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.

[Primary cutaneous cryptococcosis in a pigeon breeder]

A Danish 73 year-old male patient with polymyalgia rheumatica and in prednisone treatment presented with a cutaneous ulcer on the hand caused by a scratch from a pigeon. Initial treatment with antibiotics was unsuccessful. Biopsy revealed Cryptococcus neoformans and the patient recovered on antifungal treatment. Primary cutaneous cryptococcosis is a rare manifestation of a C. neoformans infection. This case exemplifies the importance of differential diagnosis in immunosuppressed patients who do not respond to a given treatment.

Isolated cryptococcal osteomyelitis in immunocompetent patient

Cryptococcosis is a common opportunistic infection in AIDS patients. Almost all cases present with meningitis with or without fungaemia. Cryptococcal osteomyelitis occurs as part of a disseminated infection. Isolated cryptococcal osteomyelitis is rare and more so in immunocompetent patients. A case of isolated osteomyelitis caused by Cryptococcus neoformans in an immunocompetent patient is reported here. A female patient of 60 years old presented with pain and swelling of left clavicle. The histopathological examination of the biopsied material (bony fragment) showed histiocytes, lymphocytes with many foam cells showing organisms, the morphology was consistent with cryptococcus. Fluconazole was advised and she responded favourably.

Cryptococcal choroid plexitis: rare imaging findings of central nervous system cryptococcal infection in an immunocompetent individual

Central nervous system (CNS) cryptococcosis is a common opportunistic fungal infection in immunocompromised patients, and the imaging findings differ from those in immunocompetent patients. Here, we present the imaging findings in an immunocompetent woman of a rare case of central nervous system cryptococcal choroid plexitis with trapped temporal horns, enlarged enhancing bilateral choroid plexuses and multiple intraventricular choroid plexus cysts.

Isolated intramedullary cryptococcal granuloma of the conus medullaris: Case report and review of the literature

Infection of the nervous system by Cryptococcus neoformans most often causes meningitis and meningoencephalitis. While there have been several cases of cerebral cryptoccal granuloma published in the literature, the isolated occurrence of intramedullary cryptococcal granuloma is very rare. We present an immunocompetent patient with such a lesion of the conus medullaris. The patient's clinical symptoms mimicked an intramedullary spinal cord tumor. The diagnosis was made by histopathology, rather than by image or laboratory examinations. The case was successfully managed with surgical removal of the lesion and postoperative anti-fungal treatment.

Uncommon presentation of intracranial cryptococcal infection mimicking tuberculous infection in two immunocompetent patients

Cryptococcal infection of the brain is commonly seen in immunocompromised patients but rarely considered as the differential diagnosis in immunocompetent patients. We present two cases of cryptococcosis involving the brain in immunocompetent patients, which strongly mimicked tuberculous infection in both conventional as well as advanced magnetic resonance (MR) imaging, and the disease was only confirmed after histopathological/cerebrospinal fluid serological study. One patient was a 52-year-old woman, and the second patient was a 23-year-old man. These two cases highlight the need for workup of fungal infections in immunocompetent patients from the tuberculous endemic regions, even when the imaging is highly suspicious of tuberculous lesions. The imaging findings in advanced MR imaging techniques such as diffusion, perfusion, susceptibility-weighted imaging and MR spectroscopy are discussed.

[A case of colonic cryptococcosis]

We experienced a rare case of colonic cryptococcosis in an apparently immunocompetent individual. A 27-year- old woman admitted our hospital for intermittent melena. Initial abdominal CT scan revealed a mass lesion obstructing most of the lumen in ascending colon. Colonoscopy showed huge ulcerofungating mass in proximal ascending colon. Colonoscopic biopsy was performed and pathologic diagnosis was made as colonic cryptococcosis with positive PAS stain. Laboratory test evaluating immune status and bone marrow examination was normal. The patient was treated with intravenous amphotericin B for four weeks and six months of oral fluconazole afterwards. Follow-up abdominal CT scan and colonoscopy were taken at four weeks and seven months after the beginning of treatment. On completion of intravenous amphotericin B treatment, the mass lesion was decreased in abdominal CT and colonoscopy. After seven months, abdominal CT and colonoscopy showed near-complete resolution of the colonic lesion so the treatment ended. Cryptococcosis in a healthy individual is a rare disease and there have been only several sporadic case reports on pulmonary or central nervous system involvement. Hence, we report a case of colonic cryptococcosis in an apparently immunocompetent individual.

