A study for precision diagnosing and treatment strategies in difficult-to-treat AIDS cases and HIV-infected patients with highly fatal or highly disabling opportunistic infections: Study protocol for the optimal early intervention for cryptococcal antigenemia in HIV-infected patients

BACKGROUND

Asymptomatic cryptococcal antigenemia is a state of cryptococcal infection commonly seen in immunocompromised HIV-infected persons. Without early intervention, a proportion of HIV-infected persons with cryptococcal antigenemia may go on to develop cryptococcosis, especially cryptococcal meningitis, which is associated with high mortality. The benefits of antifungal intervention and optimal therapeutic intervention regimens for HIV-infected persons with cryptococcal antigenemia remain controversial. We therefore designed the present study in order to investigate the necessity of, and the optimal regimens for antifungal intervention in the clinical management of cryptococcal antigenemia in HIV-infected populations.

METHODS/DESIGN

This study will be an open-labeled, multi-center, prospective, randomized controlled trial, and 450 eligible participants will be randomized into a control arm and 2 intervention arms at a 1:1:1 ratio, with 150 subjects in each arm. Participants in the control arm will not receive antifungal treatment during the study period. Participants in intervention arm 1 will receive oral fluconazole 800 mg/day for 2 weeks, followed by 400 mg/day for 8 weeks and 200 mg/day for 42 weeks, and participants in intervention arm 2 will receive oral fluconazole 400 mg/day for 52 weeks. The primary outcome is the incidence of CM among the 3 groups during the study period. The secondary outcomes include the differences in all-cause mortality, proportion of patients reverting to blood CrAg negativity, change of CrAg titers, and adverse events among the 3 groups during the follow-up period.

DISCUSSION

We envisage that the results of this study will reveal the necessity of, and the optimal therapeutic regimens for, antifungal intervention in clinical management of HIV-infected patients with cryptococcal antigenemia.

TRIAL REGISTRATION

The study was registered as one of the 12 clinical trials under a general project at the Chinese Clinical Trial Registry on February 1, 2019, and the registration number of the general project is ChiCTR1900021195.

Landmark clinical observations and immunopathogenesis pathways linked to HIV and Cryptococcus fatal central nervous system co-infection

Cryptococcal meningitis remains one of the leading causes of death among HIV-infected adults in the fourth decade of HIV era in sub-Saharan Africa, contributing to 10%-20% of global HIV-related deaths. Despite widespread use and early induction of ART among HIV-infected adults, incidence of cryptococcosis remains significant in those with advanced HIV disease. Cryptococcus species that causes fatal infection follows systemic spread from initial environmental acquired infection in lungs to antigenaemia and fungaemia in circulation prior to establishment of often fatal disease, cryptococcal meningitis in the CNS. Cryptococcus person-to-person transmission is uncommon, and deaths related to blood infection without CNS involvement are rare. Keen to the persistent high mortality associated with HIV-cryptococcal meningitis, seizures are common among a third of the patients, altered mental status is frequent, anaemia is prevalent with ensuing brain hypoxia and at autopsy, brain fibrosis and infarction are evident. In addition, fungal burden is 3-to-4-fold higher in those with seizures. And high immune activation together with exacerbated inflammation and elevated PD-1/PD-L immune checkpoint expression is immunomodulated phenotypes elevated in CSF relative to blood. Lastly, though multiple Cryptococcus species cause disease in this setting, observations are mostly generalised to cryptococcal infection/meningitis or regional dominant species (C neoformans or gattii complex) that may limit our understanding of interspecies differences in infection, progression, treatment or recovery outcome. Together, these factors and underlying mechanisms are hypotheses generating for research to find targets to prevent infection or adequate therapy to prevent persistent high mortality with current optimal therapy.

Umbilicated papules on the bilateral upper and lower extremities

Cryptococcosis is a rare opportunistic infection with morphologically diverse cutaneous presentations. Primary infection typically occurs in the lungs with subsequent hematogenous dissemination to other organ systems, especially in immunocompromised patients. Herein, we report a woman in her 70's who presented with pruritic, umbilicated papulonodules of the bilateral upper and lower extremities present for many weeks. She was diagnosed with disseminated Cryptococcus and subsequently evaluated for potential pulmonary and meningeal disease involvement. She died as a result of multiple medical comorbidities.

Anastrozole-induced pulmonary cryptococcosis in a patient with early breast cancer: A case report

INTRODUCTION

Estrogen is a key factor in breast cancer carcinogenesis, and reductions in its synthesis can decrease breast cancer risk. Anastrozole can reduce plasma estrogen levels by inhibiting the enzyme aromatase, and is approved for adjuvant treatment of breast cancer. We report a case of pulmonary cryptococcosis in a patient who was treated with anastrozole for an early-stage tumor. This case is of special interest because the patient achieved a better curative effect after the administration of anastrozole was discontinued.

PATIENT CONCERNS

A 61-year-old woman was found to have multiple pulmonary nodules on chest computed tomography (CT) after being treated for 5 months with anastrozole as an adjuvant breast cancer therapy. A biopsy of the largest lesion of the right lung showed cryptococcus fungal bodies with granulomatous inflammation, so the patient was diagnosed with pulmonary cryptococcosis. She was treated with fluconazole (400 mg/day) for 1 month, but a follow-up CT scan of chest showed no improvement.

DIAGNOSIS

Pulmonary cryptococcosis.

INTERVENTIONS

Because the pulmonary cryptococcosis was not improving, the administration of anastrozole was discontinued. Fluconazole was continued.

OUTCOMES

The pulmonary lesions diminished in size 2 months after discontinuing anastrozole. The patient continued taking fluconazole for a total of 6 months without re-administration of anastrozole, and the lesions of pulmonary cryptococcosis almost disappeared.

