1
|
Tan L, Zhao L, Tang G, Ren Y, Tian H, Chen T. Unexpected exacerbation of cryptococcal meningitis after unilateral adrenalectomy in a PMAH patient: a case report and literature review. BMC Endocr Disord 2023; 23:199. [PMID: 37723545 PMCID: PMC10506208 DOI: 10.1186/s12902-023-01457-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 09/13/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Primary bilateral macronodular adrenal hyperplasia (PMAH) combined with infection by an opportunistic pathogen is complicated. Clinical evidence on managing PMAH patients with infections by opportunistic pathogens is insufficient. CASE PRESENTATION A 66-year-old male was admitted with bilateral adrenal masses and was diagnosed with PMAH. Fever and disturbance of consciousness appeared after laparoscopic left adrenalectomy. Cryptococcal meningitis was confirmed by cerebrospinal fluid (CSF) culture. The exacerbation of his medical condition was suspected to result from immune reconstitution inflammatory syndrome (IRIS), and he had been treated with antifungal therapy and glucocorticoid replacement, but he responded poorly and eventually died of multiorgan failure. We summarized the clinical observations of 12 Cushing's syndrome (CS) patients infected by Cryptococcus. Seven out of nine patients who were treated for cryptococcus infection before receiving CS survived, while three patients treated for cryptococcus infection after CS treatment developed signs of IRIS and eventually died. CONCLUSION Cushing's syndrome, complicated with cryptococcal infection, has a high mortality rate, mainly when IRIS emerges. Carefully identifying the presence of the suspected infection, and controlling cryptococcal infection before removing the culprit adrenals could be the rational choice.
Collapse
Affiliation(s)
- Lu Tan
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Lianling Zhao
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Guangmin Tang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, P. R. China
| | - Yan Ren
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Haoming Tian
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China
| | - Tao Chen
- Department of Endocrinology and Metabolism, Adrenal Center, West China Hospital of Sichuan University, 37 GuoXue Lane, Chengdu, Sichuan, 610041, P. R. China.
| |
Collapse
|
2
|
Shroufi A, Chiller T, Jordan A, Denning DW, Harrison TS, Govender NP, Loyse A, Baptiste S, Rajasingham R, Boulware DR, Ribeiro I, Jarvis JN, Van Cutsem G. Ending deaths from HIV-related cryptococcal meningitis by 2030. Lancet Infect Dis 2021; 21:16-18. [PMID: 33271065 PMCID: PMC8611658 DOI: 10.1016/s1473-3099(20)30909-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022]
Affiliation(s)
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alex Jordan
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David W Denning
- Manchester Fungal Infection Group, The University of Manchester, Manchester, UK; Global Action Fund for Fungal Infections, Geneva, Switzerland
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, UK; MRC Centre for Medical Mycology, University of Exeter, Exeter, UK; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Nelesh P Govender
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Angela Loyse
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, UK
| | - Solange Baptiste
- International Treatment Preparedness Coalition, Johannesburg, South Africa
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Isabela Ribeiro
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; London School of Hygiene & Tropical Medicine, London, UK
| | - Gilles Van Cutsem
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa; Southern Africa Medical Unit, Doctors Without Borders Southern Africa, Cape Town, South Africa
| |
Collapse
|
3
|
Kelentse N, Moyo S, Mogwele ML, Ditshwanelo D, Mokaleng B, Moraka NO, Lechiile K, Leeme TB, Lawrence DS, Musonda R, Kasvosve I, Harrison TS, Jarvis JN, Gaseitsiwe S. HIV-1C env and gag Variation in the Cerebrospinal Fluid and Plasma of Patients with HIV-Associated Cryptococcal Meningitis in Botswana. Viruses 2020; 12:E1404. [PMID: 33297399 PMCID: PMC7762280 DOI: 10.3390/v12121404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/26/2020] [Accepted: 11/26/2020] [Indexed: 12/19/2022] Open
Abstract
HIV-1 compartmentalization in reservoir sites remains a barrier to complete HIV eradication. It is unclear whether there is variation in HIV-1 env and gag between cerebrospinal fluid (CSF) and plasma of individuals with HIV-associated cryptococcal meningitis (CM). We compared HIV-1 env characteristics and the gag cytotoxic T-lymphocyte (CTL) escape mutations from CSF and plasma samples. Employing population-based Sanger sequencing, we sequenced HIV-1 env from CSF of 25 patients and plasma of 26 patients. For gag, 15 CSF and 21 plasma samples were successfully sequenced. Of these, 18 and 9 were paired env and gag CSF/plasma samples, respectively. There was no statistically significant difference in the proportion of CCR5-using strains in the CSF and plasma, (p = 0.50). Discordant CSF/plasma virus co-receptor use was found in 2/18 pairs (11.1%). The polymorphisms in the HIV-1 V3 loop were concordant between the two compartments. From the HIV-1 gag sequences, three pairs had discordant CTL escape mutations in three different epitopes of the nine analyzed. These findings suggest little variation in the HIV-1 env between plasma and CSF and that the CCR5-using strains predominate in both compartments. HIV-1 gag CTL escape mutations also displayed little variation in CSF and plasma suggesting similar CTL selective pressure.
Collapse
MESH Headings
- AIDS-Related Opportunistic Infections/blood
- AIDS-Related Opportunistic Infections/cerebrospinal fluid
- AIDS-Related Opportunistic Infections/diagnosis
- AIDS-Related Opportunistic Infections/metabolism
- Adult
- Amino Acid Sequence
- Amino Acid Substitution
- Botswana
- CD4 Lymphocyte Count
- Cross-Sectional Studies
- Disease Susceptibility
- Female
- HIV Infections/complications
- HIV Infections/virology
- Humans
- Immunocompromised Host
- Male
- Meningitis, Cryptococcal/blood
- Meningitis, Cryptococcal/cerebrospinal fluid
- Meningitis, Cryptococcal/etiology
- Meningitis, Cryptococcal/metabolism
- Middle Aged
- Mutation
- RNA, Viral
- Viral Load
- env Gene Products, Human Immunodeficiency Virus/blood
- env Gene Products, Human Immunodeficiency Virus/cerebrospinal fluid
- env Gene Products, Human Immunodeficiency Virus/metabolism
- gag Gene Products, Human Immunodeficiency Virus/blood
- gag Gene Products, Human Immunodeficiency Virus/cerebrospinal fluid
- gag Gene Products, Human Immunodeficiency Virus/metabolism
Collapse
Affiliation(s)
- Nametso Kelentse
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana;
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Mompati L. Mogwele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Doreen Ditshwanelo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
| | - Baitshepi Mokaleng
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana;
| | - Natasha O. Moraka
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Department of Pathology, Stellenbosch University, Stellenbosch 7505, South Africa
| | - Kwana Lechiile
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Tshepo B. Leeme
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - David S. Lawrence
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, The London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Rosemary Musonda
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Ishmael Kasvosve
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana;
| | - Thomas S. Harrison
- Centre for Global Health, Institute for Infection and Immunity, St. George’s University of London, London SW17 0RE, UK;
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, The London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Simani Gaseitsiwe
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (M.L.M.); (D.D.); (B.M.); (N.O.M.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (J.N.J.)
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| |
Collapse
|
4
|
Affiliation(s)
- Jordan D Anderson
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Vincent T Ho
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Kyle T Wright
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Bruce D Levy
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| |
Collapse
|
5
|
Abstract
We herein report a 76-year-old Japanese man with myelofibrosis who developed cryptococcal meningitis. After treatment for 5 months with ruxolitinib, the patient presented with fever and disturbance of consciousness. Marked nuchal stiffness was noted. The magnetic resonance imaging results of the brain were normal. Lumbar puncture showed an opening cerebrospinal fluid (CSF) pressure of 110 mm H2O, pleocytosis (85 mononuclear cells and 222 polymorphonuclear cells/μL), decreased CSF/serum glucose ratio (43%), and elevated protein (194 mg/dL). Blood and CSF cultures grew no bacteria or fungi. However, cryptococcal antigen was detected in the blood and CSF samples. We discontinued ruxolitinib and started administration of amphotericin B. His condition improved gradually 1 week after initiation of treatment. There have been only a few reports on cryptococcal meningitis associated with ruxolitinib. Physicians should consider the possibility of cryptococcal meningitis in patients receiving ruxolitinib.
