Emergence of Cryptococcus gattii in a novel environment provides clues to its incubation period

Cryptococcus gattii emerged in 1999 in a distinct ecologic environment on Vancouver Island, Canada. Estimates of incubation period were derived from an analysis of travelers with discreet exposures to this region. Individual case incubation periods ranged from 2 to 11 months, with a median of 6 to 7 months.

[Pulmonary cryptococcosis occurring 6 months after cladribine therapy for relapsed follicular lymphoma]

We report a case of follicular lymphoma in which pulmonary cryptococcosis occurred with cladribine therapy. The case involved a 72-year-old man. He was diagnosed as having follicular lymphoma, grade 1, clinical stage IVA from a tongue tumor biopsy in January 2003. A total of 6 courses of R-CHOP therapy was performed, but no clear effect was found. A new cervical lesion appeared, so he was treated with a total of 2 courses of R-EPOCH therapy, and the effect was classed as stable disease. We started cladribine therapy (0.09 mg/kg, seven days of continuous infusion) from February 2004, and complete remission was achieved after 4 courses of cladribine therapy. In January 2005, an abnormal nodular shadow in the right S10 area was found on chest CT images which was diagnosed as pulmonary cryptococcosis by serum antigen and a trans-bronchial lung biopsy. We started fluconazole (200 mg a day, initially intravenous drip infusion, followed by oral intake), following which both the pulmonary shadow and serum antigen improved. Afterward, the fifth course of cladribine therapy and local radiation therapy were performed against a relapse of lymphoma, but cryptococcosis did not reappear. The prolonged bone marrow suppression after cladribine therapy was considered to be a severe adverse event. These findings suggest that it is very important to pay attention to any opportunistic infection such as pulmonary cryptococcosis.

[Dermatological zoonosis by fungi in Japan]

Dermatophytosis, cryptococcosis and sporotrichosis are dermatological zoonosis caused by fungi. Control of dermatophytosis is still difficult, although it is well known as a transmittable disease from animal to human. Exotic animals such as hamster, guinea pig and rabbit, some imported from foreign countries, have become a frequent source of human dermatophytosis, and the emergence of fungal pathogens followed. The nasal cavity of dogs and cats is an important reservoir of pathogens of cryptococcosis, in addition to bird droppings. Though there have been many reports of human sporotrichosis caused by patients' pet, especially cats in Europe and U.S., since there has been no report of zoonotic transmission of sporotrichosis, zoonosis is not believed do be present in Japan. The interrelation and cooperation of medical and veterinary doctors and all other scientists involved is therefore required to prevent fungal zoonosis, because the condition may be partly due to changes in the environments of human and animal life and the more intimate relationships between humans and animals.

Community acquired pneumonia (CAP) caused by Cryptococcus neoformans in a healthy individual

A 41-y-old male had been diagnosed as having community acquired pneumonia (CAP) with consolidations in the chest radiograph, fever and cough. Since clarithromycin and ss-lactam agents were not effective, bronchoscopic examination was performed. Indian ink staining of bronchial wash smears revealed yeast-like cells with a thick capsule, and Cryptococcus neoformans was isolated several d later. Serum glucuronoxylomannan antigen was > or = x 1024. The patient was treated with itraconazole for 16 weeks.

Cryptococcal parotid involvement: an uncommon localization ofCryptococcus neoformans

We describe a cryptococcal infection localized in the parotid gland of an otherwise healthy 72-year-old woman. The patient presented with a painful, approximately 4.5 cm diameter mass in the anterior region of her right ear. Her symptoms were mild and uncharacteristic. The patient had previously fallen on her face in her garden, causing the loss and breakage of her dentures. Since the soil of the garden contained chicken droppings, it is quite likely that the oral prothesis became contaminated on contacting the soil. The fungus probably entered the parotid gland through the traumatization of the posterior lateral wall of her oral cavity by her broken denture. Numerous intra- and extracellular cryptococcal yeast cells were observed in both histopathological and mycological slide preparations. The yeastlike fungus was recovered in cultures inoculated with tissue collected through three biopsies of her parotid region. The isolates were identified as Cryptococcus neoformans by classical mycology methods and found to be susceptible, in vitro, to fluconazole, amphotericin B and flucytosine. Fluconazole treatment (400 mg/d, for 6 months) was started and the patients facial swelling resolved and the pain significantly reduced within 5 weeks of the initiation of treatment. While fungal infection of the parotid gland have been reported, to our knowledge, this is the first description of a non-disseminated primary parotid infection due to C. neoformans.

