Cryptococcal infection presenting as soft tissue abscess and arthritis: Case report

RATIONALE

Cryptococcal infection has been documented in immunocompromised patients. AIDS and renal transplant recipients account for majority of the cases. Most cases present with central nervous system or disseminated disease, with only few presenting soft tissue, bone, and joint manifestations.

PATIENT CONCERNS

We present a case of soft tissue mass in a 66-year-old female renal transplant recipient and that of arthritis in a 64-year-old immunocompetent man who presented pseudogout arthropathy. Chest radiographies of both cases were negative. Biopsy revealed cryptococcal organisms. Blood culture or cerebrospinal fluid sampling indicated positive results for cryptococcal antigen.

DIAGNOSIS

Cryptococcus neoformans was recovered in the wound culture.

INTERVENTIONS

The patients received intravenous fluconazole and flucytosine, followed by oral fluconazole administration.

OUTCOMES

Symptomatic improvements were achieved and no subsequent relapses were observed.

LESSONS

The authors experienced 2 cases of cryptococcosis with very unusual clinical presentation. Early clinical suspicion and serum cryptococcal antigen testing can help in rapid appropriate diagnosis in immunocompetent as well as immunocompromised patients even in the absence of pulmonary involvement.

ATI-2307 Exhibits Equivalent Antifungal Activity in Cryptococcus neoformans Clinical Isolates With High and Low Fluconazole IC50

Half maximal inhibitory concentrations (IC50) to the experimental drug ATI-2307 and complete inhibition (IC90) of the common clinically used antifungal drug amphotericin B were determined by microbroth dilution assay for a collection of 69 clinical isolates of Cryptococcus neoformans from Uganda that had high fluconazole IC50 values. The majority of the clinical isolates tested had fluconazole IC50 at or above 8 µg/mL, but were susceptible to both amphotericin B (IC90 ≤1 μg/mL) and ATI-2307 (IC50 ≤0.0312 µg/mL). No correlation between increased fluconazole minimum inhibitory concentration (MIC) and ATI-2307 or amphotericin B MIC was observed, suggesting that the cellular changes impacting fluconazole susceptibility did not impact the effectiveness of ATI-2307. Our results suggest that ATI-2307 is a promising new antifungal drug for use in the context of high fluconazole or other antifungal drug MICs and/or in combination drug therapy regimens.

Donor-Derived Transmission of Cryptococcus gattii sensu lato in Kidney Transplant Recipients

We describe cases of donor-derived transmission of Cryptococcus deuterogattii in 2 kidney transplant recipients in Brazil and published information on other cases. Prompt reduction of immunosuppression and initiation of antifungal therapy was required to successfully control the fungal infections and preserve engraftment.

A Case of Multiple Organ Disseminated Cryptococcosis

Cryptococcus neoformans is an encapsulated yeast found worldwide.1 Patients with immunosuppression, including individuals with HIV/AIDS, transplant recipients and/or individuals with other T-cell mediated immunosuppression are more susceptible to becoming infected with Cryptococcus neoformans than immunocompetent individuals.2 This is a case report of a 66-year-old woman who presented to the emergency department with an unsteady gait and urinary incontinence. Magnetic resonance imaging (MRI) on presentation showed a large C5-C6 central disc protrusion. The patient underwent surgical repair and was treated with five days of IV steroids. Later in the course of her hospitalization, she had an unexplained increasing leukocytosis and tachycardia with witnessed episodes of unresponsiveness. She subsequently had a pulseless electrical activity cardiac arrest and succumbed despite resuscitative efforts. A post-mortem diagnosis revealed Cryptococcus neoformans fungemia and disseminated cryptococcosis involving multiple organs. Disseminated cryptococcosis primarily affects the central nervous system3, and thus this report presents a rare case of disseminated cryptococcosis involving multiple organs.

Primary cutaneous cryptococcosis: the importance of early diagnosis

The species of the Cryptococcus neoformans complex show different epidemiological patterns in the infection of immunosuppressed or immunocompetent individuals, and a common tropism peculiarity for the central nervous system. Primary cutaneous cryptococcosis is a rare clinical entity, with manifestations that are initially restricted to the skin through fungal inoculation, and the absence of systemic disease. The authors report in the present study the case of a 61-year-old immunocompetent man, with a rapidly evolving mucoid tumor on abrasions in contact with bird droppings on the forearm. The early identification of the polymorphic skin manifestations and treatment are crucial for the favorable prognosis of the infection, which can be life-threatening.

Cryptococcal meningitis presenting with acute hearing loss

Reversible sensorineural hearing loss is a recognised complication of cryptococcal meningitis. Cryptococcal meningitis typically presents with usual symptoms of fever, headache and neck stiffness. This case highlights acute, profound, bilateral hearing loss as the initial symptom and presentation of cryptococcal meningitis in a young woman, who was later diagnosed with AIDS.