Collapse
|
6
|
Tenforde MW, Gertz AM, Lawrence DS, Wills NK, Guthrie BL, Farquhar C, Jarvis JN. Mortality from HIV-associated meningitis in sub-Saharan Africa: a systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25416. [PMID: 31957332 PMCID: PMC6970088 DOI: 10.1002/jia2.25416] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION HIV-associated cryptococcal, TB and pneumococcal meningitis are the leading causes of adult meningitis in sub-Saharan Africa (SSA). We performed a systematic review and meta-analysis with the primary aim of estimating mortality from major causes of adult meningitis in routine care settings, and to contrast this with outcomes from clinical trial settings. METHODS We searched PubMed, EMBASE and the Cochrane Library for published clinical trials (defined as randomized-controlled trials (RCTs) or investigator-managed prospective cohorts) and observational studies that evaluated outcomes of adult meningitis in SSA from 1 January 1990 through 15 September 2019. We performed random effects modelling to estimate pooled mortality, both in clinical trial and routine care settings. Outcomes were stratified as short-term (in-hospital or two weeks), medium-term (up to 10 weeks) and long-term (up to six months). RESULTS AND DISCUSSION Seventy-nine studies met inclusion criteria. In routine care settings, pooled short-term mortality from cryptococcal meningitis was 44% (95% confidence interval (95% CI):39% to 49%, 40 studies), which did not differ between amphotericin (either alone or with fluconazole) and fluconazole-based induction regimens, and was twofold higher than pooled mortality in clinical trials using amphotericin based treatment (21% (95% CI:17% to 25%), 17 studies). Pooled short-term mortality of TB meningitis was 46% (95% CI: 33% to 59%, 11 studies, all routine care). For pneumococcal meningitis, pooled short-term mortality was 54% in routine care settings (95% CI:44% to 64%, nine studies), with similar mortality reported in two included randomized-controlled trials. Few studies evaluated long-term outcomes. CONCLUSIONS Mortality rates from HIV-associated meningitis in SSA are very high under routine care conditions. Better strategies are needed to reduce mortality from HIV-associated meningitis in the region.
Collapse
Affiliation(s)
- Mark W Tenforde
- Division of Allergy and Infectious DiseasesUniversity of Washington School of MedicineSeattleWAUSA
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
| | - Alida M Gertz
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
| | - David S Lawrence
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Nicola K Wills
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
- Welcome Centre for Infectious Diseases Research in AfricaInfectious Disease and Molecular Medicine UnitUniversity of Cape TownCape TownSouth Africa
| | - Brandon L Guthrie
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Carey Farquhar
- Division of Allergy and Infectious DiseasesUniversity of Washington School of MedicineSeattleWAUSA
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| |
Collapse
|
7
|
Essouma M, Tangie LN, Temgoua MN, Kenfack UG, Ndam AN, Danwang C. Severe clinical immunodeficiency in a patient with human immunodeficiency virus infection and relatively high CD4 counts: a case report. J Med Case Rep 2019; 13:86. [PMID: 30867046 PMCID: PMC6417181 DOI: 10.1186/s13256-019-1982-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/15/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The coexistence of neuromeningeal cryptococcosis and Kaposi's sarcoma is not surprising in a patient with human immunodeficiency virus infection and a low CD4 count, although it is rarely described. However, we describe such an association in a patient with human immunodeficiency virus infection and a relatively high CD4 count. CASE PRESENTATION A 41-year old Cameroonian woman presented to our hospital with subacute occipital headaches associated with photophobia, blurred vision, phonophobia, projectile vomiting, and tonic seizures. In her past history, there was an human immunodeficiency virus infection known for 12 years, for which she had been taking (with good compliance) tenofovir-lamivudine-efavirenz-based antiretroviral therapy for the same period of time. One month before the consultation, gastric Kaposi's sarcoma had been diagnosed, justifying the treatment with doxorubicin she had received. A clinical examination was unremarkable. A computed tomography scan of her brain was normal, and cerebrospinal fluid analysis revealed Cryptococcus neoformans. Her CD4 count was 353/mm3. Orally administered antifungal treatment with fluconazole (1200 mg/day) and flucytosine (1500 mg × 4/day) was started immediately, but she died on the sixth day of this treatment. CONCLUSION This clinical case shows that the coexistence of neuromeningeal cryptococcosis and gastric Kaposi's sarcoma is possible in all patients with human immunodeficiency virus infection, regardless of CD4 count.
Collapse
Affiliation(s)
- Mickael Essouma
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Larry N. Tangie
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Mazou N. Temgoua
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Ulrich Gabin Kenfack
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Antonin N. Ndam
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
- Hepatogastroenterology Unit, Yaounde General Hospital, Yaounde, Cameroon
| | - Celestin Danwang
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| |
Collapse
|
8
|
Nosaki Y, Ohyama K, Watanabe M, Yokoi T, Nakamichi K, Saijo M, Miura Y, Iwai K. Simultaneous Development of Progressive Multifocal Leukoencephalopathy and Cryptococcal Meningitis during Methotrexate and Infliximab Treatment. Intern Med 2019; 58:2703-2709. [PMID: 31527369 PMCID: PMC6794173 DOI: 10.2169/internalmedicine.2570-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by reactivation of the JC virus under an immunosuppressed state. This condition carries a high risk of cryptococcal meningitis. We herein report a 65-year-old woman who simultaneously developed PML and cryptococcal meningitis and presented with bilateral sixth nerve palsy. She had been treated with methotrexate and infliximab for rheumatoid arthritis. Her symptoms improved with antifungal drug treatment and discontinuation of immunosuppression therapy. Although concurrent PML and cryptococcal meningitis is rare, it should be considered in immunosuppressed patients.
Collapse
Affiliation(s)
- Yasunobu Nosaki
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Ken Ohyama
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Maki Watanabe
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Takamasa Yokoi
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Japan
| | - Masayuki Saijo
- Department of Virology 1, National Institute of Infectious Diseases, Japan
| | - Yoshiharu Miura
- Department of Neurology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Japan
| | - Katsushige Iwai
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| |
Collapse
|
9
|
Migone C, Ford N, Garner P, Eshun‐Wilson I. Updating guidance for preventing and treating cryptococcal disease: how evidence and decisions interface. Cochrane Database Syst Rev 2018; 11:ED000130. [PMID: 30520517 PMCID: PMC10284627 DOI: 10.1002/14651858.ed000130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chantal Migone
- World Health OrganizationDepartment of HIV and Global Hepatitis ProgrammeGenevaSwitzerland
| | - Nathan Ford
- World Health OrganizationDepartment of HIV and Global Hepatitis ProgrammeGenevaSwitzerland
| | - Paul Garner
- Liverpool School of Tropical MedicineCentre for Evidence Synthesis in Global HealthLiverpoolUK
| | - Ingrid Eshun‐Wilson
- Stellenbosch UniversityCentre for Evidence‐based Health CareCape TownSouth Africa
| | | |
Collapse
|
10
|
Ndayishimiye E, Ross AJ. An audit of the screen-and-treat intervention to reduce cryptococcal meningitis in HIV-positive patients with low CD4 count. Afr J Prim Health Care Fam Med 2018; 10:e1-e7. [PMID: 30198285 PMCID: PMC6131693 DOI: 10.4102/phcfm.v10i1.1779] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/05/2018] [Accepted: 06/05/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND HIV-associated cryptococcal meningitis (CCM) and related mortality may be prevented by the effective implementation of a screen-and-treat intervention. Aim: The aim of this study was to assess the effectiveness of the screen-and-treat intervention at a regional hospital in KwaZulu-Natal province, South Africa. Method: This was a descriptive study in which the records of patients seen in 2015 and 2016 with a CD4 count ≤ 100 cell/mm3 were retrieved from National Health Laboratory Service (NHLS) records and matched against patients admitted for HIV-associated CCM. Results: A total of 5.1% (190 out of 3702) patients with CD4 count ≤ 100 cell/mm3 were cryptococcal antigen positive (CrAg +ve), of whom 22.6% (43 out of 190) were admitted with CCM. Patients who were CrAg +ve had significantly lower CD4 counts (mean CD4 = 38.9 ± 28.5) when compared to CrAg -ve patients (mean CD4 = 49.9 ± 37.4) with p = 0.0001. Only 2.6% (5 out of 190) of patients were referred for a lumbar puncture (LP) as part of the screen-and-treat intervention, whilst 38 who were CrAg +ve self-presented with CCM. Eighty-eight patients were admitted for suspected CCM: eight because of the screen-and-treat-intervention (none of whom had meningitis based on cerebrospinal fluid results) and 80 of whom self-presented and had confirmed CCM. The overall mortality of patients admitted with CCM was 30% (24 out of 80). Conclusion: The current ad-hoc screen-and-treat intervention was ineffective in detecting patients at risk of developing CCM. Systems need to be put in place to ensure that all CrAg +ve patients have an LP to detect subclinical CCM to improve the outcome for those with HIV-associated CCM.
