thwaites GE, Lalloo DG, Anscombe C, Nhat LTH, Perfect J, Dougan G, Baker S, Harris S, Day JN. Three phylogenetic groups have driven the recent population expansion of Cryptococcus neoformans. Nat Commun 2019; 10:2035. [PMID: 31048698 PMCID: PMC6497710 DOI: 10.1038/s41467-019-10092-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/15/2019] [Indexed: 01/04/2023] Open
Abstract
Cryptococcus neoformans (C. neoformans var. grubii) is an environmentally acquired pathogen causing 181,000 HIV-associated deaths each year. We sequenced 699 isolates, primarily C. neoformans from HIV-infected patients, from 5 countries in Asia and Africa. The phylogeny of C. neoformans reveals a recent exponential population expansion, consistent with the increase in the number of susceptible hosts. In our study population, this expansion has been driven by three sub-clades of the C. neoformans VNIa lineage; VNIa-4, VNIa-5 and VNIa-93. These three sub-clades account for 91% of clinical isolates sequenced in our study. Combining the genome data with clinical information, we find that the VNIa-93 sub-clade, the most common sub-clade in Uganda and Malawi, was associated with better outcomes than VNIa-4 and VNIa-5, which predominate in Southeast Asia. This study lays the foundation for further work investigating the dominance of VNIa-4, VNIa-5 and VNIa-93 and the association between lineage and clinical phenotype.
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Affiliation(s)
- P M Ashton
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - L T Thanh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - P H Trieu
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - D Van Anh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - N M Trinh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - J Beardsley
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Marie Bashir Institute, University of Sydney, Sydney, 2050, NSW, Australia
| | - F Kibengo
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - W Chierakul
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - D A B Dance
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - S Rattanavong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - V Davong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - L Q Hung
- Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - N V V Chau
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - N L N Tung
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - A K Chan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, M4N 3M5, ON, Canada
- Dignitas International, Zomba, Malawi
| | - G E Thwaites
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - D G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - C Anscombe
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - L T H Nhat
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - J Perfect
- Department of Medicine and Department of Molecular Genetics and Microbiology, Division of Infectious Diseases, Duke University, Durham, NC, 27710, USA
| | - G Dougan
- Wellcome Trust-Cambridge Centre for Global Health Research, Cambridge, CB2 0XY, UK
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, Cambridgeshire, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - S Baker
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Wellcome Trust-Cambridge Centre for Global Health Research, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - S Harris
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, Cambridgeshire, UK
| | - J N Day
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam.
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK.
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Ngan NTT, Mai NTH, Tung NLN, Lan NPH, Tai LTH, Phu NH, Chau NVV, Binh TQ, Hung LQ, Beardsley J, White N, Lalloo D, Krysan D, Hope W, Geskus R, Wolbers M, Nhat LTH, Thwaites G, Kestelyn E, Day J. A randomized open label trial of tamoxifen combined with amphotericin B and fluconazole for cryptococcal meningitis. Wellcome Open Res 2019; 4:8. [PMID: 30801037 PMCID: PMC6381443 DOI: 10.12688/wellcomeopenres.15010.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 01/02/2023] Open
Abstract
Background: Cryptococcal meningitis is a leading cause of death in HIV-infected patients. International treatment guidelines recommend induction therapy with amphotericin B and flucytosine. This antifungal combination is most effective, but unfortunately flucytosine is expensive and unavailable where the burden of disease is greatest. Where unavailable, guidelines recommend treatment with amphotericin and fluconazole, but this is less effective, with mortality rates of 40-50%. Faster rates of clearance of yeast from cerebrospinal fluid (CSF) are associated with better outcomes - improving the potency of antifungal therapy is likely to be an effective strategy to improve survival. Tamoxifen, a selective estrogen receptor modulator used to treat breast cancer, has anti-cryptococcal activity, appearing synergistic when combined in vitro with amphotericin, and fungicidal when combined with fluconazole. It is concentrated in the brain and macrophages, off-patent, cheap and widely available. We designed a randomized trial to deliver initial efficacy and safety data for tamoxifen combined with amphotericin and fluconazole. Method: A phase II, open-label, randomized (1:1) controlled trial of tamoxifen (300mg/day) combined with amphotericin (1mg/kg/day) and fluconazole (800mg/day) for the first 2 weeks therapy for HIV infected or uninfected adults with cryptococcal meningitis. The study recruits at Cho Ray Hospital and the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. The primary end point is Early Fungicidal Activity (EFA-the rate of yeast clearance from CSF), over the first two weeks of treatment. 50 patients will be recruited providing ≈80% and 90% power to detect a difference in the EFA of -0.11 or -0.13 log10CFU/ml/day, respectively. Discussion: The results of the study will inform the decision to proceed to a larger trial powered to mortality. The size of effect detectable has previously been associated with reduced mortality from this devastating disease. Particular side effects of interest include QT prolongation. Trial registration: Clinicaltrials.gov NCT03112031 (11/04/2017).