A case of HIV negative cryptococcal meningitis with antiphospholipid syndrome

Cryptococcal meningitis has become the largest cause for the death of infectious diseases in the central nervous system infectious disease worldwide. Most patients with cryptococcal meningitis have AIDS, autoimmune diseases, hematologic malignancies, and some other relevant diseases. It is mainly caused by infection with Cryptococcus neoformans or Cryptococcus gattii. Although the relationship between cryptococcal meningitis and autoimmune diseases, such as systemic lupus erythematosus, has been recognized, little has been studied about it. Furthermore, with the use of glucocorticoids and immunosuppressants, the incidence of cryptococcal meningitis is increasing year by year. Cryptococcal meningitis accounts for 15% of HIV-related deaths globally, compared with little research on HIV-negative cryptococcal diseases. A 54-year-old female patient with gingival bleeding was admitted to the Department of Neurology at the Second Xiangya Hospital of Central South University. The patient subsequently developed a series of central nervous system symptoms such as headache, ischemic stroke, and epilepsy. The number of thrombocytes was at 4×109/L, antinuclear antibody was (+), antihuman globulin was (++), globulin IgG anticardiolipin antibody IgG, IgA, and IgM was positive, lupus anticoagulant was strong positive, antibody against β2 glycoprotein 1 IgM >841 AU/mL with elevated cerebrospinal fluid (CSF) pressure. The CSF India ink staining was positive, CSF was cultured cryptococcus neoformans. Antiphospholipid syndrome (APS) and cryptococcal neoformans meningitis were diagnosed. After active antifungal therapy and control of APS, the patient still had a serial of complications including high CSF pressure, persistent positive India ink staining, refractory electrolyte disturbance, hemolytic anemia recurs, heart failure, and finally death. No cases of the combination of the two diseases have been reported, and this case of cryptococcal meningitis with APS may provide a new direction to the diagnosis and treatment for this kind of disease.

Cryptococcal Virulence in Humans: Learning From Translational Studies With Clinical Isolates

Cryptococcosis, an invasive mycosis caused by Cryptococcus spp, kills between 20% and 70% of the patients who develop it. There are no vaccines for prevention, and treatment is based on a limited number of antifungals. Studying fungal virulence and how the host responds to infection could lead to new therapies, improving outcomes for patients. The biggest challenge, however, is that experimental cryptococcosis models do not completely recapitulate human disease, while human experiments are limited due to ethical reasons. To overcome this challenge, one of the approaches used by researchers and clinicians is to: 1) collect cryptococcal clinical isolates and associated patient data; 2) study the set of isolates in the laboratory (virulence and host-pathogen interaction variables, molecular markers); 3) correlate the laboratory and patient data to understand the roles fungal attributes play in the human disease. Here we review studies that have shed light on the cryptococcosis pathophysiology using these approaches, with a special focus on human disease. Isolates that more effectively evade macrophage responses, that secrete more laccase, melanize faster and have larger capsules in the cerebrospinal fluid are associated with poorer patient outcomes. Additionally, molecular studies have also shown that cryptococcal clades vary in virulence, with clinical impact. Limitations of those studies include the use of a small number of isolates or retrospectively collected clinical data. The fact that they resulted in very important information is a reflection of the impact this strategy has in understanding cryptococcosis and calls for international collaboration that could boost our knowledge.

Disseminated Cryptococcosis Presenting as Cellulitis Diagnosed by Laser Capture Microdissection: A Case Report and Literature Review

Disseminated cryptococcosis primarily affects immunosuppressed patients and has a poor outcome if diagnosis and treatment are delayed. Skin lesions are rarely manifest causing misdiagnosis. We present a case of cryptococcal cellulitis with severe pain in a kidney transplant recipient on long-term immunosuppressive therapy. Multiple organs were involved, and there was cutaneous dissemination of the lesions. Histopathology revealed abundant yeast-like cells with wide capsular halos in subcutaneous tissue, suggesting Cryptococcus spp. infection. Laser capture microdissection (LCM)-PCR on skin biopsies confirmed Cryptococcus neoformans var. grubii. A literature review of 17 cases of disseminated cryptococcosis with cutaneous cellulitis or panniculitis in HIV-negative individuals found that over half the patients (52.9%, 9/17) had a history of glucocorticoid therapy, and that the most common site was the legs (76.5%, 13/17). C. neoformans was the main pathogenic species, accounting for 88.2% (15/17) of cases. Fungal cellulitis should be included in the differential diagnosis of cellulitis that fails to respond to antimicrobial therapy in HIV-negative immunosuppressed individuals. Non-culture-based molecular techniques aid in rapid pathogen identification in histologically positive, unculturable specimens.

Glucuronoxylomannan in the Cryptococcus species capsule as a target for Chimeric Antigen Receptor T-cell therapy

BACKGROUND AIMS

The genus Cryptococcus comprises two major fungal species that cause clinical infections in humans: Cryptococcus gattii and Cryptococcus neoformans. To establish invasive human disease, inhaled cryptococci must penetrate the lung tissue and reproduce. Each year, about 1 million cases of Cryptococcus infection are reported worldwide, and the infection's mortality rate ranges from 20% to 70%. Many HIV+/AIDS patients are affected by Cryptococcus infections, with 220,000 cases of cryptococcal meningitis reported worldwide in this population every year (C. neoformans infection statistics, via the Centers for Disease Control and Prevention, https://www.cdc.gov/fungal/diseases/cryptococcosis-neoformans/statistics.html). To escape from host immune cell attack, Cryptococcus covers itself in a sugar-based capsule composed primarily of glucuronoxylomannan (GXM). To evade phagocytosis, yeast cells increase to a >45-µm perimeter and become titan, or giant, cells. Cryptococci virulence is directly proportional to the percentage of titan/giant cells present during Cryptococcus infection. To combat cryptococcosis, the authors propose the redirection of CD8+ T cells to target the GXM in the capsule via expression of a GXM-specific chimeric antigen receptor (GXMR-CAR).