Collapse
Affiliation(s)
- Egide Ndayishimiye
- Health, College of Health Sciences, University of KwaZulu-Natal, Prince Mshiyeni Memorial Hospital.
| | | |
Collapse
|
11
|
Abstract
We conducted a retrospective study of 549 adults admitted with community-acquired meningitis (CAM) to several hospitals in New Orleans, LA and Houston, TX between 1999 and 2014 to characterize the current epidemiology, clinical manifestations, cerebrospinal fluid (CSF) characteristics, and outcomes of CAM between HIV-infected and uninfected patients and to identify risk factors for adverse outcomes in CAM. Bivariate analysis and logistic regression analysis were used to identify prognostic factors. A total of 1022 patients with CAM were screened. Only 549 (53.7%) subjects had an HIV test and were included in the study. Of those, 138 (25%) had HIV infection. HIV-infected patients presented with less meningeal symptoms (headache, neck stiffness, and Kernig sign), but with higher rates of hypoglycorrhachia, elevated CSF protein, and an abnormal cranial imaging (p < 0.05). More than 50% of all the patients had an unknown etiology. Cryptococcal meningitis was the most common identified etiology of CAM in HIV-infected patients followed by neurosyphilis and varicella-zoster virus (VZV). Viral and bacterial etiologies were the most frequent etiologies in non-HIV-infected patients. Streptococcus pneumoniae was the most common bacterial pathogen in both groups, but it was rare overall (2%). Adverse clinical outcomes were similar in both groups (27% vs. 24%). Logistic regression identified hypoglycorrhachia and an abnormal neurological examination as independent predictor factors of worse outcome in all patients with meningitis. Our results demonstrate that the etiology, clinical presentation, and CSF findings differ between HIV-infected and HIV-uninfected adults with CAM, but clinical outcomes are similar.
Collapse
Affiliation(s)
- Karen J Vigil
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center , Houston, Texas
| | - Lucrecia Salazar
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center , Houston, Texas
| | - Rodrigo Hasbun
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center , Houston, Texas
| |
Collapse
|
12
|
Liu Y, Feng M, Yao Y, Deng K, Bao X, Liu X, Wang R. Cryptococcal meningitis after transnasal transsphenoidal pituitary microsurgery of ACTH-secreting pituitary adenoma: A case report. Medicine (Baltimore) 2017; 96:e7124. [PMID: 28700464 PMCID: PMC5515736 DOI: 10.1097/md.0000000000007124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Microbial infection should be regarded in the differential diagnosis of neurosurgical complications after transnasal transsphenoidal pituitary microsurgery, albeit cryptococcal meningitis is rare. This article will discuss the risk factors of cryptococcal meningitis in patients underwent transnasal transsphenoidal pituitary microsurgery, and summary the potential origins of infection. PATIENT CONCERNS AND DIAGNOSIS Here, we report a case of 37-year-old male who had cryptococcal meningitis after transnasal transsphenoidal pituitary microsurgery of a relapsing ACTH-secreting pituitary adenoma. INTERVENTION Standard therapy for Cryptococcus neoformans (fluconazole [400 mg per day] and flucytosine) was administered and followed by maintenance dose. OUTCOMES The patient had been on treatment for one and a half years during follow-up and reported neurologically well with repeated negative cerebrospinal fluid (CSF) culture until sudden death of heart arrest. MAIN LESSONS TO LEARN C neoformans can be a possible cause of meningitis in immunocompetent patients after transnasal transsphenoidal pituitary microsurgery. Risk factors, such as pre-existed pulmonary infection and Cushing-associated hypercortisolemia, should be stressed. Promising preventive measures may include preoperative routine sputum smear and India-ink stain for screening, preoperative treatment of cryptococcal pneumonia, postoperative antibiotic management, and a more secure skull base reconstruction. Radiation and pharmaceutical treatment may be alternative for recurrent Cushing disease.
Collapse
|
13
|
Meiring S, Fortuin-de Smidt M, Kularatne R, Dawood H, Govender NP. Prevalence and Hospital Management of Amphotericin B Deoxycholate-Related Toxicities during Treatment of HIV-Associated Cryptococcal Meningitis in South Africa. PLoS Negl Trop Dis 2016; 10:e0004865. [PMID: 27467556 PMCID: PMC4965057 DOI: 10.1371/journal.pntd.0004865] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/29/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND We aimed to establish the prevalence of amphotericin B deoxycholate (AmBd)-related toxicities among South African patients with cryptococcosis and determine adherence to international recommendations to prevent, monitor and manage AmBd-related toxicities. METHODS Clinical data were collected from cases of laboratory-confirmed cryptococcosis at 25 hospitals, October 2012 -February 2013. Anemia was defined as hemoglobin (Hb) concentration <10 g/dl, hypokalemia as serum potassium (K) <3.4 mEq/L and nephrotoxicity as an increase in serum creatinine (Cr) to >1.1 times the upper limit of normal. To determine adherence to toxicity prevention recommendations, we documented whether baseline Hb, K and Cr tests were performed, whether pre-emptive hydration and IV potassium chloride (KCl) was administered prior to 80% and 60% of AmBd doses and whether daily oral KCl supplementation was given ≥60% of the time. To determine adherence to monitoring recommendations, we ascertained whether a daily fluid chart was completed, Hb was monitored weekly and K or Cr were monitored bi-weekly. RESULTS Of 846 patients, clinical data were available for 76% (642/846), 82% (524/642) of whom received AmBd. Sixty-four per cent (n = 333) had documented baseline laboratory tests, 40% (n = 211) were given pre-emptive hydration and 14% (n = 72) and 19% (n = 101) received intravenous and oral KCl. While on AmBd, 88% (n = 452) had fluid monitoring; 27% (n = 142), 45% (n = 235) and 44% (n = 232) had Hb, K and Cr levels monitored. Toxicities developed frequently during treatment: anemia, 16% (86/524); hypokalemia, 43% (226/524) and nephrotoxicity, 32% (169/524). CONCLUSION AmBd-related toxicities occurred frequently but were potentially preventable with adequate monitoring, supplemental fluid and electrolyte therapies.
Collapse
Affiliation(s)
- Susan Meiring
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Melony Fortuin-de Smidt
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ranmini Kularatne
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Halima Dawood
- Pietermaritzburg Hospital Complex, Pietermaritzburg and University of KwaZulu-Natal, Durban, South Africa
| | - Nelesh P. Govender
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | |
Collapse
|
14
|
Abstract
Background Cryptococcus neoformans is a ubiquitous environmental fungus that can cause life-threatening meningitis and fungemia, often in the presence of acquired immunodeficiency syndrome (AIDS), liver cirrhosis, diabetes mellitus, or other medical conditions. To distinguish risk factors from comorbidities, we performed a hospital-based, density-sampled, matched case-control study. Methods All new-onset cryptococcal meningitis cases and cryptococcemia cases at a university hospital in Taiwan from 2002–2010 were retrospectively identified from the computerized inpatient registry and were included in this study. Controls were selected from those hospitalized patients not experiencing cryptococcal meningitis or cryptococcemia. Controls and cases were matched by admission date, age, and gender. Conditional logistic regression was used to analyze the risk factors. Results A total of 101 patients with cryptococcal meningitis (266 controls) and 47 patients with cryptococcemia (188 controls), of whom 32 patients had both cryptococcal meningitis and cryptococcemia, were included in this study. Multivariate regression analysis showed that AIDS (adjusted odds ratio [aOR] = 181.4; p < 0.001), decompensated liver cirrhosis (aOR = 8.5; p = 0.008), and cell-mediated immunity (CMI)-suppressive regimens without calcineurin inhibitors (CAs) (aOR = 15.9; p < 0.001) were independent risk factors for cryptococcal meningitis. Moreover, AIDS (aOR = 216.3, p < 0.001), decompensated liver cirrhosis (aOR = 23.8; p < 0.001), CMI-suppressive regimens without CAs (aOR = 7.3; p = 0.034), and autoimmune diseases (aOR = 9.3; p = 0.038) were independent risk factors for developing cryptococcemia. On the other hand, diabetes mellitus and other medical conditions were not found to be risk factors for cryptococcal meningitis or cryptococcemia. Conclusions The findings confirm AIDS, decompensated liver cirrhosis, CMI-suppressive regimens without CAs, and autoimmune diseases are risk factors for invasive C. neoformans diseases.
