Pediatric Cryptococcosis

BACKGROUND

Seroprevalence studies have shown that 70% of children are exposed to Cryptococcus , the most common cause of meningitis in people living with human immunodeficiency virus (HIV), but reported pediatric disease prevalence is much lower than in adults.

METHODS

PubMed and Ovid Global Health databases were searched with the terms "cryptococcosis," "cryptococcal meningitis," " Cryptococcus neoformans " or " Cryptococcus gattii ." All studies reporting pediatric specific data in the English language from 1980 up until December 2022 were included.

RESULTS

One hundred sixty-eight publications were reviewed totaling 1469 children, with the majority reported from Africa (54.2%). Sixty-five percent (961) were HIV positive, 10% (147) were non-HIV immunocompromised and 19% (281) were immunocompetent. Clinical signs and symptoms were only reported for 458 children, with fever (64%), headache (55%) and vomiting (39%) being the most common. Most children (80%) suffered from meningoencephalitis. Lung involvement was rarely described in HIV-positive children (1%), but significantly more common in the non-HIV immunocompromised (36%) and immunocompetent (40%) groups ( P < 0.0001). Only 22% received the recommended antifungal combination therapy, which was significantly higher in immunocompetent children than those with HIV (39% vs. 6.8%; P < 0.0001). Overall mortality was 23%. A significant higher mortality was observed in children with HIV compared with immunocompetent children (32% vs. 16%; P < 0.001), but not compared with children with non-HIV immunosuppression (25).

CONCLUSIONS

This is the largest review of pediatric cryptococcosis with new observations on differences in clinical presentation and outcome depending on the underlying condition. The lack of granular clinical data urges prospective clinical epidemiological studies for improved insight in the epidemiology, management and outcome of cryptococcosis in children.

Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM

Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.

Autoantibodies neutralizing GM-CSF in HIV-negative Colombian patients infected with Cryptococcus gattii and C. neoformans

Background

Cryptococcosis is a life-threatening disease caused by Cryptococcus neoformans or C. gattii. Autoantibodies (auto-Abs) neutralizing granulocyte-macrophage colony-stimulating factor (GM-CSF) in otherwise healthy adults with cryptococcal meningitis have been described since 2013. We searched for neutralizing auto-Abs in sera from Colombian patients with non-HIV related cryptococcosis in a retrospective national cohort collected from 1997 to 2016.

Methods

We reviewed clinical and laboratory records and assessed the presence of neutralizing auto-Abs in 30 HIV (-) adults presenting cryptococcosis (13 by C. gattii, and 17 by C. neoformans).

Results

We detected auto-Abs neutralizing GM-CSF in the plasma of 9 out of 13 (69%) patients infected with C. gattii and 1 out of 17 (6%) patients with C. neoformans.

Conclusions

We report ten Colombian patients with cryptococcosis due to auto-Abs neutralizing GM-CSF. Nine of the ten patients were infected with C. gattii, and only one with C. neoformans.

P124 Cryptococcus neoformans-and Cryptococcus gattii-specific antibodies vary among children and adults with cryptococcosis and healthy from Colombia

 

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM

Background

Cryptococcus neoformans (Cn), predominantly, and Cryptococcus gattii (Cg) cause cryptococcosis, a life-threatening systemic mycosis of global distribution affecting mainly immunocompromised adults.

Objectives

This study aimed to determine total and specific antibodies against C. neoformans and C. gattii antigens in sera from patients with cryptococcosis and from healthy individuals from Colombia, which will help to elucidate sero-epidemiological variations in the incidence of the disease in the country.

Methods

Sera from child and adult patients with cryptococcosis (n = 109) and sera from healthy children and adults from Colombia (n = 119) were studied. Using ELISA, total and Cn- and Cg-specific levels of immunoglobulin (Ig)G, IgA, and IgM were determined in sera.

