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Wang H, Chen X, Wang Y, Yu D, Zhou Y, Liu Y, Tang Y, Wang M. Pulmonary cryptococcosis coexisting with lung adenocarcinoma: A case report and review of the literature. Oncol Lett 2024; 27:47. [PMID: 38106523 PMCID: PMC10722552 DOI: 10.3892/ol.2023.14179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/22/2023] [Indexed: 12/19/2023] Open
Abstract
Pulmonary cryptococcosis (PC) is an invasive pulmonary fungal disease caused by Cryptococcus neoformans or Cryptococcus gattii. It often presents as a single nodule or mass on radiology, which is easily misdiagnosed as lung cancer or metastases. However, cases of PC coexisting with lung cancer are rare and when this scenario is encountered in clinical practice, it is easy to be misdiagnosed as metastatic lung cancer. The present study reported the case of a 65-year-old immunocompetent patient with PC coexisting with lung adenocarcinoma. Percutaneous lung biopsy was performed on the nodule in the anterior segment of the left upper lobe and the nodule in the posterior basal segment of the left lower lobe, which were diagnosed as primary adenocarcinoma and cryptococcus, respectively. Lung cancer was treated by surgery and PC was treated successfully by antifungal treatment. During the 5-year follow-up, contrast-enhanced CT showed no recurrence of either disease. This case reminds us of the possibility of dualism in the diagnosis of multiple pulmonary nodules based on CT examination, such as the coexistence of lung carcinoma and PC. In addition, early diagnosis and treatment contribute to good prognosis.
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Affiliation(s)
- Hansheng Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, P.R. China
| | - Xiao Chen
- Department of Laboratory, Shiyan Maternal and Child Health Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, P.R. China
| | - Yunyun Wang
- Department of Thoracic Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, P.R. China
| | - Dan Yu
- Department of Pathology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, P.R. China
| | - Yanhui Zhou
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, P.R. China
| | - Yan Liu
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, P.R. China
| | - Yijun Tang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, P.R. China
| | - Meifang Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, P.R. 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: 2] [Impact Index Per Article: 2.0] [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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Messina JA, Giamberardino CD, Tenor JL, Toffaletti DL, Schell WA, Asfaw YG, Palmucci JR, Lionakis MS, Perfect JR. Susceptibility to Cryptococcus neoformans Infection with Bruton's Tyrosine Kinase Inhibition. Infect Immun 2023; 91:e0004223. [PMID: 37404186 PMCID: PMC10429641 DOI: 10.1128/iai.00042-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/01/2023] [Indexed: 07/06/2023] Open
Abstract
Patients receiving the Bruton's tyrosine kinase (BTK) inhibitor ibrutinib have an increased likelihood of fungal infections. The objectives of this study were to determine if Cryptococcus neoformans infection severity was isolate dependent with BTK inhibition and whether blocking BTK impacted infection severity in a mouse model. We compared four clinical isolates from patients on ibrutinib to virulent (H99) and avirulent (A1-35-8) reference strains. BTK knockout (KO) and wild-type (WT) C57 mice and WT CD1 mice were infected by intranasal (i.n.), oropharyngeal aspiration (OPA), and intravenous (i.v.) routes. Infection severity was assessed by survival and fungal burden (CFU per gram of tissue). Ibrutinib (25 mg/kg) or vehicle was administered daily through intraperitoneal injections. In the BTK KO model, no isolate-dependent effect on fungal burden was observed, and infection severity was not significantly different from that of the WT with i.n., OPA, and i.v. routes. Ibrutinib treatment did not impact infection severity. However, when the four clinical isolates were compared to H99, two of these isolates were less virulent, with significantly longer survival and reduced rates of brain infection. In conclusion, C. neoformans infection severity in the BTK KO model does not appear to be isolate dependent. BTK KO and ibrutinib treatment did not result in significantly different infection severities. However, based on repeated clinical observations of increased susceptibility to fungal infections with BTK inhibitor therapy, further work is needed to optimize a mouse model with BTK inhibition to better understand the role that this pathway plays in susceptibility to C. neoformans infection.