Collapse
Affiliation(s)
- Ying-Ying Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Stephanie Shiau
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Chi-Tai Fang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
| |
Collapse
|
15
|
Brown SJ, George S, Braithwaite K. A puzzling case of cryptococcal meningitis. S Afr Med J 2014; 104:720. [PMID: 25909102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
|
16
|
Wang AY, Machicado JD, Khoury NT, Wootton SH, Salazar L, Hasbun R. Community-acquired meningitis in older adults: clinical features, etiology, and prognostic factors. J Am Geriatr Soc 2014; 62:2064-70. [PMID: 25370434 PMCID: PMC4241151 DOI: 10.1111/jgs.13110] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To investigate the epidemiology and outcomes of community-acquired meningitis in older adults. DESIGN Retrospective study. SETTING Participants adults in Houston, Texas, with community-acquired meningitis hospitalized between January 1, 2005, and January 1, 2010 (N = 619; n = 54, 8.7%, aged ≥65; n = 565 aged <65). METHODS An adverse clinical outcome was defined as a Glasgow Outcome Scale score of 4 or less. RESULTS Older adults had higher rates of comorbidities, abnormal neurological and laboratory (serum white blood cell count >12,000/μL, and cerebrospinal fluid protein >100 mg/dL) findings (P < .001), abnormalities on computed tomography and magnetic resonance imaging of the head (P = .002), and adverse clinical outcomes (ACOs) (P < .001). The majority of participants (65.8%) had meningitis of unknown etiology. Bacterial meningitis was an infrequent cause of community-acquired meningitis (7.4%). Of the known causes, bacterial meningitis and West Nile virus were more common in older than younger adults; younger participants more frequently had cryptococcal and viral meningitis. On logistic regression, female sex was predictive of a poor outcome in the older participants (P = .002), whereas abnormal neurological examination (P < .001), fever (P = .01), and a cerebrospinal fluid glucose level less than 45 mg/dL (P = .002) were significant poor prognostic factors in younger participants. CONCLUSION Most cases of community-acquired meningitis are of unknown origin. Older adults are more likely than younger adults to have bacterial meningitis and West Nile virus infection when a cause can be identified. They also have more neurological abnormalities, laboratory and imaging abnormalities, and adverse clinical outcomes.
Collapse
MESH Headings
- Adolescent
- Adult
- Age Factors
- Aged
- Aged, 80 and over
- Brain/pathology
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/epidemiology
- Community-Acquired Infections/etiology
- Comorbidity
- Cross-Sectional Studies
- Female
- Glasgow Outcome Scale
- Glucose/cerebrospinal fluid
- Humans
- Magnetic Resonance Imaging
- Male
- Meningitis, Bacterial/diagnosis
- Meningitis, Bacterial/epidemiology
- Meningitis, Bacterial/etiology
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/epidemiology
- Meningitis, Cryptococcal/etiology
- Meningitis, Viral/diagnosis
- Meningitis, Viral/epidemiology
- Meningitis, Viral/etiology
- Middle Aged
- Neurologic Examination
- Prognosis
- Retrospective Studies
- Sex Factors
- Texas
- Tomography, X-Ray Computed
- West Nile Fever/diagnosis
- West Nile Fever/epidemiology
- West Nile Fever/etiology
- Young Adult
Collapse
Affiliation(s)
- Amy Y. Wang
- Department of Internal Medicine, University of Texas Health Science Center in Houston
| | - Jorge D. Machicado
- Department of Internal Medicine, University of Texas Health Science Center in Houston
| | - Nabil T. Khoury
- Department of Internal Medicine, University of Texas Health Science Center in Houston
| | - Susan H. Wootton
- Department of Pediatrics, University of Texas Health Science Center in Houston
| | - Lucrecia Salazar
- Department of Internal Medicine, University of Texas Health Science Center in Houston
| | - Rodrigo Hasbun
- Department of Internal Medicine, University of Texas Health Science Center in Houston
| |
Collapse
|
17
|
Cavalcante EG, Montoni JD, Oliveira GT, Campos LMA, Paz JA, Silva CA. Fatal cryptococcal meningitis in a juvenile lupus erythematosus patient. Rev Bras Reumatol 2014; 54:155-158. [PMID: 24878864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 05/14/2013] [Indexed: 06/03/2023] Open
Abstract
Cryptococcosis is a fungal infection caused by Cryptococcus neoformans, generally associated with immunodeficiency and immunosuppressive agents, and it is rarely reported in systemic lupus erythematosus (SLE), particularly in juvenile SLE (JSLE). From January 1983 to June 2011, 5,604 patients were followed at our University Hospital and 283 (5%) of them met the American College of Rheumatology (ACR) classification criteria for SLE. Only one (0.35%) of our JSLE patients had cryptococcal meningitis and is described in this report. A 10-year old girl was diagnosed with JSLE. By the age of 15 years, she presented persistent headaches, nausea and vomiting for a 5 day period without fever, after a cave-exploring trip. At that moment, she was under 10 mg/day of prednisone, azathioprine and hydroxychloroquine. A lumbar puncture was performed and India ink preparation was positive for cryptococcosis, cerebrospinal fluid culture yielded Cryptococcus neoformans and serum cryptococcal antigen titer was 1:128. Azathioprine was suspended, and liposomal amphotericin B was introduced. Despite of treatment, after four days she developed amaurosis and fell into a coma. A computer tomography of the brain showed diffuse ischemic areas and nodules suggesting fungal infection. Four days later, she developed severe sepsis and vancomycin and meropenem were prescribed, nevertheless she died due to septic shock. In conclusion, cryptococcal meningitis is a rare and severe opportunistic infection in juvenile lupus population. This study reinforces the importance of an early diagnosis and prompt introduction of antifungal agents, especially in patients with history of contact with bird droppings.
Collapse
Affiliation(s)
- Erica G Cavalcante
- Unidade de Reumatologia Pediátrica, Instituto da Criança, Hospital de Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - João D Montoni
- Unidade de Nefrologia Pediátrica, Instituto da Criança, Hospital de Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Guilherme T Oliveira
- Unidade de Reumatologia Pediátrica, Instituto da Criança, Hospital de Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Lucia M A Campos
- Unidade de Nefrologia Pediátrica, Instituto da Criança, Hospital de Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Jose A Paz
- Unidade de Reumatologia Pediátrica, Instituto da Criança, Hospital de Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Clovis A Silva
- Unidade de Reumatologia Pediátrica, Instituto da Criança, Hospital de Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| |
Collapse
|
18
|
Chang CC, Omarjee S, Lim A, Spelman T, Gosnell BI, Carr WH, Elliott JH, Moosa MYS, Ndung'u T, French MA, Lewin SR. Chemokine levels and chemokine receptor expression in the blood and the cerebrospinal fluid of HIV-infected patients with cryptococcal meningitis and cryptococcosis-associated immune reconstitution inflammatory syndrome. J Infect Dis 2013; 208:1604-12. [PMID: 23908492 DOI: 10.1093/infdis/jit388] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus-infected patients with treated cryptococcal meningitis who start combination antiretroviral therapy (cART) are at risk of further neurological deterioration, in part caused by paradoxical cryptococcosis-associated immune reconstitution inflammatory syndrome (C-IRIS). We hypothesized that C-IRIS is associated with alterations of chemokine receptor expression on T cells and chemokine concentrations in cerebrospinal fluid (CSF) that enhance recruitment of T-helper 1 cells and/or myeloid cells to the central nervous system. METHODS In a prospective study of 128 human immunodeficiency virus-infected patients with cryptococcal meningitis who received antifungal therapy followed by cART, we examined the proportions of CD4(+) and CD8(+) T cells expressing CCR5 and/or CXCR3, in CSF and whole blood and the concentrations of CXCL10, CCL2, and CCL3 in stored CSF and plasma. RESULTS The proportion of CD4(+) and CD8(+) T cells expressing CXCR3(+)CCR5(+) and the concentrations of CXCL10, CCL2 and CCL3 were increased in CSF compared with blood at cART initiation (P < .0001). Patients with C-IRIS (n = 26), compared with those with no neurological deterioration (n = 63), had higher CSF ratios of CCL2/CXCL10 and CCL3/CXCL10 and higher proportions of CXCR3(+)CCR5(+)CD8(+)T cells in CSF compared with blood at cART initiation (P = .03, .0053, and .02, respectively). CONCLUSION CD8(+) T-cell and myeloid cell trafficking to the central nervous system may predispose patients to C-IRIS.