RESULTS

GXMR-CAR has an anti-GXM single-chain variable fragment followed by an IgG4 stalk in the extracellular domain, a CD28 transmembrane domain and CD28 and CD3-ς signaling domains. After lentiviral transduction of human T cells with the GXMR-CAR construct, flow cytometry demonstrated that 82.4% of the cells expressed GXMR-CAR on their surface. To determine whether the GXMR-CAR+ T cells exhibited GXM-specific recognition, these cells were incubated with GXM for 24 h and examined with the use of brightfield microscopy. Large clusters of proliferating GXMR-CAR+ T cells were observed in GXM-treated cells, whereas no clusters were observed in control cells. Moreover, the interaction of GXM with GXMR-CAR+ T cells was detected via flow cytometry by using a GXM-specific antibody, and the recognition of GXM by GXMR-CAR T cells triggered the secretion of granzyme and interferon gamma (IFN-γ). The ability of GXMR-CAR T cells to bind to the yeast form of C. neoformans was detected by fluorescent microscopy, but no binding was detected in mock-transduced control T cells (NoDNA T cells). Moreover, lung tissue sections were stained with Gomori Methenamine Silver and evaluated by NanoZoomer (Hamamatsu), revealing a significantly lower number of titan cells, with perimeters ranging from 50 to 130 µm and giant cells >130 µm in the CAR T-cell treated group when compared with other groups. Therefore, the authors validated the study's hypothesis by the redirection of GXMR-CAR+ T cells to target GXM, which induces the secretion of cytotoxic granules and IFN-γ that will aid in the control of cryptococcosis CONCLUSIONS: Thus, these findings reveal that GXMR-CAR+ T cells can target C. neoformans. Future studies will be focused on determining the therapeutic efficacy of GXMR-CAR+ T cells in an animal model of cryptococcosis.

Histoplasma capsulatum Glycans From Distinct Genotypes Share Structural and Serological Similarities to Cryptococcus neoformans Glucuronoxylomannan

The cell wall is a ubiquitous structure in the fungal kingdom, with some features varying depending on the species. Additional external structures can be present, such as the capsule of Cryptococcus neoformans (Cn), its major virulence factor, mainly composed of glucuronoxylomannan (GXM), with anti-phagocytic and anti-inflammatory properties. The literature shows that other cryptococcal species and even more evolutionarily distant species, such as the Trichosporon asahii, T. mucoides, and Paracoccidioides brasiliensis can produce GXM-like polysaccharides displaying serological reactivity to GXM-specific monoclonal antibodies (mAbs), and these complex polysaccharides have similar composition and anti-phagocytic properties to cryptococcal GXM. Previously, we demonstrated that the fungus Histoplasma capsulatum (Hc) incorporates, surface/secreted GXM of Cn and the surface accumulation of the polysaccharide enhances Hc virulence in vitro and in vivo. In this work, we characterized the ability of Hc to produce cellular-attached (C-gly-Hc) and secreted (E-gly) glycans with reactivity to GXM mAbs. These C-gly-Hc are readily incorporated on the surface of acapsular Cn cap59; however, in contrast to Cn GXM, C-gly-Hc had no xylose and glucuronic acid in its composition. Mapping of recognized Cn GXM synthesis/export proteins confirmed the presence of orthologs in the Hc database. Evaluation of C-gly and E-gly of Hc from strains of distinct monophyletic clades showed serological reactivity to GXM mAbs, despite slight differences in their molecular dimensions. These C-gly-Hc and E-gly-Hc also reacted with sera of cryptococcosis patients. In turn, sera from histoplasmosis patients recognized Cn glycans, suggesting immunogenicity and the presence of cross-reacting antibodies. Additionally, C-gly-Hc and E-gly-Hc coated Cn cap59 were more resistant to phagocytosis and macrophage killing. C-gly-Hc and E-gly-Hc coated Cn cap59 were also able to kill larvae of Galleria mellonella. These GXM-like Hc glycans, as well as those produced by other pathogenic fungi, may also be important during host-pathogen interactions, and factors associated with their regulation are potentially important targets for the management of histoplasmosis.

The Lymphocytic Scavenger Receptor CD5 Shows Therapeutic Potential in Mouse Models of Fungal Infection

Invasive fungal diseases represent an unmet clinical need that could benefit from novel immunotherapeutic approaches. Host pattern recognition receptors (e.g., Toll-like receptors, C-type lectins, or scavenger receptors) that sense conserved fungal cell wall constituents may provide suitable immunotherapeutic antifungal agents. Thus, we explored the therapeutic potential of the lymphocyte class I scavenger receptor CD5, a nonredundant component of the antifungal host immune response that binds to fungal β-glucans. Antifungal properties of the soluble ectodomain of human CD5 (shCD5) were assessed in vivo in experimental models of systemic fungal infection induced by pathogenic species (Candida albicans and Cryptococcus neoformans). In vitro mechanistic studies were performed by means of fungus-spleen cell cocultures. shCD5-induced survival of lethally infected mice was dose and time dependent and concomitant with reduced fungal load and increased leukocyte infiltration in the primary target organ. Additive effects were observed in vivo after shCD5 was combined with suboptimal doses of fluconazole. Ex vivo addition of shCD5 to fungus-spleen cell cocultures increased the release of proinflammatory cytokines involved in antifungal defense (tumor necrosis factor alpha and gamma interferon) and reduced the number of viable C. albicans organisms. The results prompt further exploration of the adjunctive therapeutic potential of shCD5 in severe invasive fungal diseases.