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Affiliation(s)
- Nguyen Thi Thuy Ngan
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Dept of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | | | | | | | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Tran Quang Binh
- Dept of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Le Quoc Hung
- Dept of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Justin Beardsley
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Nicholas White
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| | - David Lalloo
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Damian Krysan
- Depatrment of Pediatrics and Microbiology/Immunology, University of Iowa, Iowa City, USA
| | - William Hope
- Molecular and Clinical Pharmacology, Universitly of Liverpool, Liverpool, UK
| | - Ronald Geskus
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| | - Marcel Wolbers
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Le Thanh Hoang Nhat
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| | - Jeremy Day
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
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Mohanty A, Bhatia M, Kabi A, Chatterjee K, Kaistha N, Omar BJ, Gupta PK, Gupta P. Cryptococcal meningitis: An under-reported disease from the hills of Uttarakhand: A hospital-based cross-sectional study. J Family Med Prim Care 2019; 8:2008-2011. [PMID: 31334171 PMCID: PMC6618182 DOI: 10.4103/jfmpc.jfmpc_216_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Cryptococcal meningitis is a fatal opportunistic neuroinfection and an AIDS defining illness. It can also occur in non-HIV patients who are immunodefecient due to chronic glucocorticoid use, organ transplantation, malignancy and sarcodiosis. Materials and Methods: A cross-sectional study was conducted in a tertiary care hospital from July to December 2018. CSF samples of 364 patients were received by Microbiology laboratory during this period for the purpose of aerobic bacterial, fungal and TB culture, respectively. All samples were subjected to examination by direct wet mount, Gram stain and India ink preparation. Ziehl Neelsen staining, solid culture for Mycobacterium tuberculosis on Lowenstein Jensen medium and Gene Xpert was also performed on all CSF samples. These samples were further subjected to fungal culture on Sabouraud's dextrose agar. Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF-MS) was used for identifying all bacterial (except M. tuberculosis) and fungal isolates. Results: Out of 364 CSF samples received, 288 were sterile after 48 hours of aerobic incubation. Bacterial isolates, M. tuberculosis and Cryptococcus spp. were obtained in culture from 51, 21 and 4 samples, respectively. The prevalence of cryptococcal meningitis in our study was 1.09% (4/364). Cryptococcus neoformans var grubii was the most common isolate (2/4; 50%) followed by Cryptococcus neoformans var neoformans (1/4; 25%) and Cryptococcus neoformans var gattii (1/4; 25%), respectively. Conclusion: Cryptococcal meningitis is a rapidly fatal condition which requires a high index of suspicion and calls for a collective effort from family physicians and diagnosticians alike. This disease is under-reported from Uttarakhand and therefore calls for further research from this region.
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Affiliation(s)
- Aroop Mohanty
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mohit Bhatia
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ankita Kabi
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Kuhu Chatterjee
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Neelam Kaistha
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Balram Ji Omar
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Puneet K Gupta
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Pratima Gupta
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Li XQ, Xia S, Ji JS, Tang YH, Zheng MZ, Li YM, Shan F, Lu ZY, Wang J, Liu JK, Zhang HJ, Shi YX, Li HJ. Comparison and Correlation of Magnetic Resonance Imaging and Clinical Severity in Nonhuman Immunodeficiency Virus Patients with Cryptococcal Infection of Central Nervous System. Chin Med J (Engl) 2018; 131:2930-2937. [PMID: 30539905 PMCID: PMC6302650 DOI: 10.4103/0366-6999.247201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The incidence of cryptococcal meningitis among immunocompetent patients increases, especially in China and imaging plays an important role. The current study was to find the correlation between magnetic resonance imaging (MRI) manifestation and clinical severity in nonhuman immunodeficiency virus patients with cryptococcal infection of central nervous system (CNS). Methods: A total of 65 patients with CNS cryptococcal infection from August 2014 to October 2016 were retrospectively included in this study. All the patients had MRI data and clinical data. The patients were divided into two groups according to whether the patients were confirmed with identifiable underlying disease. Comparison and correlation of MRI and clinical data in both groups were investigated using independent sample t-test, Chi-square test, Mann-Whitney test and Spearman rank correlation analysis. Results: In all 65 patients, 41 cases (41/65, 63.1%; Group 1) had normal immunity and 24 cases (24/65, 36.9%; Group 2) had at least one identifiable underlying disease. Fever, higher percentage of neutrophil (NEUT) in white blood cell (WBC), and increased cell number of cerebral spawell correlated with the number of cells andil fluid (CSF) were much common in patients with underlying disease (Group 1 vs. Group 2: Fever: 21/41 vs. 21/24, χ2 = 8.715, P = 0.003; NEUT in WBC: 73.15% vs. 79.60%, Z = −2.370, P = 0.018; cell number of CSF: 19 vs. 200, Z = −4.298, P < 0.001; respectively). Compared to the patients with normal immunity, the lesions are more common in the basal ganglia among patients with identifiable underlying disease (Group 1 vs. Group 2: 20/41 vs. 20/24, χ2 = 7.636, P = 0.006). The number of the involved brain areas in patients with identifiable underlying disease were well correlated with the number of cells and pressure of CSF (r = −0.472, P = 0.031; r = 0.779, P = 0.039; respectively). Conclusions: With the increased number of the involved brain areas in patients with identifiable underlying disease, the body has lower immunity against the organism which might result in higher intracranial pressure and more severe clinical status.