Capsular reactions and soluble antigens of Torula histolytica and of Sporotrichum schenckii

The present paper deals with reactions between antiserums and the capsules of Torula histolytica (Cryptococcus hominis or Torulopsis neoformans) and of Sporotrichum schenckii. The reactions, although similar in principle to the capsular swelling seen in Quellung tests of bacteria, present a special interest because the microorganisms are larger in size and more complex in structure than bacteria. That the reactions on the capsules were caused by immunologically specific antibodies was shown by the fact that the capsular reactivity of the serums was directly related to their capacities to agglutinate suspensions and to precipitate soluble antigens of Torula and of Sporotrichum, and by the fact that the capsular reactivity was removed from the serums by absorption with soluble antigens of the respective fungi. The soluble antigens included partially purified products from broth cultures of Torula and of Sporotrichum, a partially purified product from Sporotrichum-infected mice, and a purified polysaccharide from a culture of Torula grown in a synthetic medium. The purified polysaccharide was highly reactive in precipitation tests with unabsorbed serum, and its ability to absorb the Torula capsular reactivity from the serums indicates that the major antigens on the surface of encapsulated Torula cells are polysaccharides, identical with or similar to the product used in the present study.

MRI findings of intramedullary spinal cryptococcoma

Cryptococcus neoformans is a yeast that most commonly infects the central nervous system. Meningitis and meningoencephalitis are the most common presentations of cryptococcosis. Cryptococcoma, however, is a rare entity characterized by localized, solid, tumor-like masses that are usually found in the cerebral hemispheres or cerebellum, but are extremely rare in the spinal cord. We report a case of an immunocompetent patient with intramedullary cryptococcoma in the spinal cord, which presented as a spinal tumor. Diagnosis was made by histological examination of the surgical specimen.

Invasive fungal infection in systemic lupus erythematosus: an analysis of 15 cases and a literature review

OBJECTIVE

To analyse 15 cases of invasive fungal infection and mortality parameters in the largest series in the last 35 yrs of patients with systemic lupus erythematosus (SLE) at a single medical centre.

METHODS

Fifteen patients with SLE and invasive fungal infections were retrospectively enrolled. Clinical and laboratory data, fungal species and infected sites, corticosteroid and immunosuppressant doses and SLE disease activity index were assessed retrospectively. Comparison and correlation analyses utilized Fisher's exact test, the chi-square test, Mann-Whitney U-test or the Wilcoxon signed-rank test where appropriate.

RESULTS

In contrast to other review reports, Cryptococcus neoformans was the most commonly identified fungus in this Taiwanese series. Notably, the prevalence of autoimmune haemolytic anaemia and positive results for the anti-cardiolipin antibody in this study were significantly higher than those in SLE patients in general (P < 0.0001 and P < 0.0001, respectively). Fungal infection contributed to cause of death in 7 of 15 (46.7%) patients, of which Cryptococcus neoformans accounted for six of these infections. Low-dose prednisolone (<1 or <0.5 mg/kg/day based on arbitrary division) prior to fungal infection tended to correlate with 1 yr mortality after diagnosis of SLE (P = 0.077 or P = 0.080). However, following fungal infection, patients who died from infection itself had been prescribed with higher prednisolone dose or equivalent than surviving patients (P = 0.016). All SLE patients with fungal infections had active SLE (SLEDAI >7).

CONCLUSIONS

Cryptococcus neoformans infection accounted for most fatalities in SLE patients with fungal infections in this series. Active lupus disease is probably a risk factor for fungal infection in SLE patients. Notably, low prednisolone doses prior to fungal infection or high prednisolone doses following fungal infection tended to associate with or correlated to fatality, respectively. Therefore, we suggest that different prednisolone doses prescribed at various times impact the incidence of fungal infection and its associated mortality.