Cryptococcus albidus keratitis after corneal transplantation

PURPOSE

To report suspected donor-to-host transmission of Cryptococcus albidus after penetrating keratoplasty.

METHODS

Review of the literature and a case report of a 69-year-old woman who underwent penetrating keratoplasty for Fuchs corneal dystrophy and developed persistent corneal infiltrates 7 months postoperatively are presented.

RESULTS

Cryptococcus albidus was cultured from the original donor tissue at the time of the repeat keratoplasty.

CONCLUSION

This case demonstrates an unusual case of cryptococcal keratitis after keratoplasty suspected to be a donor-to-host transmission.

Intraabdominal cryptococcal lymphadenitis in a patient with systemic lupus erythematosus

Cryptococcal infection is a rare, yet well recognized complication of systemic lupus erythematosus (SLE). We present a case of mesenteric and retroperitoneal cryptococcal lymphadenitis resulting in the obstruction of the stomach and proximal duodenum in a patient suffering from SLE, while recently she did not receive any immunosuppressive treatment. A 42-yr-old woman was admitted due to high fever and diffuse abdominal pain for three weeks. Abdominal computed tomography (CT) scan showed multiple conglomerated lymphadenopathies in the retroperitoneum and the mesentery resulting in luminal narrowing of the third portion of the duodenum. Cryptococcal lymphadenitis was proven by needle biopsy and she was treated with intravenous liposomal amphotericin B, followed by oral fluconazole. After fourteen-month antifungal therapies, the clinical symptoms and follow-up images improved. This case emphasize that the intrinsic immunological defects of SLE may be directly responsible for the predisposition to fungal infections.

[Neurological manifestations of HIV-infection in the era of highly active antiretroviral therapy (HAART)]

After the introduction of highly active antiretroviral therapy (HAART) in 1996 the neurological manifestations of human immunodeficiency virus (HIV-1)-infection did not decline in incidence and prevalence like the other complications of immunodeficiency; in contrast, due to the longer survival times of HAART treated HIV-1-positive individuals, prevalence of virus associated neurological disease increased during the last years, as international studies underline. Therefore, clinicians and HIV-therapists should be able to diagnose HIV-1-associated neurological disease even in early stages. This article describes symptoms and signs, neuro-imaging and cerebrospinal fluid findings as well as therapy options in primary HIV-1-associated neurological disease like encephalo- and myelopathy and polyneuropathy. Furthermore, those opportunistic infections, caused by bacteria, viruses other than HIV and parasites emerging with manifest immunodeficiency and remaining to be relevant in the HAART era are presented from diagnostic, differential-diagnostic and therapeutic points of view. An extra paragraph describes the interaction of HAART with neurological/psychiatric standard therapies.

Cryptococcosis in human immunodeficiency virus-negative patients

OBJECTIVE

To describe the clinical characteristics, treatment, and outcomes of cryptococcosis in HIV-negative patients.

METHODS

HIV-negative adult patients with positive culture for Cryptococcus neoformans who attended Ramathibodi Hospital between 1987 and 2003 were retrospectively reviewed.

RESULTS

During the 17 year review period, 40 HIV-negative patients with cryptococcosis were identified. Of these, 37 patients had medical records available for study. The mean age was 49+/-18 (range 16-83) years and 73% were female. Twenty-four patients (65%) had associated underlying conditions. The most common associated conditions included immunosuppressive drug treatment (41%), presence of systemic lupus erythematosus (16%), malignancies (16%), and diabetes mellitus (14%). C. neoformans was mainly recovered from cerebrospinal fluid (32%), blood (28%), and sputum/bronchoalveolar lavage/lung tissue (28%). Twenty-three patients (62%) had disseminated cryptococcosis. Six of 14 patients with cryptococcal meningitis were asymptomatic. About half of the patients were treated with amphotericin B and subsequent fluconazole. Five patients (14%) were initially misdiagnosed and treated for tuberculosis or bacterial infection. The overall mortality rate was 27%.

CONCLUSIONS

Cryptococcosis is not rare in HIV-negative patients. The mortality rate is high. Early recognition of cryptococcosis and use of appropriate antifungal therapy in these patients may improve clinical outcomes.