Collapse
|
19
|
Nunnari G, Gussio M, Pinzone MR, Martellotta F, Cosentino S, Cacopardo B, Celesia BM. Cryptococcal meningitis in an HIV-1-infected person: relapses or IRIS? Case report and review of the literature. Eur Rev Med Pharmacol Sci 2013; 17:1555-1559. [PMID: 23771547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
After starting highly active antiretroviral therapy (HAART), HIV-infected patients may experience what is termed immune reconstitution inflammatory syndrome (IRIS). IRIS is characterized by a paradoxical inflammatory response to either previously or recently treated infections or unmasked subclinical infections, when the patient regains the ability to mount a suitable immune response against specific antigens or pathogens. Cryptococcal IRIS (C-IRIS) is thought to be mediated by recovery of Cryptococcus-specific immune responses, resulting in exaggerated host inflammatory responses. In HIV-positive subjects, two distinct modes of presentation of C-IRIS are recognized, "paradoxical" and "unmasking" C-IRIS. "Paradoxical" C-IRIS presents as worsening or recurrence of treated cryptococcal disease following HAART initiation, despite microbiological treatment success. In the "unmasking" form, patients with no prior diagnosis may develop acute symptoms of cryptococcosis, such as meningitis or necrotizing lymphadenopathy, after starting HAART. Here, we present the case of an HIV-positive man, who developed cryptococcal meningitis two months after having started HAART and experienced several meningeal relapses and a "paradoxical" C-IRIS during the following year.
Collapse
Affiliation(s)
- G Nunnari
- Department of Clinical and Molecular Biomedicine, Division of Infectious Diseases, University of Catania, Garibaldi Nesima Hospital, Catania, Italy
| | | | | | | | | | | | | |
Collapse
|
20
|
Bicanic T, Ogden D, Whitney L, Loyse A, Jarvis J. British HIV Association opportunistic infection guidelines: in defence of amphotericin B deoxycholate. HIV Med 2013; 13:636-7. [PMID: 23051823 DOI: 10.1111/j.1468-1293.2012.01022.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
21
|
Subils GC, Maldonado FS. [Cryptococcal meningitis as initial presentation of systemic lupus erythematosus]. Rev Fac Cien Med Univ Nac Cordoba 2012; 69:47-50. [PMID: 22917073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION Infection is one of the most frequent etiology of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Cryptococcal meningitis is a recognized complication of SLE with high mortality rates in those treated with immunosuppressive agents. We describe a patient with cryptoccoccal meningitis and SLE. This case suggests that intrinsic immunological abnormality related to SLE predisposed to opportunistic infections. CLINICAL CASE A 25 years old woman was admitted because of Pelvic Inflammatory Disease. She had ascitis and abdominal pain and neurological examination was normal.. Laboratory findings showed mild anemia, leukocytes: 6350/mm(3). Total lymphocytes: 508/mm(3) (CD4 +: 75 cel/mm(3)). Erythrocyte sedimentation rate (ESR): 40mm/h, Coombs test (+). Abdominal CT scan showed ascites and pleural bilateral effusion. Two days after her admission, VDRL test was positive ( 1/64). Lumbar puncture was done and the r cerebrospinal fluid showed: normal glucose and protein level with normal cells. Fungi elements were found and Cryptococcus neoformans were identified. She received Anfotericin B treatment. HIV and TPHA test were negative. Antinuclear and anti-ds-DNA were positive in high levels and low levels of complement were found. Methylprednisolone pulses were s administered intravenously for three days. Cerebrospinal fluid was normal after 10 weeks of antifungical treatment.
Collapse
Affiliation(s)
- Gisela C Subils
- Servicio de clínica medica - Hospital Rawson Bajada Pucara 2025, ciudad de Córdoba, Córdoba, Argentina.
| | | |
Collapse
|
22
|
Iwazu K, Iwazu Y, Takeda SI, Akimoto T, Yumura W, Takahashi H, Ito C, Kanai K, Taniguchi N, Hirai Y, Kusano E. Successful treatment of serial opportunistic infections including disseminated nocardiosis and cryptococcal meningitis in a patient with ANCA-associated vasculitis. Intern Med 2012; 51:3051-6. [PMID: 23124149 DOI: 10.2169/internalmedicine.51.7886] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein present a case of serial opportunistic infections that included disseminated nocardiosis and cryptococcal meningitis in a 67-year-old man who was diagnosed with ANCA-associated vasculitis and treated with corticosteroids. Upon admission, the initial manifestations of the disease included subcutaneous tumors and multiple lesions in the brain and lungs. Nocardia farcinica was identified in a culture of the aspirated pus. The patient was successfully treated for disseminated nocardiosis with antibiotics. However, three months after discharge, he was hospitalized with complaints of nuchal pain. Cryptococcus neoformans was identified on a culture of the cerebrospinal fluid. Anti-fungal treatment resulted in the remission of cryptococcal meningitis.
Collapse
Affiliation(s)
- Kana Iwazu
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Minta DK, Dolo A, Dembele M, Kaya AS, Sidibe AT, Coulibaly I, Maiga II, Diallo M, Traore AM, Maiga MY, Doumbo OK, Traore HA, Pichard E, Chabasse D. [Neuromeningeal cryptococcosis in Mali]. Med Trop (Mars) 2011; 71:591-595. [PMID: 22393627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Cryptococcal meningitis is the most common fatal central nervous system infection in AIDS patients in Sub-Saharan Africa. The purpose of this prospective study conducted from March 2003 to February 2004 in the internal medicine and infectious diseases departments of the Point G University Hospital Center was to investigate the clinical, prognostic and epidemiological profile of Cryptococcus neoformans infection in patients hospitalized for brain and meningeale infection (BMI). Diagnosis of neuromeningeal cryptococcosis (NMC) was based on positive identification of Cryptococcus by direct exam of the cebrospinal fluid (CSF) after India ink staining and/or culture on Sabouraud medium without actidione. During the study period, a total of 569 patients were hospitalized including 235 (41.3%) with HIV infection. Overall C. neoformans was identified in 14 patients. Median patient age was 39 +/- 8 years. There was a male preponderance with a sex ratio of 1.8 (9 men/5 women). Patients with BMI were HIV-positive in 85.7% of cases (n=12) and HIV-negative in 14.3% (n=2). The overall and HIV-specific prevalence of BMI was 2.5% and 5.1% respectively. The CD4 lymphocyte count was between I and 49 cells/mm3 in 64.3% of cases. The main clinical symptoms were cephalea in 85.7% of cases, altered consciousness in 50% and nausea/vomiting in 35.7%. Neurological manifestations (hemiparesis and cranial nerve deficit) were noted in 14.3%. HIV infection is the main purveyor of NMC in Mali. The actual incidence of cryptococcosis is unclear due to the poor sensitivity of diagnostic techniques. This study highlights diagnostic difficulties related to clinical polymorphism and poor technical facilities. Agglutination testing of blood and CSF is recommended, but mortality remains.
Collapse
Affiliation(s)
- D K Minta
- Service des maladies infectieuses, CHU du Point G, Bamako, Mali.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Majumder S, Mandal SK, Bandyopadhyay D. Prognostic markers in AIDS-related cryptococcal meningitis. J Assoc Physicians India 2011; 59:152-154. [PMID: 21751623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Despite the advent and expanding access to antiretroviral therapy, HIV-associated cryptococcal meningitis (CM) remains a significant cause of mortality and morbidity amongst individuals with this infection in resource-limited settings. METHODS We prospectively studied the clinical, biochemical and mycological parameters of 30 HIV patients diagnosed with cryptococcal meningitis at our centre over a period of 6 months with a view to identify prognostic factors predictive of poor outcome. RESULTS Our study documented a mortality rate of 36.7%. Age, sex and previous diagnosis of HIV had no bearing on the survival outcome of patients. The study identified several poor prognostic factors including low GCS score, papilledema, elevated CSF opening pressure (>250 mm of H2O) and lack of regular HIV care in those with a prior diagnosis of HIV. CSF pleocytosis was significantly higher in the mortality group. CONCLUSION There have been relatively few attempts to focus on poor prognostic markers associated with AIDS related Cryptococcal meningitis in Asian patients. Our study highlights how simple bedside clinical tools like ophthalmoscopy and CSF manometry can help in risk stratification in this group of patients.