CONCLUSION

This case of pulmonary cryptococcosis may have been induced by a decrease in estrogen level caused by the aromatase inhibitor, anastrozole. Treatment of pulmonary cryptococcosis with concurrent anastrozole use may be ineffective, and it may be better to discontinue the aromatase inhibitor.

Ulcerative cellulitis of the arm: a case of primary cutaneous cryptococcosis

Cutaneous cryptococcosis is usually secondary to the hematogenous dissemination of pulmonary or meningeal Cryptococcus neoformans. Primary cutaneous cryptococcosis (PCC) is a rare form of the infection, typically caused by direct inoculation from trauma to the skin [1]. Most cases of PCC present as a localized cellulitis, abscess, nodule, or ulceration. Herein, we present a case of a rapidly spreading cellulitis characterized by bullae and ulceration, caused by direct inoculation from a fall.

Cryptococcal meningitis after transnasal transsphenoidal pituitary microsurgery of ACTH-secreting pituitary adenoma: A case report

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.

MLST-Based Population Genetic Analysis in a Global Context Reveals Clonality amongst Cryptococcus neoformans var. grubii VNI Isolates from HIV Patients in Southeastern Brazil

Cryptococcosis is an important fungal infection in immunocompromised individuals, especially those infected with HIV. In Brazil, despite the free availability of antiretroviral therapy (ART) in the public health system, the mortality rate due to Cryptococcus neoformans meningitis is still high. To obtain a more detailed picture of the population genetic structure of this species in southeast Brazil, we studied 108 clinical isolates from 101 patients and 35 environmental isolates. Among the patients, 59% had a fatal outcome mainly in HIV-positive male patients. All the isolates were found to be C. neoformans var. grubii major molecular type VNI and mating type locus alpha. Twelve were identified as diploid by flow cytometry, being homozygous (AαAα) for the mating type and by PCR screening of the STE20, GPA1, and PAK1 genes. Using the ISHAM consensus multilocus sequence typing (MLST) scheme, 13 sequence types (ST) were identified, with one being newly described. ST93 was identified from 81 (75%) of the clinical isolates, while ST77 and ST93 were identified from 19 (54%) and 10 (29%) environmental isolates, respectively. The southeastern Brazilian isolates had an overwhelming clonal population structure. When compared with populations from different continents based on data extracted from the ISHAM-MLST database (mlst.mycologylab.org) they showed less genetic variability. Two main clusters within C. neoformans var. grubii VNI were identified that diverged from VNB around 0.58 to 4.8 million years ago.

The members of the Cryptococcus neoformans / Cryptococcus gattii species complex are the cause of cryptococcosis, a life-threatening human disease responsible for 624,000 deaths annually. Infection is acquired through inhalation of dehydrated yeast cells from environmental sources. After reaching the lungs, the fungus disseminates to the central nervous system causing meningoencephalitis. The majority of meningitis cases in HIV-infected patients are caused by C. neoformans, a species well studied in regions with a high prevalence of HIV infection, such as Asia and Africa. A similar high prevalence has been reported from Brazil however the epidemiology of these infections is less well understood. We studied clinical and environmental isolates from the southeast region of Brazil using MLST. The results that we obtained showed a clonal population structure of C. neoformans var. grubii VNI, with low variability when compared against populations from different continents. This lower variability is probably the result of multiple recent dispersal events from Africa to the Americas. The majority of clinical isolates were of one sequence type (ST93), which was also found in environmental samples. By expanding the analysis to isolates from around the globe, it was possible to identify two major groups among C. neoformans var. grubii VNI.

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

Background

Early mortality among HIV-positive adults starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis (TB) the leading cause of death. However, current methods to estimate TB-related deaths are inadequate and most autopsy studies do not adequately represent those attending primary health clinics (PHCs). This study aimed to determine the autopsy prevalence of TB and other infections in adults enrolled at South African PHCs in the context of a pragmatic trial of empiric TB treatment (“TB Fast Track”).

Methods and Findings

Adults with CD4 ≤150 cells/μL, not on ART or TB treatment, were enrolled to TB Fast Track and followed up for at least six months. Minimally invasive autopsy (MIA) was conducted as soon as possible after death. Lungs, liver, and spleen were biopsied; blood, CSF, and urine aspirated; and bronchoalveolar lavage fluid obtained. Samples underwent mycobacterial, bacterial, and fungal culture; molecular testing (including Xpert® MTB/RIF); and histological examination. 34 MIAs were conducted: 18 (53%) decedents were female; median age was 39 (interquartile range 33–44) years; 25 (74%) deaths occurred in hospitals; median time from death to MIA was five (IQR 3–6) days. 16/34 (47%) had evidence of TB (14/16 [88%] with extrapulmonary disease; 6/16 [38%] not started on treatment antemortem); 23 (68%) had clinically important bacterial infections; four (12%) cryptococcal disease; three (9%) non-tuberculous mycobacterial disease; and two (6%) Pneumocystis pneumonia. Twenty decedents (59%) had evidence of two or more concurrent infections; 9/16 (56%) individuals with TB had evidence of bacterial disease and two (13%) cryptococcal disease.

Conclusions

TB, followed by bacterial infections, were the leading findings at autopsy among adults with advanced HIV enrolled from primary care clinics. To reduce mortality, strategies are needed to identify and direct those at highest risk into a structured pathway that includes expedited investigation and/or treatment of TB and other infections.

[Opportunistic infections and sarcoidosis]

Opportunistic infections (OI) are uncommon in sarcoidosis (1 to 10%) and mostly occur in patients with previously diagnosed disease or can rarely be the presenting manifestation. The most common OIs are, in descending order: aspergillosis, cryptococcosis, and mycobacterial infections. Treatment with corticosteroids is the most frequent risk factor for OI occurrence during sarcoidosis but immunosuppressive drugs and therapy with anti-TNFα are also risk factors. Overall, clinical presentation, treatment, and outcome are identical to that occur in other conditions complicated with the occurrence of OIs. However, some atypical presentations of OIs can mimic sarcoidosis exacerbation and misdiagnosis may lead clinicians to increase immunosuppression, causing worsening of the OI. The meticulous collection of patient's history along with factors differentiating OI from sarcoidosis exacerbation is key factor to optimally manage these patients.