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Affiliation(s)
- Julia A. Messina
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Charles D. Giamberardino
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Jennifer L. Tenor
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Dena L. Toffaletti
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Wiley A. Schell
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Yohannes G. Asfaw
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Julia R. Palmucci
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Michail S. Lionakis
- National Institutes of Health, Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institutes of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - John R. Perfect
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
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4
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Khot RS, Patil A, Rathod BD, Patidar M, Joshi PP. Uncovering the Unusual: A Case of Mixed Connective Tissue Disease With Rare Presentation, Atypical Complications, and Therapeutic Dilemmas. Cureus 2023; 15:e36298. [PMID: 37073214 PMCID: PMC10106112 DOI: 10.7759/cureus.36298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
Mixed connective tissue disease (MCTD) is an overlap syndrome characterized by features of systemic lupus erythematosus, scleroderma, and polymyositis, along with the presence of the U1RNP antibody. A 46-year-old female patient presented with severe anemia, cough, and breathlessness, and was diagnosed with cold agglutinin disease, a type of autoimmune hemolytic anemia (AIHA). Autoimmune workup revealed MCTD by positive antinuclear and U1RNP antibodies. She had bilateral miliary mottling on X-ray and a tree-in-bud appearance on high-resolution computed tomography of the thorax, which were suggestive of pulmonary tuberculosis. Standard therapy with steroids was not advisable. She was subsequently started on anti-tuberculosis treatment (anti-Koch's therapy), followed by steroid therapy and immunosuppressive therapy after three weeks. The patient responded well to treatment, but after two months, she developed cytomegalovirus (CMV) retinitis. Adult-onset CMV disease may occur as a result of primary infection, reinfection, or activation of a latent infection. Although not directly related, it can occur as an atypical association in the setting of immunosuppressive therapy. Morbidity and mortality are significantly increased in this population secondary to infectious potentiation: immunosuppression causes infections, and infections cause AIHA. The management of MCTD and secondary AIHA and immunosuppression poses a therapeutic challenge.
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Zhao H, Cheng J, Zhou L, Luo Y, Zhu R, Jiang Y, Wang X, Zhu L. Induction therapy with high dose fluconazole plus flucytosine for human immunodeficiency virus‐uninfected cryptococcal meningitis patients: Feasible or not? Mycoses 2022; 66:59-68. [PMID: 36111370 PMCID: PMC10087831 DOI: 10.1111/myc.13528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/05/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cryptococcal meningitis (CM) is increasingly recognised in human immunodeficiency virus (HIV)-uninfected patients with high mortality. The efficacy and safety profiles of induction therapy with high-dose fluconazole plus flucytosine remain unclear. METHODS HIV-uninfected CM patients who received high-dose fluconazole (800 mg/d) for initial therapy in Huashan Hospital were included in this retrospective study from January 2013 to December 2018. Efficacy and safety of initial therapy, clinical outcomes and risk factors were evaluated. RESULTS Twenty-seven (71.1%) patients who received high-dose fluconazole with flucytosine combination therapy and 11 (28.9%) having fluconazole alone for induction therapy were included. With a median duration of 42 days (IQR, 28-86), the successful response rate of initial therapy was 76.3% (29/38), while adverse drug reactions occurred in 14 patients (36.8%). The rate of persistently positive cerebrospinal fluid (CSF) culture results was 30.6% at 2 weeks, which was significantly associated with CSF CrAg titre >1:1280 (OR 9.56; 95% CI 1.40-103.65; p = .010) and CSF culture of Cryptococcus >3.9 log10 CFU/ml (OR 19.20; 95% CI 1.60-920.54; p = .011), and decreased to 8.6% at 4 weeks. One-year mortality was 15.8% (6/38), and low serum albumin (35 g/L) was found as an independent risk factor for 1-year mortality (HR 6.31; 95% CI 1.150-34.632; p = .034). CONCLUSIONS Induction therapy with high-dose fluconazole (800 mg/d), combined with flucytosine, effectively treated HIV-uninfected CM and was well tolerated. Long-term fluconazole treatment with continued monitoring is beneficial for patients with persistent infection.