The Use of Adjunctive Steroids in Central Nervous Infections

Central nervous system (CNS) infections continue to be associated with significant neurological morbidity and mortality despite various existing therapies. Adjunctive steroid therapy has been employed clinically to reduce inflammation in the treatment of CNS infections across various causative pathogens. Steroid therapy can potentially improve clinical outcomes including reducing mortality rates, provide no significant benefit, or cause worsened outcomes, based on the causative agent of infection. The data on benefits or harms of adjunctive steroid therapy is not consistent in outcome or density through CNS infections, and varies based on the disease diagnosis and pathogen. We summarize the existing literature on the effects of adjunctive steroid therapy on outcome for a number of CNS infections, including bacterial meningitis, herpes simplex virus, West Nile virus, tuberculosis meningitis, cryptococcal meningitis, Angiostrongylus cantonensis, neurocysticercosis, autoimmune encephalitis, toxoplasmosis, and bacterial brain abscess. We describe that while steroid therapy is beneficial and supported in pathogens such as pneumococcal meningitis and tuberculosis, for other diseases, like Listeria monocytogenes and Cryptococcus neoformans they are associated with worse outcomes. We highlight areas of consistent and proven findings and those which need more evidence for supported beneficial clinical use of adjunctive steroid therapy.

Multilocus sequence typing (MLST) of clinical and environmental isolates of Cryptococcus neoformans and Cryptococcus gattii in six departments of Colombia reveals high genetic diversity

INTRODUCTION

The average annual incidence of cryptococcosis in Colombia is 0.23 cases per 100,000 inhabitants in the general population, and 1.1 cases per 1000 in inhabitants with Acquired Immune Deficiency Syndrome (AIDS). In addition, the causal fungus has been isolated from the environment, with serotypes A-B and C in different regions. This study aims to determine the genetic association between clinical and environmental isolates of C. neoformans/C. gattii in Colombia.

METHODS

Multilocus sequence typing (MLST) was used to identify possible clones, providing information about the epidemiology, ecology, and etiology of this pathogen in Colombia.

RESULTS

A total of 110 strains, both clinical (n=61) and environmental (n=49), with 21 MLST sequence types (ST) of C. neoformans (n=14STs) and C. gattii (n=7STs) were identified. The STs which shared clinical and environmental isolate sources were grouped in different geographical categories; for C. neoformans, ST93 was identified in six departments, ST77 in five departments; and for C. gattii, ST25 was identified in three departments and ST79 in two.

CONCLUSIONS

High genetic diversity was found in isolates of C. neoformans/gattii by MLST, suggesting the presence of environmental sources harboring strains which may be sources of infection for humans, especially in immunocompromised patients; these data contribute to the information available in the country on the distribution and molecular variability of C. neoformans and C. gattii isolates recovered in Colombia.

Are Italy and Iran really suffering from COVID-19 epidemic? A controversial study

The number of global COVID-19 infected cases is increased rapidly to exceed 370 thousand. COVID-19 is transmitted between humans through direct contact and touching dirty surfaces. This paper aims to find the similarity between DNA sequences of COVID-19 in different countries, and to compare these sequences with three different diseases [HIV, Hand-Foot-Mouth disease (HFMD), and Cryptococcus]. The study used pairwise distance, maximum likelihood tree, and similarity between amino acid to find the results. The results showed that different three main types of viruses namely, COVID-19 are found. The virus in both Italy and Iran is not similar to COVID-19 in China and USA. While, two viruses were spread in Wuhan (before and after December 26, 2019). Besides Cryptococcus and HFMD are found as dominant diseases with Group 1 and Group 3, respectively. Authors claim that the current virus in Italy and Iran that killed thousands of people is not COVID-19 based on the available data.

Pulmonary cryptococcosis: Report of the first confirmed autochthonous case in Nepal

We report a case of cryptococcal pneumonia in a 53 years old female Nepali patient with uncontrolled diabetes mellitus type 2 who empirically received multiple broad-spectrum antibiotics and standard anti-tubercular treatment as well as glucocorticosteroids for suspected sarcoidosis before the diagnosis was finally established. To our knowledge, this is the first confirmed autochthonous case of cryptococcosis reported from Nepal.

Synergic effect of simvastatin in combination with amphotericin B against environmental strains of Cryptococcus neoformans from northeastern Brazil: a prospective experimental study

BACKGROUND

Statins are used as cholesterol-lowering drugs and may also have direct antimicrobial effects.

OBJECTIVE

To evaluate synergic interactions between simvastatin and both amphotericin B and fluconazole, against environmental strains of Cryptococcus neoformans isolated from captive birds' droppings.

DESIGNAND SETTING

Experimental study conducted at Federal University of Piauí, Parnaíba, in collaboration with Federal University of Triângulo Mineiro, Uberaba, Brazil.

METHODS

Statin susceptibility tests of Cryptococcus neoformans samples were performed as prescribed in standards. Interactions of simvastatin with amphotericin and fluconazole were evaluated using the checkerboard microdilution method. Presence of these interactions was quantitatively detected through determining the fractional inhibitory concentration index (FICI).

RESULTS

Isolates of Cryptococcus neoformans were obtained from 30 of the 206 samples of dry bird excreta (14.5%) that were collected from pet shops and houses. Ten isolates were selected for susceptibility tests. All of them were susceptible to amphotericin and fluconazole. All presented minimum inhibitory concentration (MIC) > 128 µg/ml and, thus, were resistant in vitro to simvastatin. An in vitro synergic effect was shown through combined testing of amphotericin B and simvastatin, such that six isolates (60%) presented FICI < 0.500. Two isolates showed considerable reductions in MIC, from 1 µg/ml to 0.250 µg/ml. No synergic effect was observed through combining fluconazole and simvastatin.