Cryptococcal cellulitis on the shin of an immunosuppressed patient

Cryptococcus neoformans is a common fungus found throughout the environment that causes opportunistic disease in immunocompromised individuals. Infection of humans with C neoformans usually manifests as lung disease through inhalation of spores or meningoencephalitis by involvement of the central nervous system. Rarely, dissemination in the form of cutaneous lesions can occur in individuals with long term immunosuppression. We present a patient with C. neoformans manifesting as cellulitis with focal segmental glomerulosclerosis treated with corticosteroids. Because of the mortality associated with disseminated cryptococcosis, early identification, especially of atypical cutaneous presentations is critical from a dermatological perspective.

Disseminated Cryptococcosis in a 63-year-old Patient with Multiple Sclerosis Treated with Fingolimod

We herein report the case of a 63-year-old man who presented with a 3-month history of a cutaneous nodular lesion of his jaw, low grade fever, lethargy and progressive cognitive impairment. He had a 30-year history of multiple sclerosis and had been treated with fingolimod for the previous 2 years. Laboratory data revealed CD4 lymphocytopenia and a tissue culture of the skin nodule was positive for Cryptococcus neoformans. Cerebrospinal fluid and serum cryptococcal antigen tests were also positive and we diagnosed him to have disseminated cryptococcosis. This dissemination might be associated with fingolimod-induced CD4 lymphocytopenia. The risk of an opportunistic infection should therefore be considered when encountering fingolimod-treated patients.

Cryptococcus neoformans and Streptococcus pneumoniae co-infection in post-traumatic meningitis in a patient with unknown HIV status

Meningitis is a serious disease associated with considerable morbidity and mortality. Mixed meningeal infections due to bacteria and fungi are exceptionally rare. Here we report a case of meningeal co-infection with cryptococcus neoformans and streptococcus pneumoniae in a patient with unknown human immunodeficiency virus status. Because of the rarity of such cases, stringent screening of every cerebrospinal fluid specimen to exclude the presence of multiple pathogens is imperative. Assessment of patients for immunodeficiencies in case of isolation of an opportunistic organism like cryptococcus is also needed.

Overview of infectious diseases and other nonmalignant conditions in the acquired immune deficiency syndrome

Treatment of an AIDS patient with opportunistic infections is clearly complicated by the immunological and nutritional deficiencies associated with the syndrome. Clinical control of some individual infections may be achieved with traditional or investigational measures, but relapse or appearance of another serious infection may be expected within months in most patients. While progress has been made in the treatment of infections such as those discussed in this paper and elsewhere in this symposium, 'successful' treatment of an opportunistic infection in a patient with AIDS is comparable to achieving a remission in a patient's cancer. Such 'successful' treatment in no way implies cure or even control of the acquired immune deficiency itself.

Primary laryngeal cryptococcosis resembling laryngeal carcinoma

A case of an 82-year-old female with primary laryngeal cryptococcosis who had undergone long-term corticosteroid therapy for chronic obstructive pulmonary disease and rheumatoid arthritis is reported. She complained hoarseness with swallowing pain and irritability of the larynx for over a month. Endoscopic examination revealed a white, exudative irregular region on right arytenoid that mimicked a laryngeal carcinoma. Histological examination showed pseudoepitheliomatous hyperplasia and severe submucosal inflammation with ovoid budding yeasts by Grocott's stain. A serological study indicated a high titer of cryptococcal antigen. After treating with oral fluconazole for 3 months, her primary lesion of larynx turned to be clear. We implicate a long-term use of steroids as the significant risk factor in developing cryptococcosis of the larynx.

Cryptococcosis in patients living with hepatitis C and B viruses

Cryptococcosis, a systemic fungal infection, has become a significant, global public health problem. Patients with liver disease have an increased predisposition to infections, such as Cryptococcosis. To report the underlying disease, the variety of etiologic agents involved and the outcomes of the Cryptococcosis in patients living with HBV and/or HCV, we reviewed 34 medical records of patients who were diagnosed with Cryptococcosis by the Mycology Laboratory of Santa Casa Hospital, Porto Alegre, Brazil. Males corresponded to 79% of the patients, and the average patient age was 46.9 years. The cultures of 26/34 patients were positive: 25 patients were infected with Cryptococcus neoformans and one with C. gattii. A total of 14 deaths (41%) occurred. As a criterion of our study, all patients had viral hepatitis infection: 27 (80%) were infected with HCV, five (15%) were infected with HBV, and two patients were infected with both viruses. Because HBV and/or HCV are transmitted among drug users through infected blood, and the end-stage cirrhotic liver must be transplanted, these two population types were well represented in this study and were analyzed in detail. Cryptococcosis patients living with HCV and/or HBV appear to have the same symptoms, mean age and gender distribution as the general Cryptococcosis population. Once Cryptococcosis affects the brain, a high mortality rate ensues; therefore, physicians must be aware of the possible occurrence of this disease in patients living with HCV and HBV.

Concurrent subcutaneous candidal abscesses and pulmonary cryptococcosis in a patient with diabetes mellitus and a history of corticosteroid therapy

A 50-year-old man with a history of long-term corticosteroid treatment following adrenalectomy for Cushing's syndrome and uncontrolled diabetes mellitus was admitted for an examination of an abnormal thoracic shadow. Cryptococcal serum antigens were positive, and the histopathology of a lung biopsy showed encapsulated yeast resembling Cryptococcus neoformans. On admission, the serum β-D-glucan level was approximately twice the cutoff value, several nodules were observed on both legs and magnetic resonance imaging revealed subcutaneous abscesses. Candida albicans was identified from needle aspirates, and the patient was successfully treated with fluconazole and flucytosine. We herein report the first case of concurrent C. albicans skin abscesses and pulmonary cryptococcosis.