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Affiliation(s)
- Hua‐Zhen Zhao
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Jia‐Hui Cheng
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Ling‐Hong Zhou
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Yu Luo
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Rong‐Sheng Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Ying‐Kui Jiang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Xuan Wang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Li‐Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
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One deep learning local-global model based on CT imaging to differentiate between nodular cryptococcosis and lung cancer which are hard to be diagnosed. Comput Med Imaging Graph 2021; 94:102009. [PMID: 34741847 DOI: 10.1016/j.compmedimag.2021.102009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 10/05/2021] [Accepted: 10/14/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES We aim to evaluate a deep learning (DL) model and radiomic model for preoperative differentiation of nodular cryptococcosis from solitary lung cancer in patients with malignant features on CT images. MATERIALS AND METHODS We retrospectively recruited 319 patients with solitary pulmonary nodules and suspicious signs of malignancy from three hospitals. All lung nodules were resected, and one by one radiologic-pathologic correlation was performed. A three-dimensional DL model was used for tumor segmentation and extraction of three-dimensional radiomic features. We used the Max-Relevance and Min-Redundancy algorithm and the eXtreme Gradient Boosting algorithm to select the nodular radiomics features. We proposed a DL local-global model, a DL local model and radiomic model to preoperatively differentiate nodular cryptococcosis from solitary lung cancer. The DL local-global model includes information of both nodules and the whole lung, while the DL local model only includes information of solitary lung nodules. Five-fold cross-validation was used to select and validate these models. The prediction performance of the model was evaluated using receiver operating characteristic curve (ROC) and calibration curve. A new loss function was applied in our deep learning framework to optimize the area under the ROC curve (AUC) directly. RESULTS 295 patients were enrolled and they were non-symptomatic, with negative tumor markers and fungus markers in blood tests. These patients have not been diagnosed by the combination of CT imaging, laboratory results and clinical data. The lung volume was slightly larger in patients with lung cancers than that in patients with cryptococcosis (3552.8 ± 1184.6 ml vs 3491.9 ± 1017.8 ml). The DL local-global model achieved the best performance in differentiating between nodular cryptococcosis and lung cancer (area under the curve [AUC] = 0.88), which was higher than that of the DL local model (AUC = 0.84) and radiomic (AUC = 0.79) model. CONCLUSION The DL local-global model is a non-invasive diagnostic tool to differentiate between nodular cryptococcosis and lung cancer nodules which are hard to be diagnosed by the combination of CT imaging, laboratory results and clinical data, and overtreatment may be avoided.
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Zhao J, Weng W, Chen C, Zhang J. The prevalence and mortality of cryptococcal meningitis in patients with autoimmune diseases: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2021; 40:2515-2523. [PMID: 34258688 DOI: 10.1007/s10096-021-04293-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/14/2021] [Indexed: 12/01/2022]
Abstract
Growing evidence suggests that autoimmune diseases (AIDs) are risk factors for cryptococcal meningitis (CM). Therefore, understanding the epidemiological and clinical profile of CM in patients with AIDs is important. This meta-analysis assessed the prevalence, clinical profiles, and clinical outcomes of CM in AIDs. Studies on CM in patients with AIDs were searched for in PubMed, EMBASE, Web of Science, and China National Knowledge Infrastructure, and meta-analyses were performed using the statistical program of R. Nineteen studies with 36,631 patients with AIDs were analyzed. The overall pooled CM prevalence was 0.4% (95% confidence interval [CI], 0.3-0.6%), 90.7% of which occurred in female patients. Thirteen studies with 77 patients with AIDs diagnosed with CM were analyzed, and the mortality rate was 26.7% (95% CI, 9.5-47.2%). Of patients with systemic lupus erythematosus, 30.1% of CM cases were initially misdiagnosed (95% CI, 0-65.6%). The primary symptom of CM with AIDs was headache (99.4%; 95% CI, 92.1-100%), followed by fever (93.7%; 95% CI, 82.8-100%) and vomiting (37.2%; 95% CI, 13.2-61.2%). The prevalence of CM infections among patients with AIDs should not be underestimated despite non-specific clinical presentations as there were fatal outcomes. Our results suggest that more research is needed to understand the relationship between AIDs and CM, and clinical trials are necessary to improve treatment strategies.
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Affiliation(s)
- Jing Zhao
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Weipin Weng
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Chunli Chen
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jie Zhang
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China.
