Prevalence of cryptococcal meningitis among people living with human immunodeficiency virus/acquired immunodeficiency syndrome in a Tertiary Care Hospital, Southern Odisha, India

Cryptococcal meningitis among perinatally HIV-infected adolescents: Case series on presentation and management challenges

Diagnosis and management of cryptococcal meningitis in HIV-infected adolescents is challenging in poor resource settings. A high index of suspicion based on clinical presentation is critical for early identification and treatment. This report sought to describe the clinical presentation and outcomes of HIV-associated cryptococcal meningitis in adolescents.

Clinical insights and epidemiology of central nervous system infection due to Cryptococcus neoformans/gattii species complexes: A prospective study from South India

In the last two decades, central nervous system (CNS) cryptococcosis (CNSc) has emerged as a major opportunistic infection in the immunocompromised population of India. We have analyzed the clinical features of CNSc and epidemiology of Cryptococcus neoformans and Cryptococcus gattii. A total of 160 clinical isolates of C. neoformans/gattii recovered from CNSc patients were analyzed. The origin, clinical parameters, and imaging features of the patients were recorded, and clinical parameters were analyzed based on their human immunodeficiency virus (HIV) status and infecting species, namely, C. neoformans or C. gattii. Serotypes and mating types of the isolates were determined. Molecular typing was performed by polymerase chain reaction (PCR) fingerprinting using M13 microsatellite primer (GTG)5, and multilocus sequence typing (MLST). Majority of the patients were from Bangalore Urban, Karnataka. Among 160 cases 128 (80%) were HIV seropositive, and 32 (20%) were HIV negative. Middle-aged males (36-55 years) were highly affected. There were statistically significant differences in the clinical manifestations, imaging and CSF parameters of HIV coinfected and noninfected cases, whereas limited differences were observed in these parameters in the cases infected with C. neoformans and C. gattii. We identified 80% C. neoformans VNI, 8.75% VNII and 22.5% C. gattii (VGI), 8.75% C. tetragattii (VGIV) among clinical strains. This comprehensive study will contribute toward a better prognosis of CNS cryptococcosis patients during the hospital stay, treatment strategies for HIV coinfected and noninfected cases and will provide the molecular epidemiology of these two pathogenic fungal species in south India, which was unclear in this part of the country.

Cryptococcal meningitis: An under-reported disease from the hills of Uttarakhand: A hospital-based cross-sectional study

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.

An atypical initial presentation of AIDS as cryptococcal lymphadenitis

A patient complained of fever on and off, difficulty in swallowing and cough (with scanty expectoration) since one and a half months and weight loss over 2 months. On examination, pallor was found to be present. Then ultrasonography of abdomen was done and it showed mesenteric and retroperitoneal lymphadenopathy. Sputum for acid-fast Bacilli was examined and found to be negative but despite this, based on the epidemiological data, antitubercular therapy (ATT) was started but after 2 weeks no clinical improvement was found. Then, fine-needle aspiration cytology of lymph node was done and it resulted in the presence of cryptococcal lymphadenitis as the final report. Antifungal therapy was initiated with amphotericin B followed by fluconazole and there was clinical improvement. Ultrasonographical findings also supported it. Though it is a rare case (but not impossible) that cryptococcus is the cause of lymphadenopathy. Thus, in initial presentation of acquired immuno deficiency syndrome it should always be kept in mind that such cases may happen. In India, presuming Mycobacterium tuberculosis as the leading cause exposes the patient to unwanted hepatic and renal toxicity of ATT.

In vitro and in vivo effect of PD-1/PD-L1 blockade on microglia/macrophage activation and T cell subset balance in cryptococcal meningitis

This study aimed to investigate the PD-1/ PD-L1 signaling pathway and its effects the activation of microglia/macrophage and balancing T cell subsets in cryptococcal meningitis (CM). A total of 126 CM patients and 126 healthy individuals were recruited for the study. The CM patients were treated with amphotericin B (AmB). Seventy five C57BL/6 mice were grouped into the normal control, CM model, CM + AmB, sham, and CM + PD-1 antibodies (Ab) groups. CD4⁺ and CD8⁺ T cells as well as microglia/macrophages were analyzed by means of flow cytometry. Ionized calcium-binding adaptor molecule 1 (Ibal) expression was detected using western blotting and immunohistochemistry techniques. And the expression of Rab5 and Rab11 were detected using an immunofluorescence assay. Both PD-1 and PD-L1 mRNA and protein expression among the mice in the study were evaluated by qRT-PCR and western blotting methods. Compared to the CM model group, the CM + AmB and CM + PD-1 Ab groups exhibited increased levels of Th1 cytokines and chemokines expression, and reduced levels of Th2 cytokines expressions. Elevated cell purity and viability of CD4⁺ T cell were recorded as well as increases in microglia, however, there were reductions in the number of CD8⁺ T cells. Depleted expressions of Ibal, Rab5, and Rab11 as well as reduced mRNA expressions of PD-1 and PD-L1 in CD4⁺ , microglia, and macrophage cells. The findings suggested that suppression of the PD-1/PD-L1 signaling pathway restricts the proliferation of CM by down-regulating the expressions of Th2 cells and suppressing microglia and macrophage activation.

Use of multiplex PCR based molecular diagnostics in diagnosis of suspected CNS infections in tertiary care setting-A retrospective study

OBJECTIVES

CNS infections like meningitis and encephalitis pose enormous healthcare challenges due to mortality, sequelae and socioeconomic burden. In tertiary setting, clinical, microbiological, cytological and radiological investigations are not distinctive enough for diagnosing microbial etiology. Molecular diagnostics is filling this gap. We evaluated the clinical impact of a commercially available multiplex molecular diagnostic system - SES for diagnosing suspected CNS infections.

PATIENTS AND METHODS

This study was conducted in our tertiary level Neurology ICU. 110 patients admitted during Nov-2010 to April-2014 were included. CSF samples of patients clinically suspected of having CNS infections were subjected to routine investigation in our laboratory and SES test at XCyton Diagnostics. We studied the impact of SES in diagnosis of CNS infections and its efficacy in helping therapeutic management.

RESULTS

SES showed detection rate of 42.18% and clinical specificity of 100%. It had 10 times higher detection rate than conventional tests. Streptococcus pneumoniae and Mycobacterium tuberculosis were two top bacterial pathogens. VZV was most detected viral pathogen. SES results elicited changes in therapy in both positive and negative cases. We observed superior patient outcomes as measured by GCS scale. 75% and 82.14% of the patients positive and negative on SES respectively, recovered fully.

CONCLUSION

Detecting causative organism and ruling out infectious etiology remain the most critical aspect for management and prognosis of patients with suspected CNS infections. In this study, we observed higher detection rate of pathogens, target specific escalation and evidence based de-escalation of antimicrobials using SES. Institution of appropriate therapy helped reduce unnecessary use of antimicrobials.