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Affiliation(s)
- Xue-Qin Li
- Department of Radiology, Beijing Youan Hospital Affiliated to Capital Medical University, Beijing 100069, China
| | - Shuang Xia
- Department of Radiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Jian-Song Ji
- Department of Radiology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Zhejiang University Lishui Hospital, Lishui, Zhejiang 323000, China
| | - Yong-Hua Tang
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200020, China
| | - Mei-Zhu Zheng
- Department of Radiology, Tianjin Third Central Hospital, Tianjin 300170, China
| | - Yong-Mei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400042, China
| | - Fei Shan
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Zhi-Yan Lu
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Jian Wang
- Department of Imaging Center, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
| | - Jin-Kang Liu
- Department of Radiology, Xiangya Hospital Affiliated of Central South University, Changsha, Hunan 410013, China
| | - Hui-Juan Zhang
- Department of Radiology, Shengli Clinical Medical College of Fujian Medical University, FuJian Provincial Hospital South Branth, Fuzhou, Fujian 350004, China
| | - Yu-Xin Shi
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Hong-Jun Li
- Department of Radiology, Beijing Youan Hospital Affiliated to Capital Medical University, Beijing 100069, China
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Cryptococcus neoformans Cda1 and Its Chitin Deacetylase Activity Are Required for Fungal Pathogenesis. mBio 2018; 9:mBio.02087-18. [PMID: 30459196 PMCID: PMC6247093 DOI: 10.1128/mbio.02087-18] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Cryptococcus neoformans is unique among fungal pathogens that cause disease in a mammalian host, as it secretes a polysaccharide capsule that hinders recognition by the host to facilitate its survival and proliferation. Even though it causes serious infections in immunocompromised hosts, reports of infection in hosts that are immunocompetent are on the rise. The cell wall of a fungal pathogen, its synthesis, composition, and pathways of remodelling are attractive therapeutic targets for the development of fungicides. Chitosan, a polysaccharide in the cell wall of C. neoformans is one such target, as it is critical for pathogenesis and absent in the host. The results we present shed light on the importance of one of the chitin deacetylases that synthesize chitosan during infection and further implicates chitosan as being a critical factor for the pathogenesis of C. neoformans. Chitin is an essential component of the cell wall of Cryptococcus neoformans conferring structural rigidity and integrity under diverse environmental conditions. Chitin deacetylase genes encode the enyzmes (chitin deacetylases [Cdas]) that deacetylate chitin, converting it to chitosan. The functional role of chitosan in the fungal cell wall is not well defined, but it is an important virulence determinant of C. neoformans. Mutant strains deficient in chitosan are completely avirulent in a mouse pulmonary infection model. C. neoformans carries genes that encode three Cdas (Cda1, Cda2, and Cda3) that appear to be functionally redundant in cells grown under vegetative conditions. Here we report that C. neoformans Cda1 is the principal Cda responsible for fungal pathogenesis. Point mutations were introduced in the active site of Cda1 to generate strains in which the enzyme activity of Cda1 was abolished without perturbing either its stability or localization. When used to infect CBA/J mice, Cda1 mutant strains produced less chitosan and were attenuated for virulence. We further demonstrate that C. neoformans Cda genes are transcribed differently during a murine infection from what has been measured in vitro.
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Damasceno-Escoura AH, de Souza ML, de Oliveira Nunes F, Pardi TC, Gazotto FC, Florentino DH, Mora DJ, Silva-Vergara ML. Epidemiological, Clinical and Outcome Aspects of Patients with Cryptococcosis Caused by Cryptococcus gattii from a Non-endemic Area of Brazil. Mycopathologia 2018; 184:65-71. [PMID: 30415450 DOI: 10.1007/s11046-018-0304-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 10/19/2018] [Indexed: 11/28/2022]
Abstract
Cryptococcosis by Cryptococcus gattii occurs mainly in immunocompetent hosts, however, during the last decades, a growing number of cases in immunocompromised individuals have been noticed around the world. This report presents epidemiological, clinical and outcome aspects of patients with cryptococcosis caused by this species from a non-endemic area in Brazil. Of 278 Cryptococcus spp. clinical isolates recovered during the same period, 267 (96%) were molecularly identified as Cryptococcus neoformans VNI genotype and 11 (4%) as C. gattii VGII genotype by URA-5 RFLP. Of the 11 C. gattii patients, eight were male, mean age of 47.5 years. Of these, four were HIV-infected, one was kidney transplanted, one presented low CD4+ T cells values of unknown cause, another presented chronic liver disease meanwhile the remaining four were apparently immunocompetent. Disseminated disease and cryptococcal meningitis were present in four patients each. Most patients received amphotericin B plus fluconazole. Seven out of the 11 patients cured and four died before or during the therapy. The increased number of individuals with cryptococcosis by this species during the last decades needs to be carefully evaluated specially those who are HIV-infected. Nevertheless, Cryptococcus species differentiation is currently relevant in order to better know their relation with geographical, clinical host preference and outcome particularities.