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Cheng JH, Yip CW, Jiang YK, Zhou LH, Que CX, Luo Y, Wang X, Zhao HZ, Zhu LP. Clinical Predictors Impacting Cryptococcal Dissemination and Poor Outcome in Patients With Cirrhosis. Open Forum Infect Dis 2021; 8:ofab296. [PMID: 34250196 PMCID: PMC8266647 DOI: 10.1093/ofid/ofab296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/04/2021] [Indexed: 01/03/2023] Open
Abstract
Background Cirrhosis is an end-stage liver disease and is reported as an independent risk factor for cryptococcosis. Information about cryptococcosis in patients with cirrhosis remains sparse. Methods Human immunodeficiency virus–uninfected patients with cryptococcosis and cirrhosis admitted to Huashan Hospital from July 2005 to June 2020 were reviewed. Efficacy and safety of antifungal treatments, clinical outcome, and prognostic factors of mortality were evaluated. Results A total of 49 cryptococcosis patients with cirrhosis were included. Sites of infection involved central nervous system (n = 38), lung (n = 21), bloodstream (n = 11), skin (n = 1), and bone (n = 1). Nine patients (18.4%) had pulmonary cryptococcosis alone. Viral hepatitis B infection (57.1%) was the most common cause of cirrhosis. Patients with decompensated cirrhosis (Child-Pugh class B and C) were more likely to have extrapulmonary cryptococcosis than those with compensated cirrhosis (90.7% vs 64.7%; P = .049). In patients with cryptococcal meningitis (CM), 7 were treated with amphotericin B with/without flucytosine, 5 with amphotericin B plus fluconazole with/without flucytosine, and 12 with fluconazole with/without flucytosine. Fluconazole (>400 mg/day) was well tolerated and only 1 patient had a mild adverse drug reaction. At 1-year follow-up, all patients treated with fluconazole with or without flucytosine survived, whereas the mortality rate was 14.3%–20.0% in the remaining groups. In addition, Child-Pugh class C cirrhosis (hazard ratio [HR], 7.555 [95% confidence interval {CI}, 1.393–40.971]) and time to diagnosis >120 days (HR, 18.619 [95% CI, 2.117–163.745]) were independent factors for 1-year mortality in patients with CM. Conclusions Severity of cirrhosis was associated with developing extrapulmonary cryptococcosis and mortality in CM. Early diagnosis and intervention of cryptococcosis are key for outcome.
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Affiliation(s)
- Jia-Hui Cheng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ching-Wan Yip
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ying-Kui Jiang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ling-Hong Zhou
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Chun-Xing Que
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu Luo
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuan Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Hua-Zhen Zhao
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Ping Zhu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
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Kurata K, Nishimura S, Higashime A, Kawaguchi K, Nagao S, Kozuki Y, Sai S, Yakushijin K, Yamamoto K, Ito M, Matsuoka H, Minami H. Disseminated cryptococcosis resembling miliary tuberculosis in a patient with acute myeloid leukemia. J Infect Chemother 2020; 26:1216-1219. [PMID: 32747210 DOI: 10.1016/j.jiac.2020.07.004] [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: 06/02/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
Disseminated cryptococcosis, usually involving the lungs and central nervous system, carries a high risk of morbidity and mortality in immunocompromised hosts. In this report, we describe a case of miliary pulmonary cryptococcosis in a patient with acute myeloid leukemia, initially resembling miliary tuberculosis. The diagnosis of disseminated cryptococcosis was made based on transbronchial lung biopsy with subsequent detection of Cryptococcus neoformans in blood and cerebrospinal fluid. The patient was treated with liposomal amphotericin B as induction therapy, followed by fluconazole as consolidation and maintenance therapies thereafter. The infection was improved immediately, and he successfully underwent hematopoietic stem cell transplantation. The present case serves as a timely reminder that a radiological miliary pattern necessitates a thorough search for a definitive microbiological and histopathological diagnosis.