Results

Total IgG, IgA, and IgM levels were higher in HIV + compared with HIV− patients with cryptococcosis. Specific IgG, IgA, and IgM levels tended to be higher in cryptococcosis patients than in healthy controls and to be higher in adults than in children, with a positive correlation between antibody reactivity and age. All serum immunoglobulins were more reactive against Cn-proteins than Cg-proteins. Including all samples, a positive correlation between total and specific IgG, IgA, and IgM levels was found.

Conclusions

In cryptococcosis patients from Colombia, serum immunoglobulins levels differ depending on HIV status, as reported previously. However, this study shows for the first-time variations in immunoglobulin production among adults and children with cryptococcal disease and between Cn and Cg-protein antigens. The observation of differential antibody reactivity with cryptococcal proteins encourages further studies of the humoral immunity for host defense against cryptococcosis.

Cryptococcus neoformans- and Cryptococcus gattii-specific IgG, IgA and IgM differ among children and adults with and without cryptococcosis from Colombia

Cryptococcus neoformans (Cn) and Cryptococcus gattii (Cg) cause cryptococcosis, a life-threatening systemic mycosis of global distribution affecting mainly immunocompromised adults. Although a humoral response occurs during cryptococcosis, the role of antibody production against this mycosis is not fully understood. We aimed to determine total and specific antibodies against cryptococcal protein antigens in sera from people with and without diagnosis of cryptococcosis from Colombia. Using ELISA, total and specific levels of immunoglobulin (Ig)G, IgA and IgM were determined in sera from children and adults with (n = 109) and without (n = 119) cryptococcosis. Specific antibodies were those binding Cn- and Cg-protein antigens. In general, the mean of the total IgG production was higher in cryptococcosis patients than in controls (13 942.32 vs. 6459.91 µg/ml), while levels of IgA (488.13 vs. 1564.53 µg/ml) and IgM (775.69 vs. 1014.72 µg/ml) were higher in controls than in cryptococcosis patients (p ≤ 0.05). In patients with cryptococcosis, total IgG, IgA and IgM levels were higher in HIV + compared with HIV- (p ≤ 0.05). Specific antibodies tended to be higher in cryptococcosis patients than in controls and in adults than in children, with a positive correlation between antibody reactivity and age. All immunoglobulins were more reactive against Cn-proteins than Cg-proteins. Overall, a positive weak correlation between total and specific antibodies was found, although not always statistically significant. In patients with cryptococcosis from Colombia, the levels of immunoglobulins, total and specific, differ with respect to people without cryptococcosis. Variations in antibody production among adults and children with cryptococcosis and between Cn- and Cg-protein antigens were as well established. Our findings encourage further studies to determine the role of humoral immunity for host defence against cryptococcosis.

The status of cryptococcosis in Latin America

Cryptococcosis is a life-threatening fungal infection caused by the encapsulated yeasts Cryptococcus neoformans and C. gattii, acquired from the environment. In Latin America, as occurring worldwide, C. neoformans causes more than 90% of the cases of cryptococcosis, affecting predominantly patients with HIV, while C. gattii generally affects otherwise healthy individuals. In this region, cryptococcal meningitis is the most common presentation, with amphotericin B and fluconazole being the antifungal drugs of choice. Avian droppings are the predominant environmental reservoir of C. neoformans, while C. gattii is associated with several arboreal species. Importantly, C. gattii has a high prevalence in Latin America and has been proposed to be the likely origin of some C. gattii populations in North America. Thus, in the recent years, significant progress has been made with the study of the basic biology and laboratory identification of cryptococcal strains, in understanding their ecology, population genetics, host-pathogen interactions, and the clinical epidemiology of this important mycosis in Latin America.