PRESENCE OF CRYPTOCOCCUS SPECIES IN DOMESTIC CHICKEN (GALLUS GALLUS) DROPPINGS AND THE POSSIBLE RISK IT POSED TO HUMANS IN KABIGERIET VILLAGE, NAKURU COUNTY, KENYA

OBJECTIVE

To isolate and identify Cryptococcus from domestic Chicken dropping.

DESIGN

cross sectional study.

SETTING

Kabigeriet village, Olenguorone Division, Nakuru county, approximately 282 km from Nairobi, Kenya.

SUBJECTS

Sixty four domestic chicken droppings were sampled in thirty two homesteads after obtaining the farmers consent.

RESULTS

Two species of Cryptococcus were isolated.

CONCLUSION

Domestic chicken (Gallus gallus) harbor Pathogenic Cryptococcus in their dropping and their close proximity to human habitation poses a risk of AIDS to immunocompromised persons.

Cryptococcal infections in non-HIV-infected patients

Infections due to Cryptococcus species occur globally and in a wide variety of hosts, ranging from those who are severely immunosuppressed to those who have phenotypically "normal" immune systems. Approximately 1 million cases of cryptococcosis occur throughout the world, and is it estimated that there are 650,000 associated deaths annually. Most of these cases occur among patients with advanced HIV disease, but a growing number occur among solid organ transplant recipients and others receiving exogenous immunosuppression, patients with innate and acquired immunodeficiency, and otherwise immunologically normal hosts. Much of our recent knowledge is solely derived from clinical experience over the last 2 to 3 decades of cryptococcosis among HIV-infected patients. However, based on recent observations, it is clear that there are substantial differences in the epidemiology, clinical features, approaches to therapy, and outcome when comparing HIV-infected to non-HIV-infected individuals who have cryptococcosis. If one carefully examines cryptococcosis in the three largest subgroups of patients based on host immune status, specifically, those with HIV, solid organ transplant recipients, and those who are non-HIV, non-transplant (NHNT) infected persons, then one can observe very different risks for infection, varied clinical presentations, long-term complications, mortality, and approaches to therapy. This article focuses on cryptococcosis in the non-HIV-infected patient, including a brief review of ongoing events in the Pacific Northwest of the United States and Canada relative to the outbreak of Cryptococcus gattii infections among a largely immunologically normal population, and highlights some of the key insights and questions which have emerged as a result of these important new observations.

[Cryptococcosis in hematology practice]

AIM

To study the clinical manifestations of cryptococcosis, its diagnostic features, and treatment results in patients with hemoblastoses.

SUBJECTS AND METHODS

The study included adult patients with cryptococcosis treated at the Hematology Research Center (HRC) in 2005 to 2011. The diagnosis of cryptococcosis was established on the basis of isolation of Cryptococcus neoformans from a blood culture or determination of positive cryptococcal antigen in the cerebrospinal fluid (CSF) of patients with infection symptoms.

RESULTS

During 7 years, 19 patients aged 19 to 68 years (median 47 years) were diagnosed as having cryptococcosis. In the pattern of cryptococcosis, there was a preponderance of patients with lymphoma (31%) and those with acute lymphoblastic leukemia (26%) at the stages of hemoblastosis remission induction (32%) and consolidation (26%). The diagnosis was made in 9 (47%) patients at the Intensive Care Department, HRC. The major risk factors of cryptococcosis were previous cytostatic drug exposure (68%), use of immunosuppressive and glucocorticoid drugs (63%), and granulocytopenia (42%). Seventeen (78%) patients were diagnosed with cryptococcal meningitis or meningoencephalitis; 1 patient had cryptococcal sepsis and 1 patient had possible cryptococcal pneumonia. All the patients were given antifungal agents. Amphotericin B, fluconazole, and a combination of antimycotics were used as first-line drugs in 16 (84%), 1 (5.5%), and 2 (10.5%), respectively. When their health became better, the patients were treated with voriconazole or fluconazole. Within 30 days after the diagnosis of cryptococcosis, 5 (26%) patients died; of them 2 had tumor progression concurrent with infection.

CONCLUSION

In cryptococcosis, the central nervous system is predominantly involved in the infectious process. The determination of cryptococcal antigen in CSF is a necessary diagnostic component in meningitis and meningoencephalitis in patients with blood system tumors, lymphatic ones in particular. When cryptococcosis is timely diagnosed and treated, its mortality, when the tumor is controlled, is lower than that in other invasive mycoses.

Generalized Cryptococcus albidus in an immunosuppressed patient with palmopustular psoriasis

Cryptococcal infection is relatively uncommon, except among immunocompromised individuals. The most common human pathogenic species is Cryptococcus neoformans. Virtually all organs can be affected, particularly the central nervous and pulmonary systems. The prototypical manifestations of cutaneous cryptococcal infection include generalized papules, periorificial acneiform pustules, and molluscumlike vesicles on the upper body. We describe an unusual case of Cryptococcus albidus infection presenting atypically with generalized hemorrhagic plaques. Furthermore, we review the literature on diagnostic evaluation and treatment.

Primary cutaneous cryptococcosis due to Cryptococcus gattii in Singapore

Cryptococcosis is an invasive fungal infection that occurs worldwide. Infections caused by Cryptococcus (C.) neoformans are commonly associated with immunocompromised patients, while those caused by C. gattii predominantly affect immunocompetent hosts. However, the latter has also been increasingly reported in immunocompromised patients such as those with HIV. Cutaneous involvement by C. gattii in immunocompetent patients is a rare manifestation, with only a few cases reported worldwide. C. gattii infection has rarely been reported in Singapore, with all three reported cases presenting as meningitis in immunocompetent individuals. Its natural habitat is the Eucalyptus tree, which is common in Singapore. We report the case of a 37-year-old migrant worker who had primary cutaneous infection due to C. gattii after sustaining traumatic inoculation.