Study of common functional genetic polymorphisms ofFCGR2A,3Aand3Bgenes and the risk for cryptococcosis in HIV-uninfected patients

A pilot candidate gene association study was conducted to investigate the role of three common functional genetic polymorphisms of the low-affinity Fc gamma receptors, FCGR2A (131H/R), FCGR3A (158F/V) and FCGR3B (NA1/NA2) in Cryptococcus neoformans infections in individuals not infected with HIV. The FCGR2A 131RR and FCGR3A 158VV genotypes were over-represented [OR: 1.67 (1.05-2.63) and 2.04 (1.06-4.00), respectively] whereas the FCGR3B NA2NA2 was under-represented in patients with cryptococcosis (28% vs. 40% in controls). An analysis of haplotypes showed a significant difference in distribution between cases and controls overall and in Caucasians.

[Inflammatory reconstitution immune syndrome associated to antiretroviral therapy and meningeal cryptococcosis]

The objective of high activity antiretroviral therapy (HAART) in patients with AIDS, is to obtain immune restoration. This means a reduction of the viral load and restitution of the CD4 cell count. A decreased rate of HIV replication improves both the number and function of CD4 cells. Nevertheless, this treatment sometimes results in the reappearance of previous symptoms from treated conditions due to opportunistic infections (ie: tuberculosis, criptococcosis, hepatitis, Pneumocystis jirovesi, toxoplasmosis, etc) or non infectious condition such as sarcoidosis, Graves disease or Kaposi sarcoma. This is known as Inflammatory Reconstitution Immune Syndrome (IRIS). We report a 37 year-old woman in stage C3-AIDS with a previous criptococcal meningitis. She was treated, achieving a marked improvement with treatment and subsequent suppressive therapy with fluconazole 200 mg/day. IRIS appeared after 8 months of ongoing antiretroviral therapy with immune restoration with the development of aseptic meningitis and intracranial hypertension. The opportunistic agent could not be identified by cultures. Additional laboratory tests excluded toxoplasmosis, tuberculosis, bacterial cerebral abscesses, syphilitic cerebral gummas, and lymphoma. Brain CT and magnetic resonance studies were compatible with brain vasculitis and leptomeningitis. The patient condition improved with general measures, such as a repeated lumbar punctures and non steroidal anti-inflammatory drugs. We conclude that this patient had an IRIS due to a Cryptococcus neoformans antigen.

Vertigo after renal transplantation: a sign of paucisymptomatic cryptococcal meningitis

We report what is to our knowledge the first case of severe isolated vertigo that developed after renal transplantation and was a manifestation of cryptococcal meningitis. Treatment with antifungal therapy resulted in the complete resolution of vertiginous symptoms. Immunosuppressed patients with an opportunistic infection of the central nervous system can present with extremely tenuous features of infection and atypical neurologic signs.

Immunologic homeostasis during infection: coexistence of strong pulmonary cell-mediated immunity to secondary Cryptococcus neoformans infection while the primary infection still persists at low levels in the lungs

Maintenance of immunity to persistent pathogens is poorly understood. In this study, we used a murine model of persistent pulmonary fungal infection to study the ongoing cell-mediated immune response. CBA/J mice with low-level persistent Cryptococcus neoformans infection had CD4+ T cells of effector memory phenotype present in their lungs. Although unable to eliminate the primary infection to sterility, these mice displayed hallmarks of immunologic memory in response to rechallenge with C. neoformans: 1) the secondary cryptococcal challenge was controlled much more rapidly, 2) the inflammatory response developed and resolved more rapidly, 3) CD4+ T and CD8+ T cell responses were higher in magnitude, and 4) effector cytokine production by T cells was greatly enhanced. Depletion of CD4+ T cells at the time of secondary challenge adversely affected clearance of C. neoformans from the lungs. These results demonstrate that persistent low-level infection with C. neoformans does not impair the cell-mediated response to the fungus. Although they are relatively free of overt disease, these mice can respond with a rapid secondary immune response if the burden of C. neoformans increases. These data support the concept that immunologically healthy individuals can maintain low numbers of cryptococci that can become a nidus for re-activation disease during immunodeficient states such as AIDS.