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Affiliation(s)
- Keiji Kurata
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan.
| | - Sho Nishimura
- Division of Infectious Diseases, Kobe University Hospital, Japan
| | - Ako Higashime
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Koji Kawaguchi
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Shigeki Nagao
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Yoko Kozuki
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Satoshi Sai
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Kimikazu Yakushijin
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Katsuya Yamamoto
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Mitsuhiro Ito
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Hiroshi Matsuoka
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
| | - Hironobu Minami
- Department of Medical Oncology and Hematology, Kobe University Hospital, Japan
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Yao K, Qiu X, Hu H, Han Y, Zhang W, Xia R, Wang L, Fang J. Pulmonary cryptococcosis coexisting with central type lung cancer in an immuocompetent patient: a case report and literature review. BMC Pulm Med 2020; 20:161. [PMID: 32503511 PMCID: PMC7275487 DOI: 10.1186/s12890-020-01200-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/28/2020] [Indexed: 12/27/2022] Open
Abstract
Background Pulmonary Cryptococcosis is a common fungal infection mainly caused by Cryptococcus neoformans/C.gattii species in immunocompromised patients. Cases of pulmonary cryptococcosis in patients with normal immune function are increasingly common in China. Clinical and radiographic features of pulmonary cryptococcosis are various and without obvious characteristics, so it is often misdiagnosed as pulmonary metastatic tumor or tuberculosis. When coexisting with malignant lung tumors, it was more difficult to differentiate from metastatic lung cancer, although the coexistence of pulmonary cryptococcosis and central type lung cancer is rare. Reviewing the imaging manifestations and diagnosis of the case and the relevant literature will contribute to recognition of the disease and a decrease in misdiagnoses. Case presentation A 72-year-old immunocompetent Han Chinese man had repeated dry cough for more than half a year. CT examination of chest showed an irregular mass at the left hilum of the lung, and two small nodules in the right lung, which were considered as the left central lung cancer with right lung metastasis. However, the patient was diagnosed with pulmonary cryptococcosis coexisting with central type lung cancer based on the results of laboratory examination, percutaneous lung biopsy, fiberoptic bronchoscopy, and surgical pathology. The patient underwent surgical resection of the left central type lung cancer and was placed on fluconazole treatment after a positive diagnosis was made. Five years after the lung cancer surgery, the patient had a recurrence, but the pulmonary cryptococcus nodule disappeared. Conclusion Our case shows that CT findings of central type lung cancer with multiple pulmonary nodules are not necessarily metastases, but may be coexisting pulmonary cryptococcosis. CT images of cryptococcosis of the lung were diverse and have no obvious characteristics, so it was very difficult to distinguish from metastatic tumors. CT-guided percutaneous lung biopsy was a simple and efficient method for identification.
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Affiliation(s)
- Kelin Yao
- Affiliated Hospital of Shaoxing university, Shaoxing, 312000, Zhejiang Province, China
| | - Xiaofang Qiu
- Yuecheng district maternal and child health and family planning service center, Shaoxing, 312000, Zhejiang Province, China
| | - Hongjie Hu
- Sir Run Run Shaw Hospital affiliated Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang Province, China.
| | - Yuxin Han
- Sir Run Run Shaw Hospital affiliated Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang Province, China
| | - Wenming Zhang
- Sir Run Run Shaw Hospital affiliated Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang Province, China
| | - Ruiming Xia
- Affiliated Hospital of Shaoxing university, Shaoxing, 312000, Zhejiang Province, China
| | - Liang Wang
- Affiliated Hospital of Shaoxing university, Shaoxing, 312000, Zhejiang Province, China
| | - Jieming Fang
- City Hope National Medical Center, Duarte, California, USA
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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Setianingrum F, Rautemaa-Richardson R, Denning DW. Pulmonary cryptococcosis: A review of pathobiology and clinical aspects. Med Mycol 2019; 57:133-150. [PMID: 30329097 DOI: 10.1093/mmy/myy086] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/05/2018] [Indexed: 01/13/2023] Open
Abstract
Pulmonary cryptococcosis is an important opportunistic invasive mycosis in immunocompromised patients, but it is also increasingly seen in immunocompetent patients. The main human pathogens are Cryptococcus neoformans and C. gattii, which have a worldwide distribution. In contrast to cryptococcal meningitis, pulmonary cryptococcosis is still underdiagnosed because of limitations in diagnostic tools. It can mimic lung cancer, pulmonary tuberculosis, bacterial pneumonia, and other pulmonary mycoses both clinically and radiologically. Pulmonary nodules are the most common radiological feature, but these are not specific to pulmonary cryptococcosis. The sensitivity of culture of respiratory samples for Cryptococcus is poor and a positive result may also reflect colonisation. Cryptococcal antigen (CrAg) with lateral flow device is a fast and sensitive test and widely used on serum and cerebrospinal fluid, but sera from patients with pulmonary cryptococcosis are rarely positive in the absence of disseminated disease. Detection of CrAg from respiratory specimens might assist the diagnosis of pulmonary cryptococcosis but there are very few data. Molecular detection techniques such as multiplex reverse transcription polymerase chain reaction (RT-PCR) could also provide better sensitivity but these still require validation for respiratory specimens. The first line of treatment for pulmonary cryptococcosis is fluconazole, or amphotericin B and flucytosine for those with central nervous system involvement. Pulmonary cryptococcosis worsens the prognosis of cryptococcal meningitis. In this review, we summarize the biological aspects of Cryptococcus and provide an update on the diagnosis and management of pulmonary cryptococcosis.