[Case of pulmonary cryptococcosis which developed in a patient receiving abatacept therapy for rheumatoid arthritis]

A 59-year-old woman who had been receiving abatacept therapy for rheumatoid arthritis was noted to have multiple nodules in both lungs on routine chest X-ray films. Chest computed tomography (CT) revealed multiple nodules with small cavities in both lung fields. The Cryptococcus neoformans antigen was detected from her serum and bronchial lavage fluids, indicating a diagnosis of pulmonary cryptococcosis. Abatacept was discontinued, and antifungal treatment with fluconazole was started. The lung nodules gradually shrank, and the cavities disappeared. To the best of our knowledge, we describe the first case of pulmonary cryptococcosis associated with abatacept therapy.

Cost-effectiveness of primary prophylaxis of AIDS associated cryptococcosis in Cambodia

Background

Cryptococcal infection is a frequent cause of mortality in Cambodian HIV-infected patients with CD4+ count ≤100 cells/µl. This study assessed the cost-effectiveness of three strategies for cryptococcosis prevention in HIV-infected patients.

Methods

A Markov decision tree was used to compare the following strategies at the time of HIV diagnosis: no intervention, one time systematic serum cryptococcal antigen (CRAG) screening and treatment of positive patients, and systematic primary prophylaxis with fluconazole. The trajectory of a hypothetical cohort of HIV-infected patients with CD4+ count ≤100 cells/µl initiating care was simulated over a 1-year period (cotrimoxazole initiation at enrollment; antiretroviral therapy within 3 months). Natural history and cost data (US$ 2009) were from Cambodia. Efficacy data were from international literature.

Results

In a population in which 81% of patients had a CD4+ count ≤50 cells/ µl and 19% a CD4+ count between 51–100 cells/µl, the proportion alive 1 year after enrolment was 61% (cost $ 472) with no intervention, 70% (cost $ 483) with screening, and 72% (cost $ 492) with prophylaxis. After one year of follow-up, the cost-effectiveness of screening vs. no intervention was US$ 180/life year gained (LYG). The cost-effectiveness of prophylaxis vs. screening was $ 511/LYG. The cost-effectiveness of prophylaxis vs. screening was estimated at $1538/LYG if the proportion of patients with CD4+ count ≤50 cells/µl decreased by 75%.

Conclusion

In a high endemic area of cryptococcosis and HIV infection, serum CRAG screening and prophylaxis are two cost effective strategies to prevent AIDS associated cryptococcosis in patients with CD4+ count ≤100 cells/µl, at a short-term horizon, screening being more cost-effective but less effective than prophylaxis. Systematic primary prophylaxis may be preferred in patients with CD4+ below 50 cells/µl while systematic serum CRAG screening for early targeted treatment may be preferred in patients with CD4+ between 51–100 cells/µl.

Cryptococcal panniculitis in an immunocompromised patient: a case report and review of the literature

Cryptococcus neoformans is a dimorphic fungus known to cause disease predominately in immuno-compromised patients. It is not uncommon for cryptococcal disease to manifest within the cutaneous tissues of these patients, and it can have drastically varied presentations, from ulcerated nodules to a more subtle cellulitis. We present a patient who underwent a cardiac transplant and developed a fever and mildly erythematous, indurated plaques on his legs and flank several years later. Skin biopsy revealed cryptococcal panniculitis and C neoformans subsequently grew from both the biopsy culture and the cerebrospinal fluid (CSF). This case report highlights the varied and subtle presentations of cutaneous cryptococcosis in immunocompromised patients and encourages a high index of suspicion for this potentially fatal disease in the setting of immunosuppression.

Cryptococcosis in organ transplantation

Opportunistic infection is one of the important cause of graft dysfunction after organ transplantation. It usually occurs one year after post transplantation in a immunocompromised transplant recipient. Among the opportunistic infections fungal infection is important cause of graft dysfunction as well as increase morbidity and mortality of post transplant recipient. Cryptococcosis is the third most common invasive fungal infection in an organ transplant recipient next to Candidiasis and Aspergillosis. A 27 years young male is known case of live related renal allograft recipient on immunosuppression for last one and half years. Patient was admitted with irregular fever, severe headache, nausea and vomiting in the department of Nephrology on July 2007. After admission patient was thoroughly evaluated and clinically found features of meningitis. Subsequent investigation report revealed swollen of 3rd ventricle on CT scan brain and growth of Cryptococcus in CSF culture and diagnosis was made post renal transplant cryptococcal meningitis. Treatment was given with Injection Amphotericin B along with immunosuppression and other supportive measured. But inspite of treatment, within few days after diagnosis patient was underwent coma and died. In conclusion, cryptococcal meningitis is a serious invasive fungal infection in post transplant immunocompromised recipient and responsible for graft lose and increase morbidity of the transplant patients.

[Cryptococcemia with a severe bronchial asthma: case report and review of the literature]

A 64-year old hospitalized male for severe bronchial asthma began to complain fatigue and appetite loss. His asthma had been treated with oral bethamethasone. The Chest CT at this time revealed a bilateral consolidation of the lower lung. Despite a week of treatment with antibiotics and anti-fungals, the patient expired from DIC progression. His premortem sputum and blood culture grew Cryptococcus Neoformans. We concluded his diagnosis as cryptococcal pneumonia and sepsis. Sepsis by Cryptococcus neoformans is a rare clinical event, and only 20 cases have been reported in Japan. Although 16 of the 20 had preexisting medical conditions, a case with underlying bronchial asthma has never been reported. A comparison of the reported cases of the US and Europe to that of Japan revealed differences in the patients' underlying conditions. We report a case with a brief review of the literature and summarize the 20 cases that have been reported in Japan.