In the Absence of Reactive Oxygen Species, T Cells Default to a Th1 Phenotype and Mediate Protection against PulmonaryCryptococcus neoformansInfection

In recent years, the prevalence of invasive fungal infections has increased, attributed mostly to the rising population of immunocompromised individuals. Cryptococcus neoformans has been one of the most devastating, with an estimated 6-8% of AIDS-infected patients succumbing to Cryptococcus-associated meningitis. Reactive oxygen species (ROS) are potent antimicrobial agents but also play a significant role in regulating immune cell phenotype, but cause immunopathology when produced in excess. We now show that mice lacking phagocyte NADPH oxidase have heightened macrophage and Th1 responses and improved pathogen containment within pulmonary granulomatous lesions. Consequently, dissemination of this fungus to the brain is diminished, an effect that is independent of IL-12. Similar results are described using the metalloporphyrin antioxidant manganese(III) tetrakis(N-ethyl pyridinium-2-yl)porphyrin, which also promoted a protective Th1 response and reduced dissemination to the brain. These findings are in sharp contrast to the protective potential of ROS against other fungal pathogens, and highlight the pivotal role that ROS can fulfill in shaping the profile of the host's immune response.

Phagocytic efficacy of macrophage-like cells as a function of cell cycle and Fcgamma receptors (FcgammaR) and complement receptor (CR)3 expression

Previous studies have shown that the efficiency of phagocytosis is a function of cell cycle and that phagocytosis promotes cell cycle progression. Because phagocytosis is dependent on cellular receptors we hypothesized that Fcgamma receptors (FcgammaR) and complement receptors (CR) expression varied with cell cycle. Consequently, we used centrifugal elutriation of macrophage-like cells, fluorescence activated cell sorting analysis and receptor staining to investigate expression of FcgammaR and CR as a function of cell cycle. We confirmed that FcgammaR expression on macrophage-like cells increased as the cells progressed from G1 to G2 phases. Moreover, CR3 expression varied as a function of cell cycle in a manner similar to FcgammaR. Correlation of receptor expression with cell size showed that FcgammaR and CR3 expression on macrophages was determined largely by cell size enlargement during the cell cycle. The efficacy of both Fc- and complement-mediated phagocytosis of live Cryptococcus neoformans (Cn) showed a biphasic pattern with the efficacy of phagocytosis decreasing when the cells approached the G1-S interface, which paralleled the changes in receptor surface expression when cells exited G1 phase. Live Cn cells were significantly more resistant to phagocytosis than dead cells at all stages of macrophage-like cell cycle. In contrast to live cells, the efficacy of phagocytosis of dead Cn decreased as surface receptor expression increased. Hence, the efficacy of phagocytosis in this system as function of cell cycle is not related to phagocytic receptor expression.

Myeloradiculitis caused by Cryptococcus neoformans infection in a patient with ulcerative colitis: A neuropathological study

Meningitis is the most common feature of cryptococcal infection of the nervous system. We herein describe the case of a 48-year-old man with fulminant cryptococcal myeloradiculitis, whose initial symptoms were impotence, dysuria and weakness of the lower extremities. He had been administered prednisolone and azathioprine for 7years for ulcerative colitis before onset of myeloradiculitis. He finally developed meningoencephalitis and died 2 months after onset despite treatment with amphotericin B and flucytosine. Post-mortem examination revealed numerous infiltrations of cryptococci in the spinal roots as well as in the meninges and subarachnoid space. Inflammatory cells and cryptococci had infiltrated the vessel walls in the spinal cord, and this was accompanied by necrotizing myelopathy. Myeloradiculitis is rare in cryptococcal infection, and this is the first case report to demonstrate direct cryptococcal infection in the spinal roots. Cryptococcal infection should be considered while managing myeloradiculopathy of unknown etiology, especially in immunocompromised patients.

Efficacy of voriconazole in experimental Cryptococcus neoformans infection

Voriconazole is a third generation triazole with improved activity against many fungal pathogens. We examined the efficacy of voriconazole in a murine infection model and evaluated the drug's effect on cellular characteristics and serum polysaccharide levels. The antifungal reduced serum polysaccharide and significantly prolonged the survival of lethally infected animals.

Systemic and cerebrospinal fluid T-helper cytokine responses in organ transplant recipients with Cryptococcus neoformans infection

BACKGROUND

The role of Th1 and Th2 mediated cytokine responses in the pathogenesis of Cryptococcus neoformans infection in organ transplant recipients has not been defined.