Collapse
Affiliation(s)
- S Majumder
- Apollo Gleneagles Hospital, Kolkata, West Bengal
| | | | | |
Collapse
|
25
|
|
26
|
Wu JQ, Xu B, Ou XT, Zhu LP, Weng XH. [Factors associated with mortality in cryptococcal meningitis]. Zhonghua Yi Xue Za Zhi 2010; 90:33-37. [PMID: 20356522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To investigate factors associated with mortality in non-AIDS patients with cryptococcal meningitis. METHODS We retrospectively reviewed 154 cases of non-HIV cryptococcal meningitis in a tertiary care hospital in China, from 1997 through 2007. RESULTS The 1-year attributable mortality was 19.6% (28/143), and overall mortality was 28.7% (41/143). Advanced age (> or = 60 years), delay in diagnosis (> 4 months), hematologic malignancy, solid malignancy, altered mental status (coma, seizure, herniation), and CSF drainage or shunting were factors associated with increased death; factors associated with increased survival were amphotericin B based initial therapy and flucytosine containing therapy. In multivariate analysis, age > or = 60 years, the time from symptom onset to diagnosis > 4 months, coma, cerebral herniation, and non-amphotericin B based initial therapy were independently associated with increased overall mortality; factors independently associated with cause-specific mortality were time from symptom onset to diagnosis > 4 months, cerebral herniation and non-amphotericin B based initial therapy. CONCLUSION A variety of factors were associated with mortality in non-AIDS cryptococcal meningitis. Amphotericin B based initial treatment was independently correlated to improved 1-year survival.
Collapse
Affiliation(s)
- Ji-qin Wu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | | | | | | | | |
Collapse
|
27
|
Tilak R, Prakash P, Nigam C, Tilak V, Gambhir IS, Gulati AK. Cryptococcal meningitis with an antecedent cutaneous Cryptococcal lesion. Dermatol Online J 2009; 15:12. [PMID: 19930999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Cutaneous cryptococcosis, caused by an encapsulated yeast, Cryptococcus neoformans, is generally associated with concomitant systemic infection. Here we report a case of primary cutaneous cryptococcosis with spread to central nervous system in an HIV seronegative young boy. In the present case, a 17-year-old boy who was suffering from a non-healing ulcer on his right great toe for 5 months, presented with the signs and symptoms of meningitis. Cryptococcus neoformans var. gattii was isolated from the CSF of the patient. Amphotericin B administration produced recovery from the meningitis as well as from the ulcer. This case study suggests that primary cutaneous cryptococcosis can be diagnosed provisionally by a simple Gram stained smear and India ink examination in order to avoid occurrence of disseminated cryptococcosis, including meningial involvement, which may have a fatal outcome.
Collapse
Affiliation(s)
- Ragini Tilak
- Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi.
| | | | | | | | | | | |
Collapse
|
28
|
Kao CD, Liao KK. A flow chart proposed for early diagnosis of cryptococcal infection as a cause of stroke. Acta Neurol Taiwan 2009; 18:30-33. [PMID: 19537572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
An 82-year-old woman had a transient ischemic attack and stroke of the left middle cerebral artery syndrome that turned out to be attributed to cryptococcal meningoencephalitis (CM). An initial presentation of central nervous system infection, such as fever and headache, was absent. It was masked by chronic use of corticosteroids and immunosuppressants for her rheumatoid arthritis. The diagnosis was made by the clinical setting of stroke-in-evolution and progression of hydrocephalus on the second brain imaging study. In this case, we discuss the atypical presentation of CM in an immunosuppressed patient and offer a flow chart for early diagnosis, thus improving outcome and survival rates.
Collapse
Affiliation(s)
- Chuen-Der Kao
- Department of Neurology, Taipei-Veterans General Hospital, Taiwan
| | | |
Collapse
|
29
|
Tajiri T, Ikeue T, Nakagawa A, Huruta K, Morita K, Maniwa K, Watanabe S, Sugita T, Horikawa S, Nishiyama H, Maekawa N. [A case of cryptococcal pneumonia accompanying meningitis]. Nihon Kokyuki Gakkai Zasshi 2009; 47:12-15. [PMID: 19198229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
UNLABELLED Cryptococcosis is a fungal infection caused by cryptococcus neoformans. Cryptococcal pneumonia occurs due to inhalation of the organism into the respiratory tract, sometimes accompanied by meningitis in immunocompromised patients, and can be life-threatening. We report a case of cryptococcal meningitis occurring during corticosteroid therapy for rheumatoid arthritis. CASE A 82-year-old woman with rheumatoid arthritis was given a diagnosis of cryptococcal meningitis, and improved after administeration of amphotericin B in combination with flucytosine. However 3 weeks later, side effects occurred, she was given fluconazole alone, but her condition worsened and she died. In severe cases of cryptococcal meningitis, we should take into account drug susceptibility tests and drug concentrations at the site of infection.
Collapse
Affiliation(s)
- Tomoko Tajiri
- Department of Respiratory Diseases, Japan Red Cross Society, Wakayama Medical Center
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Kwok SK, Seo SH, Ju JH, Yoon CH, Park SC, Kim BS, Kim HY, Park SH. Cryptococcal meningitis presenting with isolated sixth cranial nerve palsy in a patient with systemic lupus erythematosus. J Korean Med Sci 2008; 23:153-5. [PMID: 18303219 PMCID: PMC2526483 DOI: 10.3346/jkms.2008.23.1.153] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cryptococcal meningitis is a rare complication of systemic lupus erythematosus (SLE). The nonspecific neurologic findings associated with this infection delays accurate diagnosis because initial neuropsychiatric manifestations of SLE are in instances indistinguishable from that of crytococcal meningitis. We report a case of cryptococcal meningitis presenting with unilateral sixth cranial nerve palsy in a male patient with SLE, which was successfully treated with antifungal agents.
Collapse
Affiliation(s)
- Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo-Hong Seo
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chong-Hyeon Yoon
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo Chul Park
- Department of Ophthalmology, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bum Soo Kim
- Department of Radiology, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho-Youn Kim
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
31
|
Parkhutik V, Roig-Morata S, Pérez-Saldaña MT, Sevilla T. [Cerebral cryptococcosis as the first symptom of infection by human immunodeficiency virus]. Rev Neurol 2008; 46:182-183. [PMID: 18297627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- V Parkhutik
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España.
| | | | | | | |
Collapse
|
32
|
Jongwutiwes U, Malathum K, Sungkanuparph S. Cryptococcal meningoradiculitis: an atypical presentation after initiation of antiretroviral therapy. J Med Assoc Thai 2007; 90 Suppl 2:85-88. [PMID: 19230429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Atypical presentations of cryptococcal infection have been described as clinical manifestations of immune reconstitution inflammatory syndrome (IRIS) in HIV-infected patients following commence of antiretroviral therapy (ART). The authors describe a patient presenting with cryptococcal meningoradiculitis two weeks after initiation of ART. In patients with advanced HIV disease, immune reconstitution induced by ART can precipitate onset of atypical clinical manifestations in those patients with latent cryptococcal infection of the central nervous system.
Collapse
Affiliation(s)
- Ubonvan Jongwutiwes
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | | | | |
Collapse
|
33
|
Abstract
BACKGROUND Opportunistic infections commonly occur in immunocompromised patients; however, it is unusual for an adult to present with a combined cellular and humoral immunodeficiency. Cryptococcal meningitis is a fatal condition if untreated and is usually found in patients with cellular immunodeficiency. OBJECTIVE To report the case of an adult patient with cryptococcal meningitis secondary to intestinal lymphangiectasia. METHODS A 59-year-old man was admitted to the hospital for disseminated cryptococcal meningitis and osteomyelitis. Laboratory evaluation, computed tomography, esophagogastroduodenoscopy, and biopsy were performed. RESULTS Laboratory evaluation revealed a lymphopenia, hypoalbuminemia, hypogammaglobulinemia, and negative human immunodeficiency virus test results by enzyme-linked immunosorbent assay and polymerase chain reaction. The complete blood cell count, urinalysis, serum and urine protein electrophoresis, and functional antibody responses to protein and polysaccharide antigens were normal. Results of computed tomography of the chest, abdomen, and pelvis were unremarkable. Multiple lymphangiectasias were visualized with esophagogastroduodenoscopy and confirmed by biopsy. The patient was treated with intravenous amphotericin B and flucytosine, and the meningitis resolved. CONCLUSIONS Based on a computerized search of the medical literature, this is the first description of cryptococcal meningitis secondary to intestinal lymphangiectasias. The combination of lymphopenia, hypogammaglobulinemia, and hypoalbuminemia should alert the clinician to the possibility of intestinal lymphangiectasias and the potential for immune dysfunction.
