Fatal meningitis by Cryptococcus laurentii in a post-partum woman: A manifestation of immune reconstitution inflammatory syndrome

Pregnancy-Related Tuberculous Meningitis and Immune Reconstitution Inflammatory Syndrome: A Case Series and Systematic Review

Background

Tuberculosis is a leading cause of death among women of reproductive age. However, tuberculous meningitis, the most severe form of extrapulmonary tuberculosis, is rarely discussed in pregnancy despite this being a unique period of immune modulation that may predispose women to active disease.

Methods

We identified and described cases of tuberculous meningitis among pregnant or postpartum women screened during meningitis clinical trials in Uganda from 2018 to 2022. We conducted a systematic literature review via PubMed/Medline and Embase for all English-language publications from 1970 to 10 July 2022, to identify additional cases.

Results

We identified 8 cases of pregnancy-related tuberculous meningitis in Ugandan women living with human immunodeficiency virus (HIV) and 40 additional cases via systematic literature review (none HIV-positive). Of all combined cases, 50% (24/48) were diagnosed postpartum; 50% (24/48) had initial onset during pregnancy, of which 38% (9/24) had worsening of symptoms or disease relapse following pregnancy cessation. Diagnosis was missed or delayed in 33% (16/48) of cases. For those with known outcomes, maternal mortality was 23% (11/48) and fetal/neonatal mortality was 30% (13/44). Of maternal survivors, 30% (11/37) had residual neurologic deficits.

Conclusions

The true incidence of tuberculous meningitis in pregnancy or the postpartum period is unclear but likely underappreciated. To date, nearly all published cases have occurred in HIV-negative or otherwise immunocompetent women. Given the well-described physiological immunosuppression during pregnancy and subsequent reconstitution postpartum, physicians must be aware of tuberculous meningitis and pregnancy-related immune reconstitution inflammatory syndrome, especially in countries with a high burden of tuberculosis and in women living with HIV.

Papiliotrema laurentii fungemia in a premature, very low-birth-weight neonate in Kuwait successfully treated with liposomal amphotericin B

Papiliotrema laurentii (formerly Cryptococcus laurentii) and Papiliotrema albidus (formerly Cryptococcus albidus) are yeast-like environmental fungi which are largely considered as non-pathogenic to humans. However, invasive infections caused by P. laurentii have recently been reported in some patients with an impaired immune system. Here, we describe the first case of P. laurentii fungemia in a premature, very low-birth-weight neonate in Kuwait and the Middle East. Repeated bloodstream isolates were obtained and were tentatively identified as P. laurentii by Vitek 2 yeast identification system. The identification of the yeast isolates as P. laurentii was confirmed by PCR-sequencing of ribosomal DNA (rDNA). Antifungal susceptibility testing data showed that the isolates were susceptible to amphotericin B, fluconazole and voriconazole but appeared resistant to caspofungin. The baby was successfully treated with liposomal amphotericin B.

Molecular identification, genotypic heterogeneity and comparative pathogenicity of environmental isolates of Papiliotrema laurentii

Introduction. Papiliotrema laurentii, formerly Cryptococcus laurentii, is typically isolated from environmental sources, but also occasionally from clinical specimens. Other close relatives may be misidentified as P. laurentii by phenotypic methods. P. laurentii usually lacks melanin; however, melanin-forming strains have also been isolated.

Hypothesis/Gap Statement. Although melanin production by encapsulated budding yeasts is considered a major virulence factor, the comparative pathogenicity of melanin-forming and non-melanized environmental strains of P. laurentii has rarely been studied.

Aim. We performed phenotypic and molecular identification and determined the genotypic heterogeneity among P. laurentii isolates. We also studied the pathogenicity of melanin-forming and non-melanized strains in normal and immunosuppressed mice.

Methodology. Eleven environmental isolates were tested for their identity by Vitek2 and/or ID32C systems, and by PCR-sequencing of the internal transcribed spacer (ITS) region and D1/D2 domains of ribosomal DNA (rDNA). Genotypic heterogeneity was studied by sequence comparisons. The pathogenicity of melanized and non-melanized P. laurentii strains was studied in intravenously infected normal and immunosuppressed BALB/c mice.

Results. Phenotypic methods identified seven of the environmental isolates, while PCR-sequencing of the ITS region and D1/D2 domains of rDNA detected two and five isolates, respectively, as P. laurentii. Sequence comparisons demonstrated genotypic heterogeneity among P. laurentii. The remaining four environmental isolates yielded expected results. None of the normal mice infected with 105 cells of melanized/non-melanized P. laurentii strains died. Infection of immunosuppressed mice with 107 cells caused higher mortality with non-melanized P. laurentii, while viable counts in brain/lung tissue were higher in mice infected with a melanized strain and were detectable for up to 14 days.

Conclusion. Phenotypic methods lacked specificity, but PCR-sequencing of D1/D2 domains correctly identified P. laurentii and sequence comparisons demonstrated the genotypic heterogeneity of the isolates. Both melanized and non-melanized strains at a higher dose caused mortality in immunosuppressed mice and persisted in brain/lung tissue up to 14 days post-infection.

Clinical diversity of invasive cryptococcosis in AIDS patients from central China: report of two cases with review of literature

Background

Although antiretroviral therapy (ART) has greatly improved the prognosis of acquired immunodeficiency syndrome (AIDS) patients globally, opportunistic infections (OIs) are still common in Chinese AIDS patients, especially cryptococcosis.