A Dual Role For TGF-β1 in the Control and Persistence of Fungal Pneumonia

TGF-beta1 (TGF) has been implicated in the pathogenesis of several chronic infections and is thought to promote microbial persistence by interfering with macrophage function. In rats with experimental pulmonary cryptococcosis, increased lung levels of TGF were present at 12 mo of infection. Within the lung, expression of TGF localized to epithelioid cells and foamy macrophages in areas of inflammation. Increased TGF expression was also observed in the lungs of experimentally infected mice and a patient with pulmonary cryptococcosis. TGF reduced Ab and serum-mediated phagocytosis of Cryptococcus neoformans by rat alveolar macrophages (AM) and peripheral blood monocytes, and this was associated with decreased chemokine production and oxidative burst. Interestingly, TGF-treated rat AM limited both intracellular and extracellular growth of C. neoformans. Control of C. neoformans growth by TGF-treated rat AM was due to increased secretion of lysozyme, a protein with potent antifungal activity. The effects of TGF on the course of infection were dependent on the timing of TGF administration relative to the time of infection. TGF treatment of chronically infected rats resulted in reduced lung fungal burden, while treatment early in the course of infection resulted in increased fungal burden. In summary, our studies suggest a dual role for TGF in persistent fungal pneumonia whereby it contributes to the local control of infection by enhancing macrophage antifungal efficacy through increased lysozyme secretion, while limiting inflammation by inhibiting macrophage/monocyte phagocytosis and reducing associated chemokine production and oxidative burst.

Cryptococcus neoformans peritonitis in a patient with alcoholic cirrhosis: case report and review of the literature

In the absence of coexisting HIV infection Cryptococcus neoformans is rarely considered in the differential diagnosis of peritonitis that occurs in patients with cirrhosis and ascites. Here, we report on a 39-year-old male, HIV-negative patient with decompensated alcohol toxic liver cirrhosis who developed a lethal intraperitoneal infection with C. neoformans. We reviewed the literature and found an additional 19 cases with culture confirmed cryptococcal peritonitis in combination with liver disease or AIDS. We suggest that awareness of this unusual but lethal entity may lead to earlier diagnosis and proper treatment.

Primary cutaneous cryptococcal cellulitis secondary to insect bite in an immunosupressed patient after liver transplantation

Cutaneous cryptococcosis is usually a manifestation of disseminated disease, especially in immunosuppressed patients. Primary cutaneous cryptococcosis has also been described in some patients without evidence of systemic disease. Distinguishing between primary and secondary cutaneous cryptococcosis may be difficult as patients can be asymptomatic or cutaneous lesions may precede systemic involvement by some months. Features supporting primary disease are a history of cutaneous inoculation, and solitary superficial lesions on uncovered parts of the body. We present a liver transplant patient with cutaneous cryptococcal cellulitis subsequent to an insect bite, without systemic involvement and with excellent response to treatment with amphotericin B for 15 days and surgical debridement plus oral fluconazole for 3 months. In immunosupressed patients with cellulitis a cryptococcal infection must be excluded. If cutaneous cryptococcosis is diagnosed, systemic evaluation and prompt lengthy treatment are required.

Immunology of infection caused by Cryptococcus neoformans

Cryptococcus neoformans is an opportunistic fungal pathogen that may lead to life-threatening meningoencephalitis and pulmonary infections in immunosuppressed hosts. The lack of an effective fungicidal regimen and the development of antifungal resistant strains suggest that continued investigation is necessary to devise immunotherapeutic strategies and/or drug targets to combat C. neoformans infections. Studies to date involve investigating the host-pathogen interaction of cryptococcal infections through the genetic manipulation of the yeast, as well as the characterization of the host immune response. Macrophage phagocytosis and killing assays have proven to be invaluable tools in evaluating the putative effects of the genetic manipulation of C. neoformans strains on the virulence composite of the yeast. In addition, the assay is used to assess the efficacy of various immunotherapeutic agents (i.e., antibodies and cytokines) to enhance this cell-based antifungal activity. The purpose of this chapter is to provide a brief overview on host immunity to C. neoformans infection and, in addition, describe a protocol for performing macrophage phagocytosis and killing assays with C. neoformans and its mutants.

An Immune Reconstitution Syndrome-Like Illness Associated withCryptococcus neoformans Infection in Organ Transplant Recipients

BACKGROUND

We describe an immune reconstitution syndrome (IRS)-like entity in the course of evolution of Cryptococcus neoformans infection in organ transplant recipients.

METHODS

The study population comprised a cohort of 83 consecutive organ transplant recipients with cryptococcosis who were observed for a median of 2 years in an international, multicenter study.

RESULTS

In 4 (4.8%) of the 83 patients, an IRS-like entity was observed a median of 5.5 weeks after the initiation of appropriate antifungal therapy. Worsening of clinical manifestations was documented, despite cultures being negative for C. neoformans. These patients were significantly more likely to have received tacrolimus, mycophenolate mofetil, and prednisone as the regimen of immunosuppressive therapy than were all other patients (P = .007). The proposed basis of this phenomenon is reversal of a predominantly Th2 response at the onset of infection to a Th1 proinflammatory response as a result of receipt of effective antifungal therapy and a reduction in or cessation of immunosuppressive therapy.