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Affiliation(s)
- Findra Setianingrum
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Parasitology Department, Universitas Indonesia, Jakarta, Indonesia
| | - Riina Rautemaa-Richardson
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Department of Infectious Diseases, Wythenshawe Hospital Manchester University NHS Foundation Trust, Manchester, UK
| | - David W Denning
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Department of Infectious Diseases, Wythenshawe Hospital Manchester University NHS Foundation Trust, Manchester, UK
- National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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13
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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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14
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Xu L, Hu C, Hu H, Dai X, Gao H, Guo Y, Huang Y, Yang Z, Tao R, Zhu B, Xu Y. Importance of fibrosis 4 index score and mode of anti-fungal treatment to the outcome of Cryptococcal meningitis in hepatitis B virus-infected patients. Infect Dis (Lond) 2019; 51:113-121. [PMID: 30676149 DOI: 10.1080/23744235.2018.1523553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Hepatitis B virus (HBV) and the associated cirrhosis are risk factors for cryptococcal meningitis (CM). However, the clinical features of co-infection with HBV and CM are unclear. METHODS Seventy-nine HBV-infected CM patients and 79 HBV-uninfected CM patients were enrolled in a case-control matching study from 476 CM patients. Fibrosis 4 index (FIB4) was used for assessment of HBV-related fibrosis/cirrhosis. Demographic characteristics, symptoms, routine blood tests, liver function and cerebrospinal fluid (CSF) profiles were compared between the two groups. Kaplan-Meier analysis and Cox proportional hazards model were used to assess factors associated with 10-week mortality. RESULTS Male gender was associated with HBV-infected CM patients (p = .006). CM patients with HBV experienced similar frequencies of symptoms but had lower white blood cell (WBC) (p < .001), platelet (p < .001) and albumin (p = .012), and increased aspartate amino transaminase (AST) (p = .009) and total bilirubin (TBIL) levels (p < .001). Patients with and without HBV infection had similar 10-week cumulative survival rates (85.9 ± 4.2% vs. 78.6 ± 5.4%, p = .569). The hazard ratio was 3.7 times higher for those with FIB4 ≥ 3.25 (p = .020) and 4.5 times higher for those with HBV infection not treated with Amphotericin B + flucytosine ± fluconazole (p = .023). CONCLUSION HBV-infected CM population experience lower WBC, platelet and albumin, and higher AST and TBIL. Ten-week survival rate was similar between HBV-infected and HBV-uninfected CM patients. CM patients with high FIB4 or not treated with Amphotericin B + flucytosine ± fluconazole are at a higher risk of death.
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Affiliation(s)
- Lijun Xu
- a The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China.,b Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Caiqin Hu
- a The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Hangbin Hu
- c Burn unit , Jinhua municipal Central hospital , Jinhua , China
| | - Xiahong Dai
- a The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China.,d Department of infectious diseases , Shulan hospital , Hangzhou , China
| | - Hainv Gao
- d Department of infectious diseases , Shulan hospital , Hangzhou , China
| | - Yongzheng Guo
- a The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China.,b Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Ying Huang
- a The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Zongxing Yang
- e Department of HIV/AIDS , Xixi Hospital of Hangzhou , Hangzhou , China
| | - Ran Tao
- a The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China.,b Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Biao Zhu
- a The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China.,b Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Yan Xu
- a The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
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15
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Guarana M, Vidal JE, Nucci M. Cryptococcosis in Patients with Hematologic Diseases. CURRENT FUNGAL INFECTION REPORTS 2018. [DOI: 10.1007/s12281-018-0332-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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