CONCLUSION

These results demonstrate that simvastatin should be considered to be a therapeutic alternative, capable of potentiating the action of amphotericin B. However, further studies are necessary to clarify the real effect of simvastatin as an antifungal agent.

Fluconazole for Hypercortisolism in Cushing's Disease: A Case Report and Literature Review

BACKGROUND

Cushing's disease is associated with an increased risk of pulmonary fungal infection, which could be a relative contraindication for pituitary adenoma excision surgery.

CASE

We report a case of a patient with Cushing's disease and pulmonary Cryptococcus neoformans. A 48-year-old woman was admitted to our hospital because of moon face and edema. Laboratory and radiological findings suggested a diagnosis of Cushing's disease and pulmonary cryptococcus infection. Fluconazole 400 mg per day was administered intravenously and continued orally for 3 months. Both cryptococcus infection and hypercortisolism relieved and transsphenoidal resection was performed.

CONCLUSION

Cushing's disease can be effectively treated with fluconazole to normalize cortisol concentration prior to pituitary surgery. Fluconazole is an alternative treatment especially in Cushing's disease patients with cryptococcal pneumonia.

[Cryptococcal meningitis in an immunocompetent patient - a case report]

Cryptococcal meningitis is a severe neurological infection caused by the yeast Cryptococcus neoformans. It often occurs as an opportunistic infection; rarely, it may be seen in healthy people as well. The most common source of the infection is inhalation of infected bird droppings. The cryptococci may persist in the lungs and nearby lymph nodes for a long time. There are no or mild clinical manifestations of the pulmonary infection. The disease often manifests only after the cryptococci penetrate into the CNS. The case report documents the development of cryptococcal meningitis in an immunocompetent patient. It was diagnosed by microscopic detection of the yeast in the cerebrospinal fluid. The finding was confirmed by detecting cryptococcal DNA in the cerebrospinal fluid and culture. Despite immediate initiation of antifungal therapy and intensive care, the patient died.

From the environment to the host: How non-azole agrochemical exposure affects the antifungal susceptibility and virulence of Cryptococcus gattii

Agrochemicals such as the non-azoles, used to improve crop productivity, poses severe undesirable effects on the environment and human health. In addition, they induce cross-resistance (CR) with clinical drugs in pathogenic fungi. However, till date emphasis has been given to the role of azoles on the induction of CR. Herein, we analyzed the effect of a non-azole agrochemical, pyraclostrobin (PCT), on the antifungal susceptibility and virulence of the human and animal pathogens Cryptococcus gattii and C. neoformans. We determined the minimum inhibitory concentration (MIC) of fluconazole (FLC), itraconazole, ravuconazole, amphotericin B, and PCT on colonies: (i) that were not exposed to PCT (non-adapted-NA-cultures), (ii) were exposed at the maximum concentration of PCT (adapted-A-cultures) and (iii) the adapted colonies after cultivation 10 times in PCT-free media (10 passages-10p-cultures). Our results showed that exposure to PCT induced both temporary and permanent CR to clinical azoles in a temperature-dependent manner. With the objective to understand the mechanism of induction of CR through non-azoles, the transcriptomes of NA and 10p cells from C. gattii R265 were analyzed. The transcriptomic analysis showed that expression of the efflux-pump genes (AFR1 and MDR1) and PCT target was higher in resistant 10p cells than that in NA. Moreover, the virulence of 10p cells was reduced as compared to NA cells in mice, as observed by the differential gene expression analysis of genes related to ion-metabolism. Additionally, we observed that FLC could not increase the survival rate of mice infected with 10p cells, confirming the occurrence of permanent CR in vivo. The findings of the present study demonstrate that the non-azole agrochemical PCT can induce permanent CR to clinical antifungals through increased expression of efflux pump genes in resistant cells and that such phenomenon also manifests in vivo.

Concomitant severe influenza and cryptococcal infections: A case report and literature review

Concomitant influenza and cryptococcal infections are rare. Herein, we describe an unusual case of an avian influenza A (H7N9) infection with several severe mixed bacterial infections and systemic super-infection with Cryptococcus neoformans presenting as ventilator-associated pneumonia (VAP) and bloodstream infection in a previously immunocompetent man during hospitalization.A 58-year-old man was admitted to our hospital complaining of hyperpyrexia, dyspnoea, cough, and phlegm with blood. A chest computed tomography scan revealed multiple ground-glass opacities and consolidation in both lungs with right pleural effusion. An initial sputum test was positive for influenza A (H7N9) virus. After antiviral treatment and other supportive measures, the patient's condition improved. However, the patient's condition deteriorated again approximately 2 weeks after admission, and bronchoalveolar lavage fluid (BALF) and blood cultures were positive for C. neoformans. Therapy with intravenous liposomal amphotericin B and fluconazole was started. After a 2-week antifungal treatment, BALF and blood cultures were negative for C. neoformans. However, the patient had persistent lung infiltrates with severe pulmonary fibrosis with a prolonged course of disease. On hospital day 40, BALF and blood cultures were both positive for multidrug-resistant Stenotrophomonas maltophilia. Finally, the patient developed septic shock, disseminated intravascular coagulation and multi-organ failure and succumbed to treatment failure.Cryptococcal infection can occur in patients with severe influenza during hospitalization with a more severe condition, and the clinician should be aware of this infection.

Coinfection with cryptococcus and aspergillus in an immunocompetent adult: A case report

RATIONALE

Aspergillus and Cryptococcus exposure can cause serious secondary infections in human lungs, especially in immunocompromised patients or in conjunction with a chronic disease caused by low disease resistance. Primary invasive fungal infections are clinically rare; therefore, coexistence of 2 fungi at an infection site is uncommon. This paper reports a case of healthy male who was diagnosed with both Cryptococcus neoformans and Aspergillus infections.