Guillain-Barré Syndrome Associated with Zika Virus Infection in Colombia

BACKGROUND

Zika virus (ZIKV) infection has been linked to the Guillain-Barré syndrome. From November 2015 through March 2016, clusters of cases of the Guillain-Barré syndrome were observed during the outbreak of ZIKV infection in Colombia. We characterized the clinical features of cases of Guillain-Barré syndrome in the context of this ZIKV infection outbreak and investigated their relationship with ZIKV infection.

METHODS

A total of 68 patients with the Guillain-Barré syndrome at six Colombian hospitals were evaluated clinically, and virologic studies were completed for 42 of the patients. We performed reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assays for ZIKV in blood, cerebrospinal fluid, and urine, as well as antiflavivirus antibody assays.

RESULTS

A total of 66 patients (97%) had symptoms compatible with ZIKV infection before the onset of the Guillain-Barré syndrome. The median period between the onset of symptoms of ZIKV infection and symptoms of the Guillain-Barré syndrome was 7 days (interquartile range, 3 to 10). Among the 68 patients with the Guillain-Barré syndrome, 50% were found to have bilateral facial paralysis on examination. Among 46 patients in whom nerve-conduction studies and electromyography were performed, the results in 36 patients (78%) were consistent with the acute inflammatory demyelinating polyneuropathy subtype of the Guillain-Barré syndrome. Among the 42 patients who had samples tested for ZIKV by RT-PCR, the results were positive in 17 patients (40%). Most of the positive RT-PCR results were in urine samples (in 16 of the 17 patients with positive RT-PCR results), although 3 samples of cerebrospinal fluid were also positive. In 18 of 42 patients (43%) with the Guillain-Barré syndrome who underwent laboratory testing, the presence of ZIKV infection was supported by clinical and immunologic findings. In 20 of these 42 patients (48%), the Guillain-Barré syndrome had a parainfectious onset. All patients tested were negative for dengue virus infection as assessed by RT-PCR.

CONCLUSIONS

The evidence of ZIKV infection documented by RT-PCR among patients with the Guillain-Barré syndrome during the outbreak of ZIKV infection in Colombia lends support to the role of the infection in the development of the Guillain-Barré syndrome. (Funded by the Bart McLean Fund for Neuroimmunology Research and others.).

Intracerebral hemorrhage caused by varicella-induced thrombocytopenia

We present the case of a previously healthy 44-years-old man with chickenpox, severe thrombocytopenia, mucosal hemorrhage, and intracerebral hemorrhage in the right hemisphere. The patient was treated with platelets and high doses of steroids. He recovered although with persistent left homonymous hemianopsia and epilepsy, which were controlled with medication.

Cryptococcosis in Colombian children and literature review

Cryptococcosis is reported in adults and is often acquired immune deficiency syndrome (AIDS)-associated; however, its frequency in children is low. Based on the National Survey on Cryptococcosis conducted in Colombia, an epidemiological and clinical analysis was performed on cases of the disease observed in children less than 16 years old between 1993-2010. We found 41 affected children (2.6% prevalence) from the 1,578 surveys received. The country mean annual incidence rate was 0.017 cases/100,000 children under 16 years, while in Norte de Santander the incidence rate was 0.122 cases/100,000 (p < 0.0001). The average age of infected children was 8.4 and 58.5% were male. In 46.3% of cases, a risk factor was not identified, while 24.4% had AIDS. The most frequent clinical manifestations were headache (78.1%), fever (68.8%), nausea and vomiting (65.6%), confusion (50%) and meningeal signs (37.5%). Meningitis was the most frequent clinical presentation (87.8%). Amphotericin B was given to 93.5% of patients as an initial treatment. Positive microbiological identification was accomplished by India ink (94.7%), latex in cerebrospinal fluid (100%) and culture (89.5%). Out of 34 isolates studied, Cryptococcus neoformans var. grubii (VNI 85.3%, VNII 8.8%) was isolated in 94.1% of cases and Cryptococcus gattii (VGII) was isolated in 5.9% of cases. These data are complemented by a literature review, which overall suggests that cryptococcosis in children is an unusual event worldwide.