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Affiliation(s)
- Alessandro Henrique Damasceno-Escoura
- Internal Medicine Department, Infectious Diseases Unit, Triângulo Mineiro Federal University, Medicina Tropical, Caixa Postal 118, Uberaba, Minas Gerais, CEP 38001-170, Brazil
| | - Matheus Lucas de Souza
- Internal Medicine Department, Infectious Diseases Unit, Triângulo Mineiro Federal University, Medicina Tropical, Caixa Postal 118, Uberaba, Minas Gerais, CEP 38001-170, Brazil
| | - Felipe de Oliveira Nunes
- Internal Medicine Department, Infectious Diseases Unit, Triângulo Mineiro Federal University, Medicina Tropical, Caixa Postal 118, Uberaba, Minas Gerais, CEP 38001-170, Brazil
| | - Thiago César Pardi
- Internal Medicine Department, Infectious Diseases Unit, Triângulo Mineiro Federal University, Medicina Tropical, Caixa Postal 118, Uberaba, Minas Gerais, CEP 38001-170, Brazil
| | - Fernanda Castro Gazotto
- Internal Medicine Department, Infectious Diseases Unit, Triângulo Mineiro Federal University, Medicina Tropical, Caixa Postal 118, Uberaba, Minas Gerais, CEP 38001-170, Brazil
| | - Danilo Heitor Florentino
- Internal Medicine Department, Infectious Diseases Unit, Triângulo Mineiro Federal University, Medicina Tropical, Caixa Postal 118, Uberaba, Minas Gerais, CEP 38001-170, Brazil
| | - Delio José Mora
- Internal Medicine Department, Infectious Diseases Unit, Triângulo Mineiro Federal University, Medicina Tropical, Caixa Postal 118, Uberaba, Minas Gerais, CEP 38001-170, Brazil
| | - Mario León Silva-Vergara
- Internal Medicine Department, Infectious Diseases Unit, Triângulo Mineiro Federal University, Medicina Tropical, Caixa Postal 118, Uberaba, Minas Gerais, CEP 38001-170, Brazil.
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Samarasinghe H, Xu J. Hybrids and hybridization in the Cryptococcus neoformans and Cryptococcus gattii species complexes. INFECTION GENETICS AND EVOLUTION 2018; 66:245-255. [PMID: 30342094 DOI: 10.1016/j.meegid.2018.10.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/28/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022]
Abstract
The basidiomycetous yeasts of the Cryptococcus neoformans and Cryptococcus gattii species complexes (CNSC and CGSC respectively) are the causative agents of cryptococcosis, a set of life-threatening diseases affecting the central nervous system, lungs, skin, and other body sites of humans and other mammals. Both the CNSC and CGSC can be subdivided into varieties, serotypes, molecular types, and lineages based on structural variations, molecular characteristics and genetic sequences. Hybridization between the haploid lineages within and between the two species complexes is known to occur in natural and clinical settings, giving rise to intraspecific and interspecific diploid/aneuploid hybrid strains. Since their initial discovery in 1977, cryptococcal hybrids have been increasingly discovered in both clinical and environmental settings with over 30% of all cryptococcal infections in some regions of Europe being caused by hybrid strains. This review summarizes the major findings to date on cryptococcal hybrids, including their possible origins, prevalence, genomic profiles and phenotypic characteristics. Our analyses suggest that CNSC and CGSC can be an excellent model system for studying fungal hybridization.
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Affiliation(s)
- Himeshi Samarasinghe
- Department of Biology, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada
| | - Jianping Xu
- Department of Biology, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada.
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39
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Zhou X, Ballou ER. The Cryptococcus neoformans Titan Cell: From In Vivo Phenomenon to In Vitro Model. CURRENT CLINICAL MICROBIOLOGY REPORTS 2018. [DOI: 10.1007/s40588-018-0107-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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40
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Caballero Van Dyke MC, Wormley FL. A Call to Arms: Quest for a Cryptococcal Vaccine. Trends Microbiol 2018; 26:436-446. [PMID: 29103990 PMCID: PMC5910246 DOI: 10.1016/j.tim.2017.10.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 09/18/2017] [Accepted: 10/13/2017] [Indexed: 12/16/2022]
Abstract
Cryptococcosis remains a significant cause of morbidity and mortality world-wide, particularly among AIDS patients. Yet, to date, there are no licensed vaccines clinically available to treat or prevent cryptococcosis. In this review, we provide a rationale to support continued investment in Cryptococcus vaccine research, potential challenges that must be overcome along the way, and a literature review of the current progress underway towards developing a vaccine to prevent cryptococcosis.