[A case of cryptococcal pneumonia accompanying meningitis]

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.

Cryptococcal lymphadenitis as a manifestation of immune reconstitution inflammatory syndrome in an HIV-positive patient: a case report and review of the literature

Cryptococcus neoformans infections are typically associated with T-cell deficiencies, including acquired immunodeficiency syndrome (AIDS). Although highly active antiretroviral therapy (HAART) has strongly reduced AIDS-related opportunistic infections, the restoration and reactivation of CD4+ cells can induce an immune reconstitution inflammatory syndrome (IRIS), consisting in a deregulated inflammatory response to latent infectious pathogens and/or to their residual antigens. Cryptococcal lymphadenitis has occasionally been documented in IRIS. Here we report a case of histology- and culture-negative cryptococcal lymphadenitis associated with IRIS in an adult AIDS patient with a history of disseminated cryptococcosis, after the start of fully adherent HAART. Appropriate diagnosis was established on nested-PCR and sequence analysis of the interspacer region 2 of C. neoformans ribosomal DNA, and detection of slow-growing blastospores in enrichment cultures of fine-needle lymph node aspirate. Review of recent literature and our case findings suggest that IRIS-associated cryptococcal lymphadenitis is more likely the flare up of a latent infection rather than an immunopathological response to residual antigen of unviable cryptococci.

Spectrum and risk factors for invasive candidiasis and non-Candida fungal infections after liver transplantation

BACKGROUND

Invasive fungal infections are an important cause of posttransplant mortality in solid-organ recipients. The current trend is that the incidence of invasive candidiasis decreases significantly and invasive aspergillosis occurs later in the liver posttransplant recipients. The understanding of epidemiology and its evolving trends in the particular locality is beneficial to prophylactic and empiric treatment for transplant recipients.

METHODS

A retrospective analysis was made of recorded data on the epidemiology, risk factors, and mortality of invasive fungal infections in 352 liver transplant recipients.

RESULTS

Forty-two (11.9%) patients suffered from invasive fungal infection. Candida species infections (53.3%) were the most common, followed by Aspergillus species (40.0%). There were 21 patients with a superficial fungal infection. The median time to onset of first invasive fungal infection was 13 days, first invasive Candida infection 9 days, and first invasive Aspergillus infection 21 days. Fifteen deaths were related to invasive fungal infection, 10 to Aspergillus infection, and 5 to Candida infection. Invasive Candida species infections were associated with encephalopathy (P = 0.009) and postoperative bacterial infection (P = 0.0003) as demonstrated by multivariate analysis. Three independent risk factors of invasive Aspergillus infection were posttransplant laparotomy (P = 0.004), renal dysfunction (P = 0.005) and hemodialysis (P = 0.001).

CONCLUSIONS

The leading etiologic species of invasive fungal infections are Candida and Aspergillus, which frequently occur in the first posttransplant month. Encephalopathy and postoperative bacterial infection predispose to invasive Candida infection. Posttransplant laparotomy and poor perioperative clinical status contribute to invasive Aspergillus infection. More studies are needed to determine the effect of prophylactic antifungal therapy in high risk patients.

Invasive Cryptococcus neoformans infection in an asplenic patient

Individuals who are asplenic or have impaired splenic function are at increased risk of developing life-threatening infections, especially due to encapsulated bacteria. This risk is higher in children, but adults can also develop fulminant infection or "post splenectomy sepsis" (PSS). Cryptococcus neoformans is an encapsulated yeast usually causing infection in immunocompromised patients. In a recent review of cryptococcal infection in HIV-negative patients, splenectomy was reported to be a risk factor for infection in 3% of cases. Detailed case reports are lacking. Here we report a case of disseminated C. neoformans infection in a patient who had a splenectomy performed for warm autoantibody haemolytic anaemia some months before he presented with signs and symptoms of meningitis. This report aims to raise awareness of the possibility of C. neoformans infection in asplenic patients.

Serologic evidence for reactivation of cryptococcosis in solid-organ transplant recipients

Cryptococcosis is a significant infection with a high mortality in solid-organ transplant recipients. Nonetheless, the pathogenesis of this disease is poorly understood. It has been hypothesized that cryptococcosis may result from either primary infection or reactivation of a latent infection. Sera were obtained from transplant recipients prior to transplantation and at the time they developed cryptococcosis. Control sera were obtained before and after transplant from patients who did not develop cryptococcosis. Sera were tested for antibodies against Cryptococcus neoformans by using an immunoblot assay. Antibody responses were also compared with those observed in sera from rats with experimental pulmonary cryptococcosis. In all, 52% of the transplant recipients who developed cryptococcosis exhibited serologic evidence of cryptococcal infection before transplantation. These patients developed cryptococcosis significantly earlier after transplant than patients without preexisting reactivity did (5.6 +/- 3.4 months compared to 40.6 +/- 63.8 months, respectively [P = 0.0011]). The results from our study suggest that a substantial proportion of transplant-associated cryptococcosis cases result from the reactivation of a latent infection. These findings also highlight the potential utility of serologic studies in identifying patients at risk for the development of cryptococcosis after transplantation.