Collapse
Affiliation(s)
- Steven L Cole
- Department of Medicine, Division of Allergy and Immunology, University of South Florida College of Medicine, James A. Haley Veterans' Hospital, Tampa, Florida 33612, USA.
| | | | | | | | | |
Collapse
|
34
|
Paneque Rodríguez I, Valdivia J, Aguiar Agramante A, Castillo Castillo I, Martínez Arroyo M, Delgado Almora E. [Cryptococcosis in renal transplant recipients]. Rev Cubana Med Trop 2007; 59:169-172. [PMID: 23427453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This article presented the case of a 64 years-old renal transplant recipient, who was a poultry farm worker and had suffered meningoencephalitis six months after receiving immunosuppressive therapy. Rapid diagnosis was based on a cerebrospinal fluid sample analyzed with latex particles for Cryptococcus spp antigen detection. Culture of the clinical sample in agar-Sabouraund-chloramphenicol medium confirmed the initial diagnosis whereas biochemical identification was made with the API 20C AUX system. Amphotericin B treatment was immediately applied to the patient and later fluconazole until microbiological tests yielded negative results. After 5 months, the patient relapsed and restarted the specific treatment. He was followed up on outpatient service and two year after the organ transplantation, his recovery was favourable.
Collapse
|
35
|
Abstract
Abstract
OBJECTIVE
We describe a patient with undiagnosed sarcoidosis who presented with a rare isolated cerebellar cryptococcoma masquerading as a metastatic brain tumor.
CLINICAL PRESENTATION
A 58-year-old man with a history of resected squamous cell carcinoma of the larynx and pulmonary nodules was found to have a left cerebellar lesion on neuroimaging after presenting with a 4-month history of occipital headaches. Neuroimaging revealed a large, lobulated, intra-axial, left cerebellar hemispheric mass with peripheral nodular enhancement, mild adjacent edema, and dense focal areas of calcification.
INTERVENTION
The patient underwent a left suboccipital craniotomy for gross total resection of the left cerebellar mass. Pathological examination of the resected specimen demonstrated a cryptococcoma, which was confirmed with a positive cerebrospinal fluid cryptococcal antigen. Postoperative evaluation revealed pulmonary sarcoidosis.
CONCLUSION
Central nervous system cryptococcoma is a rare infection that may present in a patient with no known history of immunosuppression and no clinical signs of infection. Diagnostically, this can be difficult to distinguish from a brain tumor. Central nervous system cryptococcoma is an opportunistic infection that typically occurs in the presence of an immunosuppressed state. Sarcoidosis should be considered a predisposing factor because patients with this underlying disease have an increased susceptibility to this central nervous system fungal infection.
Collapse
Affiliation(s)
- Charles W Kanaly
- Department of Surgery, Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina 27710, USA
| | | | | | | |
Collapse
|
36
|
Tsuchida H, Ichikawa D, Shima Y, Yasuda T, Sato T, Kimura K. [A case of cryptococcal meningitis with nephrotic syndrome and renal insufficiency under immunosuppressive therapy]. Nihon Jinzo Gakkai Shi 2007; 49:54-9. [PMID: 17299987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
A 76 year-old woman was admitted to our hospital because of pyrexia and fatigue. One year earlier, she was diagnosed as nephrotic syndrome(NS) caused by focal segmental glomerulosclerosis and immunosuppressive therapy was started with marked amelioration of proteinuria. Thereafter, her renal function worsened, but only supportive treatment was continued. After admission, a cerebrospinal fluid (CSF) examination revealed Cryptococcus neoformans (C. neoformans) by india ink staining and a subsequent CSF culture confirmed C. neoformans infection. Accordingly, we made the diagnosis of cryptococcal meningitis and immediately started multiple anti fungal drugs with dosage modification according to her impaired renal function. Immunosuppressive therapy for NS was temporarily terminated. The inflammatory signs and symptoms soon were markedly improved, but the anti cryptococcal antibody titer in the serum and CSF remained high. Immunosuppressive therapy was started again at a low dosage because urinary protein had increased again. One hundred and eight days from admission, she was discharged with a regimen of multiple anti fungal drugs. Proteinuria and renal insufficiency was almost stable during hospitalization. Most fungal infection develops in patients in an immunosuppressive state induced by immunosuppressive drugs, HIV infection and so on. Patients with NS are frequently in an immunosuppressive state because of urinary loss of immunoglobulins and the use of immunosuppressive drugs. Therefore, it should be remembered that patients with NS are at a high risk of suffering from fungal infection.
Collapse
Affiliation(s)
- Hiroki Tsuchida
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | | | | | | | | | | |
Collapse
|
37
|
Brouwer AE, van Kan HJM, Johnson E, Rajanuwong A, Teparrukkul P, Wuthiekanun V, Chierakul W, Day N, Harrison TS. Oral versus intravenous flucytosine in patients with human immunodeficiency virus-associated cryptococcal meningitis. Antimicrob Agents Chemother 2006; 51:1038-42. [PMID: 17194824 PMCID: PMC1803146 DOI: 10.1128/aac.01188-06] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In a randomized controlled trial of amphotericin B-based therapy for human immunodeficiency virus (HIV)-associated cryptococcal meningitis in Thailand, we also compared the mycological efficacy, toxicity, and pharmacokinetics of oral versus intravenous flucytosine at 100 mg/kg of body weight/day for the initial 2 weeks. Half of 32 patients assigned to the two arms containing flucytosine were randomized to oral and half to intravenous flucytosine. Early fungicidal activity was determined from serial quantitative cultures of cerebrospinal fluid (CSF), and toxicity was assessed by clinical and laboratory monitoring. Flucytosine and fluorouracil concentrations in plasma and CSF were measured by high-performance liquid chromatography. No significant bone marrow or hepatotoxicity was seen, there was no detectable difference in bone marrow toxicity between patients on intravenous and those on oral formulation, and no patients discontinued treatment. In patients receiving intravenous flucytosine, the median 24-h area under the concentration-time curve was significantly higher than in the oral group. Despite this difference, there was no difference in early fungicidal activity between patients on intravenous compared with patients on oral flucytosine. The results suggest that either formulation can be used safely at this dosage in a developing country setting, without drug concentration monitoring. The bioavailability of the oral formulation may be reduced in late-stage HIV-infected patients in Thailand. Concentrations of flucytosine with intravenous formulation at 100 mg/kg/day may be in excess of those required for maximal fungicidal activity.
Collapse
Affiliation(s)
- Annemarie E Brouwer
- Centre of Infection, St George's University of London, London SW17 ORE, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Riera-Mestre A, de la Haba-Vacas I, Vidaller-Palacín A, Fernández-Viladrich P. [Cryptococcal disease and immunosuppressive treatment]. Enferm Infecc Microbiol Clin 2006; 24:595. [PMID: 17125686 DOI: 10.1157/13093886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
39
|
Snelgrove RJ, Edwards L, Williams AE, Rae AJ, Hussell T. In the Absence of Reactive Oxygen Species, T Cells Default to a Th1 Phenotype and Mediate Protection against PulmonaryCryptococcus neoformansInfection. J Immunol 2006; 177:5509-16. [PMID: 17015737 DOI: 10.4049/jimmunol.177.8.5509] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In recent years, the prevalence of invasive fungal infections has increased, attributed mostly to the rising population of immunocompromised individuals. Cryptococcus neoformans has been one of the most devastating, with an estimated 6-8% of AIDS-infected patients succumbing to Cryptococcus-associated meningitis. Reactive oxygen species (ROS) are potent antimicrobial agents but also play a significant role in regulating immune cell phenotype, but cause immunopathology when produced in excess. We now show that mice lacking phagocyte NADPH oxidase have heightened macrophage and Th1 responses and improved pathogen containment within pulmonary granulomatous lesions. Consequently, dissemination of this fungus to the brain is diminished, an effect that is independent of IL-12. Similar results are described using the metalloporphyrin antioxidant manganese(III) tetrakis(N-ethyl pyridinium-2-yl)porphyrin, which also promoted a protective Th1 response and reduced dissemination to the brain. These findings are in sharp contrast to the protective potential of ROS against other fungal pathogens, and highlight the pivotal role that ROS can fulfill in shaping the profile of the host's immune response.