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Affiliation(s)
- Marley C Caballero Van Dyke
- Department of Biology, The University of Texas at San Antonio, San Antonio, TX, USA; The South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Floyd L Wormley
- Department of Biology, The University of Texas at San Antonio, San Antonio, TX, USA; The South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX, USA.
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41
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Abstract
Fungi must meet four criteria to infect humans: growth at human body temperatures, circumvention or penetration of surface barriers, lysis and absorption of tissue, and resistance to immune defenses, including elevated body temperatures. Morphogenesis between small round, detachable cells and long, connected cells is the mechanism by which fungi solve problems of locomotion around or through host barriers. Secretion of lytic enzymes, and uptake systems for the released nutrients, are necessary if a fungus is to nutritionally utilize human tissue. Last, the potent human immune system evolved in the interaction with potential fungal pathogens, so few fungi meet all four conditions for a healthy human host. Paradoxically, the advances of modern medicine have made millions of people newly susceptible to fungal infections by disrupting immune defenses. This article explores how different members of four fungal phyla use different strategies to fulfill the four criteria to infect humans: the Entomophthorales, the Mucorales, the Ascomycota, and the Basidiomycota. Unique traits confer human pathogenic potential on various important members of these phyla: pathogenic Onygenales comprising thermal dimorphs such as Histoplasma and Coccidioides; the Cryptococcus spp. that infect immunocompromised as well as healthy humans; and important pathogens of immunocompromised patients-Candida, Pneumocystis, and Aspergillus spp. Also discussed are agents of neglected tropical diseases important in global health such as mycetoma and paracoccidiomycosis and common pathogens rarely implicated in serious illness such as dermatophytes. Commensalism is considered, as well as parasitism, in shaping genomes and physiological systems of hosts and fungi during evolution.
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Singh A, MacKenzie A, Girnun G, Del Poeta M. Analysis of sphingolipids, sterols, and phospholipids in human pathogenic Cryptococcus strains. J Lipid Res 2017; 58:2017-2036. [PMID: 28811322 DOI: 10.1194/jlr.m078600] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/13/2017] [Indexed: 01/07/2023] Open
Abstract
Cryptococcus species cause invasive infections in humans. Lipids play an important role in the progression of these infections. Independent studies done by our group and others provide some detail about the functions of these lipids in Cryptococcus infections. However, the pathways of biosynthesis and the metabolism of these lipids are not completely understood. To thoroughly understand the physiological role of these Cryptococcus lipids, a proper structure and composition analysis of Cryptococcus lipids is demanded. In this study, a detailed spectroscopic analysis of lipid extracts from Cryptococcus gattii and Cryptococcus grubii strains is presented. Sphingolipid profiling by LC-ESI-MS/MS was used to analyze sphingosine, dihydrosphingosine, sphingosine-1-phosphate, dihydrosphingosine-1-phosphate, ceramide, dihydroceramide, glucosylceramide, phytosphingosine, phytosphingosine-1-phosphate, phytoceramide, α-hydroxy phytoceramide, and inositolphosphorylceramide species. A total of 13 sterol species were identified using GC-MS, where ergosterol is the most abundant species. The 31P-NMR-based phospholipid analysis identified phosphatidylcholine, phosphatidylethanolamine, phosphatidylinositol, phosphatidylserine, phosphatidyl-N,N-dimethylethanolamine, phosphatidyl-N-monomethylethanolamine, phosphatidylglycerol, phosphatidic acid, and lysophosphatidylethanolamine. A comparison of lipid profiles among different Cryptococcus strains illustrates a marked change in the metabolic flux of these organisms, especially sphingolipid metabolism. These data improve our understanding of the structure, biosynthesis, and metabolism of common lipid groups of Cryptococcus and should be useful while studying their functional significance and designing therapeutic interventions.