PATIENT CONCERNS

A healthy 33-year-old male office worker was admitted to the Second Hospital of Jilin University for hemoptysis. A chest computed tomography (CT) scan showed a cavity, which was formed by the thick dorsal wall of the lower left lobe with an irregular inner wall and burr changes around the lesion.

INTERVENTION

After 1.0 week of antibiotic and antituberculosis treatment, the hemoptysis symptoms remained. A resection of the left lower lobe was performed.

DIAGNOSES

The postoperative pathological reports indicated the presence of both Aspergillus and Cryptococcus. The 2 fungal lesions were separate but within the same location.

OUTCOMES

After treatment, the patient no longer had hemoptysis.

LESSONS

The current study indicated that fungi can infect not only immunocompromised patients but also healthy people, and that there can be 2 separate fungal infections at the same infection site.

Laryngeal Cryptococcoma Resulting in Airway Compromise in an Immunocompetent Patient: A Case Report

Cryptococcus neoformans is a yeast than can result in isolated or disseminated infections. This case report describes an immunocompetent patient presenting with airway obstruction secondary to laryngeal crypotococcoma, mimicking a laryngeal malignancy, and describes associated management. A 68-year-old immunocompetent female with a new positron emission tomography-avid laryngeal lesion was intubated after acute respiratory decompensation. Airway evaluation revealed diffuse mucosal changes throughout the endolarynx with significant loss of normal native tissue architecture. Operative biopsy confirmed infection of C neoformans. The patient was treated with extended-course fluconazole. This case reinforces characteristic physical and histologic findings described for laryngeal cryptococcal infection. Laryngoscope, 129:926-929, 2019.

[Clinical Comparative Analysis of Cryptococcus neoformans Meningitis Between Patients with and without AIDS]

OBJECTIVE

To compare clinical characteristics and therapeutic outcomes between HIV and non-HIV patients with Cryptococcus neoformans meningitis (CNM).

METHODS

A total of 73 patients with CNM (30 patients without HIV and 43 with HIV) were admitted from January 2012 to January 2017. The clinical manifestations,biochemical and microbiological characteristics of cerebrospinal fluid (CSF) were collected and analyzed.

RESULTS

The patients in the two group displayed non-specific symptoms such as headache,fever,nausea and vomiting. Non-HIV CNM patients had more serious inflammatory reaction with higher karyocytes and protein level (P=0.000,P=0.041,respectively),while had lowere positive rate of primary ink staining in cerebrospinal fluid (70.0% vs. 93.0%,P=0.009),higher misdiagnosis rate (43.3% vs. 14.0%,P=0.005),longer hospitalization duration [(112.27±105.42) d vs. (52.64±39.17) d,P=0.021],higher adverse reactions rate of antifungal treatment was (80.0% vs. 30.2%,P=0.000). However,in HIV CNM patients,40 (93.0%) patients did not receive antiviral therapy before and were diagnosed as AIDS for the first time; the therapeutic effect in this group was very poor with higher mortality (30.2% vs. 13.4%,P=0.000).

CONCLUSION

Immunity status should be considered in the diagnosis and treatment of CNM,since it is difficult to diagnose with long treatment period and poor prognosis.

Emerging roles of inositol pyrophosphates as key modulators of fungal pathogenicity

Inositol pyrophosphates (PP-IPs) are energy-rich small molecules that are omnipresent in eukaryotic cells, from yeast to mammals, playing central roles in overall cellular homeostasis as a diverse and multifaceted class of intracellular messengers. Recent studies of the metabolic pathways and physiological roles of PP-IPs in the human pathogenic fungus Cryptococcus neoformans have revealed that the PP-IP5 (IP7) is a key metabolite essential for fungal metabolic adaptation to the host environment, immune recognition, and pathogenicity. This suggests the PP-IP biosynthesis pathway, comprising phospholipase C1 (Plc1) and a series of sequentially acting inositol polyphosphate kinases (IPKs), as a new virulence-related signaling pathway in C. neoformans. Given that fungal species have a reduced array of the kinases required for the synthesis of PP-IPs and that the homology between human and fungal IPKs is restricted to a few catalytically important residues, identification of IPK inhibitors specifically targeting the kinases of pathogenic fungi has emerged as a desirable and achievable strategy for antifungal drug development.

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.

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.

Antifungal efficacy of amphotericin B encapsulated fibrin microsphere for treating Cryptococcus neoformans infection in Swiss albino mice

A natural and biocompatible fibrin microsphere is one of the most promising dual delivery vehicle as compared to other traditionally designed delivery modalities. It represents sustained delivery of encapsulated drug and is easily biodegradable in the blood circulation. In the present study, we evaluated the systemic augmentation of the antifungal activity of amphotericin B loaded in fibrin microsphere (AMB-fibrin microsphere) against cryptococcosis in Swiss albino mice. Mice infected with Cryptococcus neoformans were treated with 0.5mg/kg AMB-fibrin microsphere that was given alternately for 7 days. The antifungal potential of AMB-fibrin microsphere was assessed on the basis of reduction of cfu count in the systemic circulation and various vital organs of infected mice. The formulation was found to be highly effective in reducing intracellular pathogen from the experimental animals where fibrin microsphere significantly controlled the release of amphotericin B for longer time duration. The AMB-fibrin microsphere chemotherapy was significantly more effective than free amphotericin B in reducing the fungal burden and showed better survival efficacy (p<0.05). The current study demonstrating the use of novel amphotericin B loaded fibrin microsphere not only imparts protection to the encapsulated amphotericin B but also offers an effective strategy to decrease the drug associated toxicities.