Cryptococcosis in liver and kidney transplant recipients receiving anti-thymocyte globulin or alemtuzumab

Rabbit anti-thymocyte globulin (ATG) and alemtuzumab have been used for induction or preconditioning and for the treatment of acute rejection in organ transplant recipients in many centers. Such regimens may lead to a substantial decline in the CD4 lymphocyte count to levels seen in other population groups at high risk of cryptococcosis. In view of this, we examined the impact of such therapy on the cumulative incidence of cryptococcosis among liver and kidney recipients. A total of 834 liver and 727 kidney transplants were performed during the study period. Seven hundred and eighty-one patients did not receive ATG or alemtuzumab; 646 received 1 dose of either drug, and 134 patients received 2 doses of either drug. The cumulative incidence of cryptococcosis was 0.26% (2/781) among those who did not receive ATG or alemtuzumab; 0.3% (2/646) among those who received only 1 dose, and 2.24% (3/134) among those who received 2 doses (P=0.03). There were 5 cases of cryptococcosis in liver recipients and 2 in kidney recipients. There were 3 cases of cryptococcal meningitis, 3 of pneumonia, and 1 of disseminated disease. The 2 kidney recipients had meningitis. Diagnosis occurred at a median of 255 days (range 7-517) after transplantation. The mortality rate was 14.2%. We conclude that the use of 1 dose of ATG or alemtuzumab is not associated with an increased cumulative incidence of cryptococcosis, but that those patients receiving 2 doses are at increased risk.

[A case of secondary pulmonary cryptococcosis with pleural effusion involving type 1 allergy]

A 69-year-old man who had been followed for pneumoconiosis complained of dyspnea with effort. He was hospitalized because chest roentogenography showed pleural effusion. Further examination of this pleural effusion revealed an eosinophilic cell population and with a varied appearance. First, we suspected tuberculous pleuritis from the characteristics of the pleural effusion, but we could not demonstrate the existence of any acid-fast bacilli. During diagnostic studies, the patient's respiratory status gradually worsened, making it impossible to obtain essential findings. We initiated steroid administration as an antidote to progressive respiratory failure, and carried out bronchoscopy; As a result, we diagnosed secondary pulmonary cryptococcosis from bronchoalveolar lavarge and transbronchial lung biopsy. Pulmonary cryptococcosis with pleural effusion is rare, and this may be the first report of a case involving a type 1 allergy. We speculate that immunological dysfunction contributed to disease progression in this case.

Disseminated cryptococcosis initially presenting as cellulitis in a rheumatoid arthritis patient

Infection with Cryptococcus neoformans often occurs in immunocompromised hosts. It is usually acquired by invasion of the respiratory tract, and then the organisms may spread hematogenously to other viscera, mainly the central nervous system. Although there are some reports of primary cutaneous cryptococcosis, cryptococcal skin disease is a rare feature of disseminated cryptococcosis, and has a poor outcome if unrecognized and untreated. We present a case of cryptococcal cellulitis in a patient with rheumatoid arthritis who was receiving long-term steroid treatment. Reviewing the literature, this is the first report of rheumatoid arthritis with disseminated cryptococcosis initially presenting as cellulitis.

Non-neoformans cryptococcal infections: a systematic review

Non-neoformans cryptococci have been generally regarded as saprophytes and rarely reported as human pathogens. However, the incidence of infection due to these organisms has increased over the past 40 years, with Cryptococcus laurentii and Cryptococcus albidus, together, responsible for 80% of reported cases. Conditions associated with impaired cell-mediated immunity are important risks for non-neoformans cryptococcal infections and prior azole prophylaxis has been associated with antifungal resistance. The presence of invasive devices was a significant risk factor for Cryptococcus laurentii infection (adjusted OR = 8.7; 95% CI = 1.48–82.9; p = 0.003), while predictors for mortality included age ≥45 years (aOR = 8.4; 95% CI = 1.18–78.82; p = 0.004) and meningeal presentation (aOR = 7.0; 95% CI = 1.85–60.5; p= 0.04). Because clinical manifestations of non-neoformans cryptococcal infections are most often indistinguishable from Cryptococcus neoformans, a high index of suspicion remains important to facilitate early diagnosis and prompt treatment for such infections.

Primary Cryptococcal Cellulitis in a Lung Transplant Recipient

In organ transplant recipients there remains controversy whether cutaneous cryptococcal infection represents a primary infection or a manifestation of disseminated cryptococcosis. We describe a lung transplant patient who developed primary cryptococcal cellulitis in the immediate post-operative period. At presentation, disseminated disease was excluded. The patient was treated with liposomal amphotericin B and fluconazole and, in addition, a surgical debridement was performed. Shortly afterwards, computed tomography revealed dissemination to the brain. The patient died of cerebral edema. As there was no involvement of the central nervous system at presentation, we believe that cryptococcal cellulitis was the primary site of infection and origin of dissemination. In this study we review cryptococcosis, which should always be considered in the differential diagnosis of cellulitis in transplant recipients.

Fungal infections in solid organ transplantation

Fungal infections in solid organ transplant recipients continue to be a significant cause of morbidity and mortality. Candida spp. and Aspergillus spp. account for most invasive fungal infections. The incidence of fungal infection varies with type of solid organ transplant. Liver transplant recipients have highest reported incidence of candida infections while lung transplant recipients have highest rate of Aspergillus infections. Recent epidemiological studies suggest the emergence of resistant strains of candida as well as mycelial fungi other than Aspergillus in these patients. The current review incorporates the recent changes in the epidemiology of fungal infections in solid organ transplant recipients and highlights the newer data on the diagnosis, prophylaxis and treatment of fungal infections in these patients.

Cutaneous manifestations in renal failure patients: A case series

Cutaneous involvement in renal disease is due to a host of factors ranging from metabolic disturbances to immunosuppressive drugs. Herein we report a series of six cases of renal failure with varied cutaneous manifestations ranging from infections to neoplasms due to prolonged immunosuppression. Our first case had cutaneous cryptococcosis where skin lesions gave a clue to the diagnosis of altered sensorium and underlying meningitis. The second case initially presented with florid warts and was treated successfully but later presented with an explosive recurrence of skin lesions due to malignant transformation. Our third case had basal cell carcinoma over the presternal region that was successfully treated with liquid nitrogen cryotherapy. Our fourth case had diabetic nephropathy that presented with septicemia and purpura fulminans. The last case had cutaneous manifestations of drug therapy because of heparin infusion. To conclude, cutaneous manifestations in patients with renal failure are varied and a high degree of suspicion is needed for early diagnosis and aggressive treatment to effectively combat mortality and morbidity.