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Affiliation(s)
- Ashutosh Singh
- Department of Molecular Genetics and Microbiology and Stony Brook University, Stony Brook, NY 11794
| | | | - Geoffrey Girnun
- Department of Pathology, Stony Brook School of Medicine, Stony Brook, NY 11794
| | - Maurizio Del Poeta
- Department of Molecular Genetics and Microbiology and Stony Brook University, Stony Brook, NY 11794 .,Veterans Administration Medical Center, Northport, NY 11768.,Division of Infectious Diseases, Stony Brook University, Stony Brook, NY 11794
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Lahiri Mukhopadhyay S, Bahubali VH, Manjunath N, Swaminathan A, Maji S, Palaniappan M, Parthasarathy S, Chandrashekar N. Central nervous system infection due to Cryptococcus gattii sensu lato
in India: Analysis of clinical features, molecular profile and antifungal susceptibility. Mycoses 2017; 60:749-757. [DOI: 10.1111/myc.12656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 12/16/2022]
Affiliation(s)
| | - Veenakumari H. Bahubali
- Department of Neuromicrobiology; National Institute of Mental Health and Neuro Sciences; Bangalore India
| | - Netravathi Manjunath
- Department of Neurology; National Institute of Mental Health and Neuro Sciences; Bangalore India
| | - Aarthi Swaminathan
- Department of Neuroimaging and Interventional Radiology; National Institute of Mental Health and Neuro Sciences; Bangalore India
| | - Sayani Maji
- Department of Neuromicrobiology; National Institute of Mental Health and Neuro Sciences; Bangalore India
| | - Marimuthu Palaniappan
- Department of Biostatistics; National Institute of Mental Health and Neuro Sciences; Bangalore India
| | | | - Nagarathna Chandrashekar
- Department of Neuromicrobiology; National Institute of Mental Health and Neuro Sciences; Bangalore India
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44
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Day JN, Qihui S, Thanh LT, Trieu PH, Van AD, Thu NH, Chau TTH, Lan NPH, Chau NVV, Ashton PM, Thwaites GE, Boni MF, Wolbers M, Nagarajan N, Tan PBO, Baker S. Comparative genomics of Cryptococcus neoformans var. grubii associated with meningitis in HIV infected and uninfected patients in Vietnam. PLoS Negl Trop Dis 2017; 11:e0005628. [PMID: 28614360 PMCID: PMC5484541 DOI: 10.1371/journal.pntd.0005628] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 06/26/2017] [Accepted: 05/07/2017] [Indexed: 12/14/2022] Open
Abstract
The vast burden of cryptococcal meningitis occurs in immunosuppressed patients, driven by HIV, and is caused by Cryptococcus neoformansvar. grubii. We previously reported cryptococcal meningitis in Vietnam arising atypically in HIV uninfected, apparently immunocompetent patients, caused by a single amplified fragment length polymorphism (AFLP) cluster of C. neoformansvar. grubii (VNIγ). This variant was less common in HIV infected individuals; it remains unclear why this lineage is associated with apparently immunocompetent patients. To study this host tropism we aimed to further our understanding of clinical phenotype and genomic variation within Vietnamese C. neoformansvar. grubii. After performing MLST on C. neoformans clinical isolates we identified 14 sequence types (STs); ST5 correlated with the VNIγ cluster. We next compared clinical phenotype by lineage and found HIV infected patients with cryptococcal meningitis caused by ST5 organisms were significantly more likely to have lymphadenopathy (11% vs. 4%, p = 0.05 Fisher’s exact test) and higher blood lymphocyte count (median 0.76 versus 0.55 X109 cells/L, p = 0.001, Kruskal-Wallis test). Furthermore, survivors of ST5 infections had evidence of worse disability outcomes at 70 days (72.7% (40/55) in ST5 infections versus 57.1% (52/91) non-ST5 infections (OR 2.11, 95%CI 1.01 to 4.41), p = 0.046). To further investigate the relationship between strain and disease phenotype we performed genome sequencing on eight Vietnamese C. neoformansvar. grubii. Eight genome assemblies exhibited >99% nucleotide sequence identity and we identified 165 kbp of lineage specific to Vietnamese isolates. ST5 genomes harbored several strain specific regions, incorporating 19 annotated coding sequences and eight hypothetical proteins. These regions included a phenolic acid decarboxylase, a DEAD-box ATP-dependent RNA helicase 26, oxoprolinases, a taurine catabolism dioxygenase, a zinc finger protein, membrane transport proteins and various drug transporters. Our work outlines the complexity of genomic pathogenicity in cryptococcal infections and identifies a number of gene candidates that may aid the disaggregation of the pathways associated with the pathogenesis of Cryptococcus neoformansvar. grubii. Cryptococcal meningitis is a brain infection caused by a yeast, Cryptococcus neoformans, and results in an estimated 600 000 deaths each year. Disease usually only occurs in patients who have some problem with their immune systems—most commonly Human Immunodeficiency Virus (HIV) infection. However, it is increasingly recognized that disease can occur, particularly in southeast and east Asia, in patients with apparently normal immune systems (‘immunocompetent’). We previously showed that almost all infections in immunocompetent patients in Vietnam are due to just one small ‘family’ (or lineage) of Cryptococcus neoformans var. grubii, which we called VNIγ. This is in contrast to disease in HIV infected patients, which can be caused by a number of different families. This suggests that VNIγ strains have an increased ability to cause disease. Here, we define the pattern of disease caused by VNIγ infections compared with other strains in HIV infected patients, and use whole genome sequencing—comparing the entire genetic codes from different strains—to try and understand which genes give the VNIγ family this special ability to cause disease in immunocompetent patients.