Thoracolumbar Scoliosis Due to Cryptococcal Osteomyelitis: A Case Report and Review of the Literature

Cryptococcus neoformans causes opportunistic infections in immunocompromised patients, with vertebral osteomyelitis being a very rare involvement.This study is to present a case of thoracolumbar scoliosis occurring in the setting of cryptococcal osteomyelitis.Pharmacological intervention with anticryptococcal medicine and medical management of immune hemolytic anemia were administered. After initial acute stabilization, she underwent spinal debridement and fusion on October 29, 2008. She eventually recovered fully from this episode with no subsequent mechanical instability or neurological deficits on subsequent clinic follow-ups.To the best of our knowledge, there have been no reports describing the onset of spinal cryptococcal osteomyelitis along with immune hemolytic anemia. We suggest a comprehensive algorithm for the diagnosis of vertebral cryptococcal osteomyelitis.

[Cryptococcosis: a potential aetiology of facial ulceration]

Cutaneous cryptococcosis is an uncommon aetiology of chronic facial ulceration but which may be associated to a potentially lethal focus of cryptococcosis.

OBSERVATION

A 35-year-old AIDS patient under antiretroviral therapy, presented with a chronic facial ulceration. Histopathological examination of a biopsy of the facial ulceration showed an inflammatory granuloma and masses of yeasts. Mycological culture of the cerebrospinal fluid revealed Cryptococcus neoformans. The diagnosis of AIDS-related cutaneous cryptococcosis of the face and cryptococcal meningitis was concluded.

DISCUSSION

Cryptococcosis should be thought as a potential aetiology of a chronic facial ulceration in an AIDS patient. Screening of other foci of the cryptococcosis such as that of the central nervous system is mandatory. Mycological examinations are of great interest for the diagnosis in rare resources setting.

Disseminated Cryptococcal Infection Resulting in Acute Respiratory Distress Syndrome (ARDS) as the Initial Clinical Presentation of AIDS

Cryptococcosis is a cosmopolitan but rare opportunistic mycosis which is usually caused by Cryptococcus neoformans. Although the most common and worrisome disease manifestation is meningoencephalitis, pulmonary cryptococcosis has the potential to be lethal. The diagnosis of cryptococcal pneumonia is challenging, given its non-specific clinical and radiographic features. Respiratory failure leading to acute respiratory distress syndrome as a consequence of cryptococcal disease has been infrequently addressed in the literature. We herein present a case of disseminated cryptococcal infection leading to acute respiratory distress syndrome, refractory shock, and multiorgan dysfunction as the initial clinical manifestation in a patient who was newly diagnosed with acquired immunodeficiency syndrome.

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.

Clinical heterogeneity of dominant chronic mucocutaneous candidiasis disease: presenting as treatment-resistant candidiasis and chronic lung disease

In gain-of-function STAT1 mutations, chronic mucocutaneous candidiasis disease (CMCD) represents the phenotypic manifestation of a complex immunodeficiency characterized by clinical and immunological heterogeneity. We aimed to study clinical manifestations, long-term complications, molecular basis, and immune profile of patients with dominant CMCD. We identified nine patients with heterozygous mutations in STAT1, including novel amino acid substitutions (L283M, L351F, L400V). High risk of azole-resistance was observed, particularly when intermittent regimens of antifungal treatment or use of suboptimal dosage occurs. We report a case of Cryptococcosis and various bacterial and viral infections. Risk of developing bronchiectasis in early childhood or gradually evolving to chronic lung disease in adolescent or adult ages emerges. Lymphopenia is variable, likely progressing by adulthood. We conclude that continuous antifungal prophylaxis associated to drug monitoring might prevent resistance to treatment; prompt diagnosis and therapy of lung disease might control long-term progression; careful monitoring of lymphopenia-related infections might improve prognosis.

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.

[Role of CD44 in monocyte transmigration across Cryptococcus neoformans-infected blood-brain barrier in vitro]

OBJECTIVE

To explore the role of CD44 in monocyte adhesion to human brain microvascular endothelial cells (HBMECs) and monocyte migration across an in vitro model of blood-brain barrier (BBB) infected by Cryptococcus neoformans (Cn).

METHODS

An in vitro blood-brain barrier model was constructed using a transwell chamber covered with a HBMEC monolayer. The wild-type strain of Cn B4500FO2, TYCC645#32 strain with CPS1 gene deletion and PCIP strain with CPS1 complementation were chosen to infect the monolayer HBMECs. THP-1 cells were added to the upper chamber of transwell, and the relative migration rate was determined by counting the number of the cells entering the lower chambers. The inhibitory effects of anti-CD44 monoclonal antibody and the CD44 inhibitor bikunin were examined on THP-1 binding to and migration across HBMECs.

RESULTS

Cn infection of the HBMECs caused markedly enhanced THP-1 cell adhesion and migration across the monolyers (P<0.01) dependent on Cn concentration and exposure time. Addition of anti-CD44 monoclonal antibody and bikunin significantly lowered THP-1 adhesion and migration rates in the BBB model with Cn-infected HBMECs (P<0.01) with a dose dependence of the antibody (within 0-1 µg) and inhibitor (within 0-20 nmol/L). Both THP-1 adhesion rate and migration rate were lowered in the BBB model infected with CPS1 gene-deleted Cn but increased in the model infected with the complemented strain compared with those in the wild-type strain-infected model.