Case presentation

We described here two Chinese AIDS patients with cryptococcal infections. Case one was a fifty-year-old male. At admission, he was conscious and oriented, with papulonodular and umbilicated skin lesions, some with ulceration and central necrosis resembling molluscum contagiosum. The overall impression reminded us of talaromycosis: we therefore initiated empirical treatment with amphotericin B, even though the case history of this patient did not support such a diagnosis. On the second day of infusion, the patient complained of intermittent headache, but the brain CT revealed no abnormalities. On the third day, a lumbar puncture was performed. The cerebral spinal fluid (CSF) was turbid, with slightly increased pressure. India ink staining was positive, but the cryptococcus antigen latex agglutination test (CrAgLAT: IMMY, USA) was negative. Two days later, the blood culture showed a growth of Cryptococcus neoformans, and the same result came from the skin culture. We added fluconazole to the patient’s treatment, but unfortunately, he died three days later.

Case two was a sixty-four-year-old female patient with mild fever, productive cough, dyspnea upon movement, and swelling in both lower limbs. The patient was empirically put on cotrimoxazole per os and moxifloxacin by infusion. A bronchofibroscopy was conducted with a fungal culture, showing growth of Cryptococcus laurentii colonies. Amphotericin B was started thereafter but discontinued three days later in favor of fluconazole 400 mg/d due to worsening renal function. The patient became afebrile after 72 h of treatment with considerable improvement of other comorbidities and was finally discharged with continuing oral antifungal therapy.

Conclusions

Our cases illustrate that cryptococcal disease is an important consideration when treating immunocompromised individuals such as AIDS patients. Life threatening meningitis or meningoencephalitis caused by C. neoformansmay still common in these populations and can vary greatly in clinical presentations, especially with regard to skin lesions. Pulmonary cryptococcosis caused by C. laurentii is rare, but should also be considered in certain contexts. Guidelines for its earlier diagnosis, treatment and prophylaxis are needed.

Catheter-related infection due to Papiliotrema laurentii in an oncologic patient: Case report and systematic review

Background

Papiliotrema laurentii is one of several non-neoformans cryptococci that have rarely been associated with human infection, since it was previously considered saprophyte and thought to be non-pathogenic to humans. Nevertheless, increasing number of reports of human infection have emerged in recent years, mostly in oncologic patients.

Aim

To report a case of a female patient with pyloric obstructive cancer with a catheter-related Papiliotrema laurentii blood stream infection and systematically review the available evidence on P. laurentii infection in humans.

Methods

Retrieval of studies was based on Medical Subject Headings and Health Sciences Descriptors, which were combined using Boolean operators. Searches were run on the electronic databases Scopus, Web of Science, MEDLINE (PubMed), BIREME (Biblioteca Regional de Medicina), LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Library for Systematic Reviews and Opengray.eu. There was no language or date of publication restrictions. The reference lists of the studies retrieved were searched manually.

Results

The search strategy retrieved 1703 references. In the final analysis, 31 references were included, with the description of 35 cases. Every patient but one had a previous co-morbidity - 48.4 % of patients had a neoplasm. Amphotericin B was the most used treatment and only a single case of resistance to it was reported. Most patients were cured of the infection.

Conclusion

P. laurentii infection in humans is usually associated to neoplasia and multiple co-morbidities, and amphotericin B seems to be a reliable agent for treatment.

Cryptococcus laurentii meningitis in a non-HIV patient

Cryptococcus species (other than Cryptococcus neoformans) have been labeled as saprophytic and nonpathogenic in immunocompetent individuals in the past. In recent years, infections caused by non-neoformans Cryptococcus species have been recognized. Cryptococcus laurentii is known to be a rare human pathogen. In this case report, we present a 59-year-old man who did not have HIV infection with meningoencephalitis caused by Cryptococcus laurentii. No significant underlying immunosuppressive disorder was found. The only identifiable risk factors were that the patient was a farmer with previous exposure to pigeon droppings. Here, we describe what we believe to be the fifth reported case of meningitis caused by Cryptococcus laurentii.

Cryptococcal Lung Infections

Cryptococcus is among the most common invasive fungal pathogens globally and is one of the leading causes of acquired immunodeficiency virus-related deaths. Cryptococcus neoformans and Cryptococcus gattii are the most clinically relevant species and account for most cryptococcal disease. Pulmonary manifestations can range from mild symptoms to life-threatening infection. Treatment is tailored based on the severity of pulmonary infection, the presence of disseminated or central nervous system disease, and patient immune status. Amphotericin B and flucytosine followed by fluconazole remain the standard agents for the treatment of severe cryptococcal infection.

Disseminated Cryptococcosis with Marked Eosinophilia in a Postpartum Woman

Disseminated cryptococcosis usually develops in immunosuppressed patients. A 33-year-old postpartum woman developed disseminated cryptococcosis with marked eosinophilia. She presented with a cough and a week-long fever. A computed tomography scan showed multiple pulmonary nodules randomly distributed. Eosinophils were observed to have increased in number in both her peripheral blood and bronchoalveolar lavage fluid. A transbronchial lung biopsy and cerebrospinal fluid specimens revealed findings consistent with cryptococcal infection. Disseminated cryptococcosis can present with marked eosinophilia of the peripheral blood and lung tissues. Additionally, the postpartum immune status may sometimes be involved in the development of opportunistic infections in previously healthy women.