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Affiliation(s)
- Jeremy N Day
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Seet Qihui
- Genome Institute of Singapore, Singapore
| | - Lam Tuan Thanh
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam
| | - Phan Hai Trieu
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam
| | - Anh Duong Van
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam
| | - Nha Hoang Thu
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam
| | - Tran Thi Hong Chau
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam
| | - Nguyen P H Lan
- Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | | | - Philip M Ashton
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Maciej F Boni
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Marcel Wolbers
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | - Stephen Baker
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Viet Nam, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,The London School of Hygiene and Tropical Medicine, London, United Kingdom
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Lofgren S, Abassi M, Rhein J, Boulware DR. Recent advances in AIDS-related cryptococcal meningitis treatment with an emphasis on resource limited settings. Expert Rev Anti Infect Ther 2017; 15:331-340. [PMID: 28111998 PMCID: PMC5602588 DOI: 10.1080/14787210.2017.1285697] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Recent advances in the treatment and prevention of cryptococcal meningitis have the potential to decrease AIDS-related deaths. Areas covered: Targeted screening for asymptomatic cryptococcal antigenemia in persons with AIDS is a cost effective method for reducing early mortality in patients on antiretroviral therapy. For persons with symptomatic cryptococcal meningitis, optimal initial management with amphotericin and flucytosine improves survival compared to alternative therapies; however, amphotsericin is difficult to administer and flucytosine has not been available in middle or low income countries, where cryptococcal meningitis is most prevalent. Expert commentary: Improved care for cryptococcal meningitis patients in resource-limited settings is possible, and new treatment possibilities are emerging.
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Affiliation(s)
- Sarah Lofgren
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - Mahsa Abassi
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - Joshua Rhein
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - David R Boulware
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
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Disseminated Cryptococcosis Due to Anti-Granulocyte-Macrophage Colony-Stimulating Factor Autoantibodies in the Absence of Pulmonary Alveolar Proteinosis. J Clin Immunol 2016; 37:143-152. [PMID: 28013480 DOI: 10.1007/s10875-016-0364-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 12/13/2016] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Autoantibodies to granulocyte-macrophage colony-stimulating factor (GM-CSF) can cause acquired pulmonary alveolar proteinosis (PAP). Cases of acquired PAP susceptible to typical respiratory pathogens and opportunistic infections have been reported. Anti-GM-CSF autoantibodies have been reported in a few patients with cryptococcal meningitis. This study evaluated the presence of neutralizing anti-GM-CSF autoantibodies in patients without known congenital or acquired immunodeficiency with severe pulmonary or extrapulmonary cryptococcal infection but without PAP. METHODS We took a clinical history and performed an immunologic evaluation and screening of anti-cytokine autoantibodies in patients with cryptococcal meningitis. The impact of autoantibodies to GM-CSF on immune function was assessed by intracellular staining of GM-CSF-induced STAT5 phosphorylation and MIP-1α production in normal peripheral blood mononuclear cells incubated with plasma from patients or normal control subjects. RESULTS Neutralizing anti-GM-CSF autoantibodies were identified in four patients with disseminated cryptococcosis, none of whom exhibited PAP. Plasma from patients blocked GM-CSF signaling and inhibited STAT5 phosphorylation and production of MIP-1α. One patient died of disseminated cryptococcosis involving the central nervous system, which was associated with defective GM-CSF activity. CONCLUSIONS Anti-GM-CSF autoantibodies increase susceptibility to cryptococcal infection in adults without PAP. Cryptococcal central nervous system infection associated with anti-GM-CSF autoantibodies could result in neurological sequelae or be life-threatening. Therefore, timely detection of neutralizing anti-GM-CSF autoantibodies and development of an effective therapy are necessary to prevent deterioration of cryptococcal infection in these patients.
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Guo LY, Liu LL, Liu Y, Chen TM, Li SY, Yang YH, Liu G. Characteristics and outcomes of cryptococcal meningitis in HIV seronegative children in Beijing, China, 2002-2013. BMC Infect Dis 2016; 16:635. [PMID: 27814690 PMCID: PMC5097362 DOI: 10.1186/s12879-016-1964-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/25/2016] [Indexed: 01/08/2023] Open
Abstract
Background Data regarding HIV-seronegative pediatric patients with cryptococcal meningitis (CM) have been very limited. Methods We retrospectively reviewed non-HIV-infected in patients with CM from January 2002 through December 2013 in Beijing Children’s Hospital. Records of the all patients were obtained and compared. Results The 34 children had a median age of 5.6 years. Most of the patients were male (67.6 %). Only 23.5 % of the cases had identifiable underlying diseases. The sensitivity of the CSF cryptococcal antigen, India ink smear and CSF culture in our study were 81.5, 85.3 and 82.4 %, respectively. And the sensitivity of combinations of these tests was 91.2 %. Out of the 34 patients, 16 (47.1 %) had other organs involvement in addition to the brain. The main abnormal features via magnetic resonance imaging (MRI) were Virchow-Robin space dilatation (44.4 %), hydrocephalus (38.9 %), gelatinous pseudocysts (33.3 %), brain atrophy (33.3 %), meningeal enhancement (27.8 %) and local lesions (27.8 %). In total, 64.7 % of the patients were successfully treated at discharge, whereas treatment failed in 35.3 % of the patients. Conclusions Cryptococcal meningitis is an infrequent disease with a high fatality rate in children in China. The majority of patients were apparently healthy. Clinicians should consider cryptococcal infection as a potential pathogen of pediatric meningitis. Cryptococcal antigen, India ink smear and culture tests are recommended for diagnosis.