Management of Cryptococcus gattii meningoencephalitis

Cryptococcosis is a fungal disease caused by Cryptococcus neoformans and Cryptococcus gattii. By inhalation and subsequent pulmonary infection, it may disseminate to the CNS and cause meningitis or meningoencephalitis. Most cases occur in immunosuppressed hosts, including patients with HIV/AIDS, patients receiving immunosuppressing drugs, and solid organ transplant recipients. However, cryptococcosis also occurs in individuals with apparently healthy immune systems. A growing number of cases are caused by C gattii, with infections occurring in both immunosuppressed and immunocompetent individuals. In the majority of documented cases, treatment of C gattii infection of the CNS requires aggressive management of raised intracranial pressure along with standard antifungal therapy. Early cerebrospinal fluid evacuation is often needed through placement of a percutaneous lumbar drain or ventriculostomy. Furthermore, pharmacological immunosuppression with a high dose of dexamethasone is sometimes needed to ameliorate a persistently increased inflammatory response and to reduce intracranial pressure. In this Grand Round, we present the case of an otherwise healthy adolescent female patient, who, despite aggressive management, succumbed to C gattii meningoencephalitis. We also present a review of the existing literature and discuss optimum clinical management of meningoencephalitis caused by C gattii.

Retrospective study of the epidemiology and clinical manifestations of Cryptococcus gattii infections in Colombia from 1997-2011

BACKGROUND

Cryptococcosis due to Cryptococcus gattii is endemic in various parts of the world, affecting mostly immunocompetent patients. A national surveillance study of cryptococcosis, including demographical, clinical and microbiological data, has been ongoing since 1997 in Colombia, to provide insights into the epidemiology of this mycosis.

METHODOLOGY/PRINCIPAL FINDINGS

From 1,209 surveys analyzed between 1997-2011, 45 cases caused by C. gattii were reported (prevalence 3.7%; annual incidence 0.07 cases/million inhabitants/year). Norte de Santander had the highest incidence (0.81 cases/million/year), representing 33.3% of all cases. The male: female ratio was 3.3∶1. Mean age at diagnosis was 41±16 years. No specific risk factors were identified in 91.1% of patients. HIV infection was reported in 6.7% of patients, autoimmune disease and steroids use in 2.2%. Clinical features included headache (80.5%), nausea/vomiting (56.1%) and neurological derangements (48.8%). Chest radiographs were taken in 21 (46.7%) cases, with abnormal findings in 7 (33.3%). Cranial CT scans were obtained in 15 (33.3%) cases, with abnormalities detected in 10 (66.7%). Treatment was well documented in 30 cases, with most receiving amphotericin B. Direct sample examination was positive in 97.7% cases. Antigen detection was positive for all CSF specimens and for 75% of serum samples. C. gattii was recovered from CSF (93.3%) and respiratory specimens (6.6%). Serotype was determined in 42 isolates; 36 isolates were serotype B (85.7%), while 6 were C (14.3%). The breakdowns of molecular types were VGII (55.6%), VGIII (31.1%) and VGI (13.3%). Among 44 strains, 16 MLST sequence types (ST) were identified, 11 of them newly reported.

CONCLUSIONS/SIGNIFICANCE

The results of this passive surveillance study demonstrate that cryptococcosis caused by C. gattii has a low prevalence in Colombia, with the exception of Norte de Santander. The predominance of molecular type VGII is of concern considering its association with high virulence and the potential to evolve into outbreaks.

Cryptococcosis in Colombia: results of the national surveillance program for the years 2006-2010

INTRODUCTION

A survey on cryptococcosis is being conducted regularly in Colombia since 1997. We present hereby the results corresponding to patients diagnosed from 2006 to 2010.

OBJECTIVE

To analyze the data obtained during this period.

MATERIALS AND METHODS

Retrospective analysis of the corresponding surveys.