CONCLUSION

In the in vitro BBB model, CD44 expressed on HBMECs may play an essential role in monocyte adhesion to and migration across the BBB. The capsular hyaluronic acid may mediate Cn-induced monocyte adhesion and migration.

Risk factors for invasive Cryptococcus neoformans diseases: a case-control study

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.

'Time-to-amphotericin B' in cryptococcal meningitis in a European low-prevalence setting: analysis of diagnostic delays

BACKGROUND

Cryptococcal meningitis is a rare disease in Europe, resulting in delayed recognition and slower initiation of specific treatment.

AIM

To analyse the time-to-treatment and the factors that delay the diagnosis and treatment in the low-prevalence setting of a European centre.

DESIGN

Retrospective review

METHODS

We reviewed full medical records of all adult patients with cryptococcal meningitis referred to an HIV centre in Berlin, Germany in 10-year period between 1st of October 2003 and 31st of September 2013. Multivariant statistics with bootstrap-resampling were performed.

RESULTS

We identified 19 patients with a diagnosis of HIV-related cryptococcal meningitis (0.55% of all consecutive HIV-infected patients). In almost half of our patients the diagnosis was not considered initially on admission to the secondary care centre and the first diagnostic clue being an accidental positive blood, cerebrospinal fluid or bronchoalveolar lavage culture growing Cryptococcus neoformans. The median time-to-treatment was 5 days (range: 1-16). Known positive HIV status accelerated the time-to-diagnosis (p < 0.05) by a median of 1.89 days, whereas the CSF cell count ≤ 10/µl delayed diagnosis by a median time of 1.93 days (p < 0.1).

CONCLUSIONS

Diagnostic delays could be avoided by encouraging practising physicians (i) to consider cryptococcal meningitis in immunosuppressed HIV-infected patients irrespective of neurological symptoms; (ii) to test for India ink, cryptococcal antigen and fungal cultures in immunosuppressed HIV-infected patients with normal CSF; (iii) to consider a possibility of underlying HIV infection in patients with unknown HIV status presenting with meningitis; and (iv) to consider early targeted HIV testing in persons at risk according to locally validated criteria.

Intracerebral coinfection with Burkholderia pseudomallei and Cryptococcus neoformans in a patient with systemic lupus erythematosus

Infections are a serious complication in patients with systemic lupus erythematosus (SLE), and are an important cause of morbidity and mortality. SLE patients are particularly susceptible to infection due to immune suppression from underlying disease or treatment. Most infections are due to common bacterial organisms. Clinicians also need to be aware of the possibility of polymicrobial infections as these may cause diagnostic delay and affect outcomes. We report the case of an intra-cerebral coinfection with Burkholderia pseudomallei and Cryptococcus neoformans in a 34-year-old woman with SLE. The diagnosis in this case was delayed since coinfection was not suspected.

Disseminated cryptococcosis with caverno-oesophageal fistula in a case of idiopathic CD4+ T-lymphocytopenia

Idiopathic CD4+ T-Lymphocytopenia is a rare immunodeficiency disorder characterised by significantly low absolute CD4 lymphocytes in absence of any viral infections. We present a case of Disseminated Cryptococcosis with Caverno- Oesophageal Fistula in a case of Idiopathic CD4+ T-Lymphocytopenia. 29 year old lady was referred to Institute in view of lung mass not responding to anti-TB treatment. Subsequently patient had developed headache. Radiological evaluation showed presence of ring enhancing lesion in the occipital region. On evaluation with Fibre-optic bronchoscopy, there was no evidence of malignancy or tuberculosis. Sputum showed presence and growth of Cryptococcus neoformans. Patient's investigations were negative for virus infection, with normal immunoglobulin levels. Her CD4 counts were 129 cells/mm3. Patient was treated with injectable antifungals. Patient developed a Caverno-oesophageal fistula which was confirmed on endoscopy and radiology. Patient was managed with percutaneous jejunal feeding (PEJ). Patient improved symptomatically with CD4 count of 475 cells/mm3.

Primary cryptococcal prostatitis--rare occurrence

Cryptococcosis is a well recognized infection in immunocompromised patients. Cryptococcal infection primarily involves the lung and is hematogeneously spread to other organs. Sometimes it might affect the genitourinary tract. The prostate gland is a rare site of primary infection due to cryptococcus neoformans. We report a case of granulomatous inflammation in the prostate as a result of crypyococcus neoformans infection in a 70 year old immunocompetent patient, a non diabetic, which was diagnosed by transrectal ultrasound guided biopsy.

[Cryptococcal meningitis as initial presentation of systemic lupus erythematosus]

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.

Endobronchial pulmonary cryptococcosis and tuberculosis in an immunocompetent host

Pulmonary cryptococcosis presenting as an endobronchial tumour-like growth has rarely been described. We report the case of a male patient with normal immune function who presented with a right upper lobe mass lesion. Bronchoscopy revealed a tumour-like growth that completely occluded the anterior segment of the right upper lobe bronchus. Bronchial biopsy and computed tomography-guided lung biopsy revealed Cryptococcus, and culture of lung biopsy specimen grew Cryptococcus neoformans and Mycobacterium tuberculosis. The patient responded clinically to amphotericin B, fluconazole and anti-tuberculous therapy. However, chest radiographic response was unremarkable. A presentation of pulmonary cryptococcosis and tuberculosis, along with endobronchial tumour-like growth in the same patient, is unusual and has not been previously described.