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Affiliation(s)
- Ling-Yun Guo
- Department of Infectious Diseases, Beijing Children's Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Major Diseases in Children and National Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, National Clinical Research Centre for Respiratory Diseases, Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lin-Lin Liu
- Department of Infectious Diseases, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yue Liu
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Tian-Ming Chen
- Department of Infectious Diseases, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Shao-Ying Li
- Department of Infectious Diseases, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yong-Hong Yang
- Key Laboratory of Major Diseases in Children and National Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, National Clinical Research Centre for Respiratory Diseases, Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China.
| | - Gang Liu
- Department of Infectious Diseases, Beijing Children's Hospital, Capital Medical University, Beijing, China.
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Ngoo QZ, Tai LME, Wan Hitam WH, Tharakan J. Bilateral optic neuropathy in acute cryptococcal meningitis. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Vélez N, Escandón P. Distribution and association between environmental and clinical isolates of Cryptococcus neoformans in Bogotá-Colombia, 2012-2015. Mem Inst Oswaldo Cruz 2016; 111:642-648. [PMID: 27706379 PMCID: PMC5066331 DOI: 10.1590/0074-02760160201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/16/2016] [Indexed: 11/22/2022] Open
Abstract
The propagules of the fungal species Cryptococcus neoformans and
C. gattii, whose varieties are distributed world wide, are the
primary cause of cryptococcosis, a life threatening disease. The study of
environmental and clinical isolates of Cryptococcosis is an
important contribution to the epidemiology and ecology of the fungus. The aim of this
work was to determine the presence of C. neoformans and C.
gattii in the environment in Bogotá, Colombia’s capital city and to
establish the relation between clinical and environmental isolates in the period
2012-2015. From a total of 4.116 environmental samples collected between October 2012
- March 2014, 35 were positive for C. neoformans var.
grubii. From 55 cryptococcosis cases reported in Bogotá during
2012-2015, 49 isolates were recovered. From those, 94% were identified as C.
neoformans var. grubii molecular type VNI; 4% as VNII
and 1,2% as C. neoformans var neoformans VNIV. The
84 detected clinical and environmental isolates studied had a similarity between
49-100% according with molecular typing. The correlation between environmental and
clinical samples confirms the hypothesis that patients acquire the disease from
environmental exposure to the fungal propagules.
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Affiliation(s)
- Norida Vélez
- Grupo de Microbiología, Instituto Nacional de Salud, Bogotá, Colombia
| | - Patricia Escandón
- Grupo de Microbiología, Instituto Nacional de Salud, Bogotá, Colombia
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The immunopathogenesis of cryptococcal immune reconstitution inflammatory syndrome: understanding a conundrum. Curr Opin Infect Dis 2016; 29:10-22. [PMID: 26658650 DOI: 10.1097/qco.0000000000000224] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Cryptococcal meningitis causes significant mortality among HIV-infected patients, despite antifungal therapy and use of antiretroviral therapy (ART). In patients with cryptococcal meningitis, ART is often complicated by immune reconstitution inflammatory syndrome (IRIS), manifesting as unmasking of previously unrecognized subclinical infection (unmasking CM-IRIS) or paradoxical worsening of symptoms in the central nervous system after prior improvement with antifungal therapy (paradoxical CM-IRIS). We review our current understanding of the pathogenesis of this phenomenon, focusing on unifying innate and adaptive immune mechanisms leading to the development of this often fatal syndrome. RECENT FINDINGS We propose that HIV-associated CD4 T-cell depletion, chemokine-driven trafficking of monocytes into cerebrospinal fluid in response to cryptococcal meningitis, and poor localized innate cytokine responses lead to inadequate cryptococcal killing and clearance of the fungus. Subsequent ART-associated recovery of T-cell signaling and restored cytokine responses, characterized by IFN-γ production, triggers an inflammatory response. The inflammatory response triggered by ART is dysregulated because of impaired homeostatic and regulatory mechanisms, culminating in the development of CM-IRIS. SUMMARY Despite our incomplete understanding of the immunopathogenesis of CM-IRIS, emerging data exploring innate and adaptive immune responses could be exploited to predict, prevent and manage CM-IRIS and associated morbid consequences.
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