The biology of the Cryptococcus neoformans species complex

Cryptococcus neoformans is a major cause of fungal meningoencephalitis in immunocompromised patients. Despite recent advances in the genetics and molecular biology of C. neoformans, and improved techniques for molecular epidemiology, aspects of the ecology, population structure, and mode of reproduction of this environmental pathogen remain to be established. Application of recent insights into the life cycle of C. neoformans and its different ways of engaging in sexual reproduction under laboratory conditions has just begun to affect research on the ecology and epidemiology of this human pathogenic fungus. The melding of these disparate disciplines should yield rich dividends in our understanding of the evolution of microbial pathogens, providing insights relevant to diagnosis, treatment, and prevention.

Cryptococcal lipid metabolism: phospholipase B1 is implicated in transcellular metabolism of macrophage-derived lipids

Cryptococci survive and replicate within macrophages and can use exogenous arachidonic acid for the production of eicosanoids. Phospholipase B1 (PLB1) has a putative, but uninvestigated, role in these processes. We have shown that uptake and esterification of radiolabeled arachidonic, palmitic, and oleic acids by the Cryptococcus neoformans var. grubii H99 wild-type strain and its PLB1 deletion mutant strain (the Deltaplb1 strain) are independent of PLB1, except under hyperosmolar stress. Similarly, PLB1 was required for metabolism of 1-palmitoyl lysophosphatidylcholine (LysoPC), which is toxic to eukaryotic cell membranes, under hyperosmolar conditions. During both logarithmic and stationary phases of growth, the physiologically relevant phospholipids, dipalmitoyl phosphatidylcholine (DPPC) and dioleoyl phosphatidylcholine, were taken up and metabolized via PLB1. Exogenous DPPC did not enhance growth in the presence of glucose as a carbon source but could support it for at least 24 h in glucose-free medium. Detoxification of LysoPC by reacylation occurred in both the H99 wild-type and the Deltaplb1 strains in the presence of glucose, but PLB1 was required when LysoPC was the sole carbon source. This indicates that both energy-independent (via PLB1) and energy-dependent transacylation pathways are active in cryptococci. Phospholipase A(1) activity was identified by PLB1-independent degradation of 1-palmitoyl-2-arachidonoyl phosphatidylcholine, but the arachidonoyl LysoPC formed was not detoxified by reacylation. Using the human macrophage-like cell line THP-1, we demonstrated the PLB1-dependent incorporation of macrophage-derived arachidonic acid into cryptococcal lipids during cryptococcus-phagocyte interaction. This pool of arachidonate can be sequestered for eicosanoid production by the fungus and/or suppression of host phagocytic activity, thus diminishing the immune response.

Cryptococcus neoformans var. grubii isolates recovered from persons with AIDS demonstrate a wide range of virulence during murine meningoencephalitis that correlates with the expression of certain virulence factors

Cryptococcus neoformans is a common cause of meningoencephalitis among AIDS patients. Several C. neoformans virulence factors have been identified, but the relative importance of particular factors is unknown. This study examined the correlation of the virulence of 18 C. neoformans var. grubii isolates from AIDS patients with the expression of several well-described virulence factors. The LD50 at 15 days after intracranial inoculation of ICR mice was <100 c.f.u. for 22 % of isolates, 100-1000 for 28 %, 1000-10,000 for 11 % and >20,000 for 39 %. Higher cryptococcal concentrations in brains were noted for isolates with lower LD50 (P = 0.002). In survival studies, no immunocompetent BALB/c mice (nu/-) infected with 3 x LD50 of three virulent isolates (LD50 = 62, 99, 1280) survived beyond 23 days, whereas 100 %, 90 % and 90 % of mice infected with 20,000 c.f.u. of three hypovirulent isolates (LD50 > 20,000) survived for 60 days (P < 0.0001). Even among BALB/c nude (nu/nu) mice, survival rates over 60 days were 100 %, 70 % and 50 %, respectively, for the hypovirulent isolates. Growth rate at 37 degrees C and capsule size within brains correlated with LD50 by univariate (P = 0.0001 and 0.028, respectively) and multivariate (P = 0.017 and 0.016, respectively) analyses. There was no correlation between LD50 and capsule size in vitro, phospholipase activity, melanin formation, proteinase activity and fluconazole MIC. In conclusion, AIDS patients are susceptible to infection by C. neoformans isolates of wide-ranging virulence, including isolates that are markedly hypovirulent. The virulence of a given isolate reflects a composite of factors rather than the contribution of a dominant factor. Growth at 37 degrees C and capsule size in vivo make particularly important contributions.

Multifocal choroiditis in disseminated Cryptococcus neoformans infection

PURPOSE

To report an uncommon case of multifocal choroiditis as the result of disseminated Cryptococcus neoformans infection in a patient who is HIV-positive.

DESIGN

Interventional case report.

METHODS

A 27-year-old HIV-positive woman with fever, headache, and vomiting was examined. Lumbar puncture was performed and revealed C neoformans infection. Her condition evolved with sudden bilateral blindness and deafness. Ophthalmologic examination revealed multiple yellowish choroidal lesions in the posterior pole of both eyes.

RESULTS

Postmortem examination showed disseminated C neoformans infection. Histologic examination of the eyes confirmed the presence of C neoformans in the choroiditis.

CONCLUSION

Multifocal choroiditis in C neoformans infection is a rare ophthalmic manifestation. The recognition of this condition by ophthalmologists can help physicians to diagnose a disseminated and fatal disease.