RESULTS

A total of 526 surveys originating from 72% of the Colombian political divisions were received during the 5-year period. Most patients (76.6%) were males and 74.9% were 21-50 years old. The most prevalent risk factor was HIV infection (83.5%) with cryptococcosis defining AIDS in 23% of the cases. In the general population the estimated mean annual incidence rate for cryptococcosis was 2.4 x 106 inhabitants while in AIDS patients this rate rose to 3.3 x 103. In 474 surveys stating clinical features, most frequent complaints were headache 84.5%, fever 63.4%, nausea and vomiting 57.5%, mental alterations 46.3%, meningeal signs 33.0%, cough 26.4% and visual alterations 24.5%. Neurocryptococcosis was recorded in 81.8% of the cases. Laboratory diagnosis was based on direct examination, culture and latex in 29.3% cases. From 413 Cryptococcus isolates analyzed, 95.6% were identified as C. neoformans var. grubii, 1% C. neoformans var. neoformans, and 3.4% C. gattii. Treatment was reported for 71.6% of the cases with amphotericin B alone or in combination with fluconazole prescribed in 28%.

CONCLUSIONS

Surveys done through passive surveillance continue to be sentinel markers for HIV infection and represent a systematic approach to the study of opportunistic problems regularly afflicting AIDS patients since cryptococcosis requires no compulsory notification in Colombia.

Evaluation of a rapid lateral flow immunoassay for the detection of cryptococcal antigen for the early diagnosis of cryptococcosis in HIV patients in Colombia

A previous study carried out in a tertiary care hospital in Colombia demonstrated the usefulness of the Cryptococcus capsular antigen detection by latex (CrAg Latex) in the early diagnosis of cryptococcosis in HIV-infected patients with low CD4 + levels. The aim of this study was to establish the performance of a new rapid lateral flow assay (CrAg LFA) in preserved sera of those HIV-infected patients collected between 2001 and 2006. A total of 421 sera from 297 patients with a confirmed diagnosis of HIV were tested with CrAg LFA and results compared with those obtained with CrAg Latex. All patients provided informed consent for specimen collection. A concordance of 100% was found between positive results obtained by both methods. However, 13 sera that were negative by CrAg Latex, were positive by CrAg LFA (3.1%). In these positive patients, median of CD4 + levels was 67 cells/μl (8-608 cells/μl), while median of viral load was 118,965 copies/ml (50-500,000 copies/ml). Patients who were negative for cryptococcosis had a median of 177 cells/μl in CD4 + levels (4-2516 cells/μl) and a median of 62,318 copies/ml in viral loads (25-50,000 copies/ml). A significant statistical difference was found when comparing CD4 + levels and viral load in patients positive for cryptococcosis and those that were proven to be negative (P < 0.0001). The use of Point-of-Care Tests (POCT) like CrAg LFA play an important role in the diagnosis of infectious diseases, especially in resource limited settings, where it will be a useful means to diagnose cryptococcosis early in HIV patients.

A superconducting transformer system for high current cable testing

This article describes the development of a direct-current (dc) superconducting transformer system for the high current test of superconducting cables. The transformer consists of a core-free 10,464 turn primary solenoid which is enclosed by a 6.5 turn secondary. The transformer is designed to deliver a 50 kA dc secondary current at a dc primary current of about 50 A. The secondary current is measured inductively using two toroidal-wound Rogowski coils. The Rogowski coil signal is digitally integrated, resulting in a voltage signal that is proportional to the secondary current. This voltage signal is used to control the secondary current using a feedback loop which automatically compensates for resistive losses in the splices to the superconducting cable samples that are connected to the secondary. The system has been commissioned up to 28 kA secondary current. The reproducibility in the secondary current measurement is better than 0.05% for the relevant current range up to 25 kA. The drift in the secondary current, which results from drift in the digital integrator, is estimated to be below 0.5 A/min. The system's performance is further demonstrated through a voltage-current measurement on a superconducting cable sample at 11 T background magnetic field. The superconducting transformer system enables fast, high resolution, economic, and safe tests of the critical current of superconducting cable samples.