Collapse
Affiliation(s)
- Robert J Snelgrove
- Kennedy Institute of Rheumatology, Imperial College London, Hammersmith, London, United Kingdom
| | | | | | | | | |
Collapse
|
40
|
Khawcharoenporn T, Apisarnthanarak A, Kiratisin P, Mundy LM, Bailey TC. Evaluation of cryptococcus laurentii meningitis in a patient with HIV infection: a case report and review of the literature. Hawaii Med J 2006; 65:260-3. [PMID: 17153670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Cryptococcus neoformans is the most common cryptococci causing infection in humans. Non-neoformans cryptococci have generally been regarded as saprophytes and rarely reported as human pathogens. We report a probable case of Cryptococcus laurentii meningitis in a HIV-infected patient and reviewed the literature on risk factors and treatment of this infection in humans. This patient was successfully treated with amphotericin B followed by fluconazole. Awareness of the emerging antifungal-resistant C. laurentii strains, as reported in the literature, should be emphasized, especially in immunocompromised patients.
Collapse
Affiliation(s)
- Thana Khawcharoenporn
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, 1356 Lusitana Street, 7th Fl, Honolulu, HI 96813, USA.
| | | | | | | | | |
Collapse
|
41
|
|
42
|
Revest M, Decaux O, Frouget T, Cazalets C, Albert JD, Chevrier S, Guiguen C, Jego P, Grosbois B. Infections à cryptocoque chez des patients non VIH. À propos de quatre cas et revue de la littérature. Rev Med Interne 2006; 27:203-8. [PMID: 16364503 DOI: 10.1016/j.revmed.2005.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2005] [Accepted: 11/24/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cryptococcal infections are frequent in HIV-infected patients and are regularly looked after. This infection may occur in others immunosuppressives situations and, in those cases, diagnosis is often delayed. METHODS We report four cases of cryptococcal infections in patients whose immunosuppression isn't related with HIV infection but due to chronic lymphocytic leukemia, giant cell temporal arteritis, gastric neoplasm and lupus. Diagnosis, prognostic and treatment are detailed. RESULTS Four patients aged from 25 to 76 presented a cryptococcal infection (three meningitis). A woman died at the admission. Another died seven years later. The two others are still alive under treatment. When infected, all patients were immunodeficiency. CONCLUSION Cryptococcal infection may occur in patients non-HIV-infected patients. Early detection is needed to improve prognostic.
Collapse
Affiliation(s)
- M Revest
- Service de Médecine Interne, Département de Médecine de l'Adulte, Hôpital Sud, 16, boulevard de Bulgarie, 35203 Rennes cedex, France
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
|
44
|
Ringstad J. Cryptococcal meningitis in two patients with HIV. Acta Biomed 2006; 77 Suppl 4:27-30. [PMID: 17370568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The onset of central nervous system (CNS) cryptococcosis may be acute or insidious. Acute manifestations with neurological signs and symptoms are more common in immunosuppressed patients. We present two cases with AIDS and cryptococcal meningitis and discuss treatment options and stress that the host immune response should be considered along with the infecting agent during treatment.
Collapse
|
45
|
Abstract
Central nervous system complications are common in HIV-1 infected patients and occur either as a result of concomitant immunosuppression (opportunistic infections, lymphoma and tumors), as a primary manifestation of HIV infection, or as an adverse effect of therapy (immune restoration and toxicity). These complications contribute largely to patient morbidity and mortality. In the era of highly active antiretroviral therapy (HAART) these disease states have changed in presentation, outcome and incidence. We review in detail the epidemiology, pathogenesis, clinical features, diagnosis, and management of these disorders.
Collapse
MESH Headings
- AIDS Dementia Complex/diagnosis
- AIDS Dementia Complex/epidemiology
- AIDS Dementia Complex/etiology
- AIDS Dementia Complex/therapy
- AIDS-Related Opportunistic Infections/diagnosis
- AIDS-Related Opportunistic Infections/epidemiology
- AIDS-Related Opportunistic Infections/etiology
- AIDS-Related Opportunistic Infections/therapy
- Adult
- Animals
- Brain Ischemia/etiology
- Brain Neoplasms/diagnosis
- Brain Neoplasms/epidemiology
- Brain Neoplasms/etiology
- Brain Neoplasms/therapy
- Central Nervous System Diseases/diagnosis
- Central Nervous System Diseases/epidemiology
- Central Nervous System Diseases/etiology
- Central Nervous System Diseases/therapy
- Child
- Cytomegalovirus Infections/complications
- Cytomegalovirus Infections/epidemiology
- Disease Susceptibility
- Encephalitis/diagnosis
- Encephalitis/epidemiology
- Encephalitis/etiology
- Encephalitis/therapy
- Encephalitis, Viral/diagnosis
- Encephalitis, Viral/epidemiology
- Encephalitis, Viral/etiology
- Encephalitis, Viral/therapy
- HIV Infections/complications
- Humans
- Immunocompromised Host
- Leukoencephalopathy, Progressive Multifocal/diagnosis
- Leukoencephalopathy, Progressive Multifocal/epidemiology
- Leukoencephalopathy, Progressive Multifocal/etiology
- Leukoencephalopathy, Progressive Multifocal/therapy
- Lymphoma, AIDS-Related/diagnosis
- Lymphoma, AIDS-Related/epidemiology
- Lymphoma, AIDS-Related/etiology
- Lymphoma, AIDS-Related/therapy
- Magnetic Resonance Imaging
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/epidemiology
- Meningitis, Cryptococcal/etiology
- Meningitis, Cryptococcal/therapy
- Middle Aged
- Myelitis, Transverse/diagnosis
- Myelitis, Transverse/epidemiology
- Myelitis, Transverse/etiology
- Myelitis, Transverse/therapy
- Neurosyphilis/diagnosis
- Neurosyphilis/epidemiology
- Neurosyphilis/etiology
- Neurosyphilis/therapy
- Toxoplasmosis, Cerebral/diagnosis
- Toxoplasmosis, Cerebral/epidemiology
- Toxoplasmosis, Cerebral/etiology
- Tuberculosis/diagnosis
- Tuberculosis/epidemiology
- Tuberculosis/etiology
Collapse
Affiliation(s)
- A Moulignier
- Service de Neurologie, Fondation Adolphe de Rothschild, Paris
| |
Collapse
|
46
|
Huston KK, Gelber AC. Simultaneous presentation of cryptococcal meningitis and lupus nephritis. J Rheumatol 2005; 32:2501-2. [PMID: 16331801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
|
47
|
Martínez-Baltanás A, Cuadrado JM, Jover F, Roig P. Criptococosis meníngea como manifestación de síndrome de reconstitución inmunitaria. Enferm Infecc Microbiol Clin 2005; 23:247-8. [PMID: 15826553 DOI: 10.1157/13073157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
48
|
Gil-Salú JL. [Cerebral cryptococcosis in theoretically immunocompetent patients]. Rev Neurol 2005; 40:318-9. [PMID: 15782365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
|
49
|
Lizarazo-Niño J. [Cryptococcosis in immunocompetent patients]. Rev Neurol 2005; 40:318. [PMID: 15782366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
|
50
|
Bodasing N, Seaton RA, Shankland GS, Kennedy D. Cryptococcus neoformans var. gattii meningitis in an HIV-positive patient: first observation in the United Kingdom. J Infect 2004; 49:253-5. [PMID: 15337344 DOI: 10.1016/j.jinf.2003.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2003] [Indexed: 10/26/2022]
Abstract
We present a case of meningitis due to Cryptococcus neoformans var. gattii in an HIV-infected man recently returned from South Africa. We believe this is the first imported case of meningitis secondary to Cryptococcus neoformans var. gattii in an HIV-infected patient to be reported in the UK.
Collapse
Affiliation(s)
- N Bodasing
- Infection Service, The Brownlee Centre, Gartnavel General Hospital, 1053 Great Western Road, Glasgow G12 OYN, UK
| | | | | | | |
Collapse
|