CONCLUSIONS

This study demonstrated that an IRS-like entity occurs in organ transplant recipients with C. neoformans infection. Furthermore, this entity may be misconstrued as a failure of therapy. Immunomodulatory agents may have a role as adjunctive therapy in such cases.

The Role of Immune Reconstitution Inflammatory Syndrome in AIDS‐RelatedCryptococcus neoformansDisease in the Era of Highly Active Antiretroviral Therapy

This study of human immunodeficiency virus (HIV)-infected patients coinfected with Cryptococcus neoformans found that 30% of patients who initiated highly active antiretroviral therapy developed immune reconstitution inflammatory syndrome (IRIS). Patients with C. neoformans-related IRIS had higher cerebrospinal fluid opening pressures, glucose levels, and white blood cell counts, compared with patients with typical HIV-associated C. neoformans meningitis.

Cryptococcosis after living donor liver transplantation: report of three cases

Cryptococcosis is the third most common invasive fungal infection in solid organ transplantation, which usually occurs more than 6 months after the primary operation. In our series of 180 consecutive adult living-donor liver transplantation recipients, three (1.5%) had cryptococcosis and one of these patients died. The serum cryptococcal antigen examination was positive in all three patients who suffered from cryptococcosis. The serum cryptococcal antigen test might contribute to the early detection and treatment of cryptococcosis.

Cryptococcal lymphadenitis: report of a case with fine needle aspiration cytology

BACKGROUND

Cryptococcosis is one of the opportunistic infections in AIDS, and therefore an expeditious diagnosis is of the utmost importance since once a cryptococcal infection disseminates, it becomes life threatening.

CASE

A 40-year-old woman presented with epistaxis, fever and cervical lymphadenopathy for 20 days. Fine needle aspiration showed reactive lymphoid hyperplasia with plump, histiocytoid cells resembling metastatic deposits. The second aspirate showed ovoid to spherical, thick-walled structures that stained positive for periodic acid-Schiff stain and mucicarmine.

CONCLUSION

Lymph node fine needle aspiration cytology provides an economical and rather quickly accomplished cytodiagnostic result.

Cryptococcus neoformans peritonitis in two patients with liver cirrhosis

Cryptococcus neoformans is an important pathogen in immunocompromised patients. We report 2 cases of spontaneous C. neoformans peritonitis in patients with liver cirrhosis, a condition not previously reported in Taiwan. Patient 1, a 59-year-old man with alcoholic liver cirrhosis, had primary C. neoformans peritonitis with fungemia. The patient recovered completely after prolonged fluconazole therapy without relapse. Patient 2, a 51-year-old woman with liver cirrhosis due to Budd-Chiari syndrome, had C. neoformans isolated from ascites, cerebrospinal fluid, and blood culture. In spite of adequate antifungal treatment, the patient died of fulminant sepsis. Information about the interaction and relation between liver cirrhosis and cryptococcal peritonitis is rare in the literature. The experience of these cases may help facilitate the diagnosis and treatment of cryptococcal peritonitis.

Granuloma and cryptococcosis

This review describes the general histopathological features of cryptococcosis in immunocompetent individuals, as well as in patients with acquired immunodeficiency syndrome (AIDS). Details of the histological examination of cryptococcal lesions are described, with the consideration of morphological modifications induced by treatment with highly active antiretroviral therapy (HAART). The essential histological features of cryptococcosis in individuals with impaired T-cell functioning are yeast-cell proliferation with a histiocytic response, but only minor lymphocytic and neutrophilic components. Several histological patterns of pulmonary cryptococcal lesions are introduced in this article, some of which could be graded with respect to the degree and type of inflammatory reaction. One pattern was a mild lesion consisting of scattered small foci of intraalveolar cryptococcal proliferation with a histiocytic response. Another pattern involved massive cryptococcal infection, which may have been simply more extensive than that in the mild lesion. Capillary involvement of alveolar septa should be understood as an important common finding in patients with AIDS who had not been treated with HAART. In those patients, the absence of T cells and a decreasing function of antigen-presenting activity in histiocytes were confirmed by immunohistological examination. These findings suggest that the lungs of AIDS patients without HAART offer little resistance to bloodstream dissemination by cryptococci. The unique histological feature demonstrated in patients treated with HAART is characterized by the presence of CD4+ cells, greater response of histiocytes and multinucleated giant-cell formation, and lack of massive capillary involvement.