[Results of nine years of the clinical and epidemiological survey on cryptococcosis in Colombia, 1997-2005]

INTRODUCTION

A national survey on cryptococcosis has been conducted in Colombia since 1997. The survey data recorded over a 9-year period, 1997 to 2005, was summarized.

MATERIALS AND METHODS

The format provided by the European Confederation of Medical Mycology was adapted with the correspondent permission.

RESULTS

Over the 9 year period, 931 surveys were received from 76 centers. The associated disease syndromes were as follows: 891 (95.7%) were neurocryptococosis cases, 27 (2.9%) pulmonary disease, 5 (0.5%) cutaneous lesions, 2 (0.2%) ganglionar forms, 2 (0.2%) oropharyngeal lesions and one case (0.1%) each from peritonitis, liver lesion, cellulitis and urinary tract infection. Demographic data indicated 82.7% of the subjects were males, and 59.4% were between 20-39 years old; 25 children less than 16 years old were reported. The prevalent risk factor was HIV infection (78.1%). The mean annual incidence rate of cryptococcosis in the general population was 2.4 X 106 inhabitants, but in AIDS patients the rate rose to one in 3 X 103. The most frequent clinical features were headache (85.2%), nausea and vomiting (59.1%), fever (59.0%), mental changes (46.2%), meningeal signs (33.4%), cough (23.6%) and visual alterations or loss of vision (20.9%). Laboratory data showed that direct examination of cerebrospinal fluid (CSF) was positive in 92.8% cases and Cryptococcus was recovered in 90.3% of the cases. Cryptococcal antigen reactivity was 98.9% in CSF and 93.7% in serum samples. From 788 isolates submitted, 95.9% were C. neoformans var. grubii serotype A, 0.3% var. neoformans serotype D, 3.3% C. gattii serotype B and 0.5% C. gattii serotype C. The majority of patients were treated initially with amphotericin B.

CONCLUSION

Cryptococcosis incidence has increased dramatically in Colombia with the AIDS pandemic and it can be considered as a sentinel marker for HIV infection.

[Paradoxical appearance of encephalic tuberculomas during treatment for tuberculosis in immunocompetent patients]

Two cases of appearance of encephalic tuberculomas during anti-tuberculous treatment in immunocompetent patients are presented. The first an adult man presenting a right frontal lesion which required surgical treatment and the second a girl with multiple lesions located mainly in the brainstem. This paradoxical presentation is attributed to a bizarre immunological reaction between the host and the tuberculosis bacillus. Patients with this condition do not require changes in anti-tuberculous treatment, and steroids are helpful in alleviating the symptoms. Surgery is indicated only for cases of uncontrollable intracranial hypertension or when there is diagnostic uncertainty. The prognosis of this entity is usually good.

[Idiopathic hypertrophic cranial pachymeningitis]

Idiopathic hypertrophic cranial pachymeningitis is an infrequent chronic inflammatory process of unknown etiology which causes thickening of the dura mater and progressive neurologic alterations due to the compression of adjacent structures. A case is presented of an adult woman with a clinical syndrome consisting of headache, progressive visual loss and bilateral optic neuropathy. The diagnosis was based upon visualization of the thickened dura mater in neuroimaging studies and the exclusion of known causes by histopathological examination. Diagnosis and follow-up of this condition are currently easier with the use of nuclear magnetic resonance with contrast medium. Biopsy of the dura mater continues to be the gold standard for the definitive diagnosis of this disease. Steroid therapy causes clinical improvement in most of the patients; however, relapses are frequent, making necessary the concomitant use of other immunosuppressive agents such as cyclophosphamide or azathioprine. Mortality is low but definitive neurologic sequelae are common.