METHODS

We assessed cytokine levels in the sera and CSF collected prospectively at the time of diagnosis of infection in 25 transplant recipients with cryptococcosis. Serum levels were compared with those in healthy individuals and transplant recipients without cryptococcosis. IFN-gamma or IL-12 (Th1)/IL-10 (Th2) ratio < 1.0 was considered a dominant Th2 response.

RESULTS

Cases had lower ratios of IFN-gamma/IL-10 (p = 0.03) and IL-12/IL-10 (p = 0.03) compared to healthy individuals. Cytokine responses, however, did not differ significantly for cases vs. transplant controls. Cases with fungemia compared to those without fungemia tended to have higher serum IL-10 levels (p = 0.07) and lower IL-12/IL-10 ratios (p = 0.06). CSF ratios of IFN-gamma/IL-10 (p = 0.04) and IL-12/IL-10 (p = 0.04) were lower in cases with cryptococcal meningitis compared to those without meningitis; 80% (8/10) of the cases with cryptococcal meningitis vs. 0% (4/4) of those without meningitis had CSF IFN-gamma/IL-10 ratio of < 1.0 (p = 0.015). The levels of IL-10 (p = 0.04) and IFN-gamma (p = 0.04) in the CSF in cases with cryptococcal meningitis were significantly higher than those in their serum, respectively.

CONCLUSIONS

High expression of Th2 phenotype in cryptococcal meningitis and in fungemia suggests that Th dysregulation may contribute to the pathogenesis of cryptococcosis in organ transplant recipients.

Cutaneous cryptococcus in an elderly woman with chronic essential dermatitis

Cryptococcus neoformans is a common cause of life-threatening infection. Cutaneous manifestations of Cryptococcus can be primary or secondary, most commonly from immunosuppression. With the global emergence of acquired immunodeficiency syndrome (AIDS), incidence of cryptococcosis is increasing and now represents a major life-threatening fungal infection in these patients. Nonspecific lesions may cause misdiagnosis. Disseminated Cryptocoocus requires early clinical diagnosis and effective management to decrease mortality. We review a case of cutaneous Cryptococcus as a complication of chronic essential dermatitis treated with long-term immunosuppressive agents and discuss updated guidelines on the treatment of Cryptococcus.

Distinct compartmentalization of CD4+ T-cell effector function versus proliferative capacity during pulmonary cryptococcosis

The activation and expansion of T cells and their acquisition of effector function are key steps in the development of the adaptive immune response. Most infections are predominantly outside of the lymphoid tissues, and it is unclear at what point developmentally and anatomically T cells acquire effector function in vivo. In these studies, we compared the activation and polarization of T cells during murine pulmonary Cryptococcus neoformans infection in the secondary lymphoid tissues and at the site of primary infection. Few CD4(+) and CD8(+) T cells expressed an activated phenotype (CD44(hi,) CD25(+), CD69(+), CD62L(lo), CD45RB(lo)) at the sites of clonal expansion (lymph nodes, spleen, and blood). In contrast, a high percentage of T cells expressed activation markers at the site of primary infection, the lungs. Additionally, the polarization of CD4(+) T cells to interferon-gamma-producing effector cells occurred at the site of infection, the lungs. CD4(+) and CD8(+) T cells from secondary lymphoid organs responded to TCR restimulation by proliferating, whereas T cells from the lungs proliferated poorly. This report demonstrates for the first time that T-cell activation and effector function in secondary lymphoid tissues during fungal infection is characteristically different from that at the site of primary infection.

Enhanced allergic inflammation and airway responsiveness in rats with chronic Cryptococcus neoformans infection: potential role for fungal pulmonary infection in the pathogenesis of asthma

Although Cryptococcus neoformans is recognized for its ability to cause meningoencephalitis and pneumonia among immunocompromised persons, subclinical pulmonary infection is also common among immunocompetent persons. The significance of this infection is unknown. Using a rat model, we explored the potential for pulmonary cryptococcosis to modify allergic responses and airway reactivity. Our findings indicate that localized pulmonary cryptococcal infection (but not disseminated infection) can exacerbate allergic responses to respiratory challenge with ovalbumin, as measured by total immunoglobulin E levels, ovalbumin-specific immunoglobulin E titers, and eosinophil content of bronchoalveolar lavage fluid. Infection-associated enhancement of allergic responses was not dependent on cryptococcal encapsulation and was partially ameliorated by the administration of fluconazole. Increases in both the number of goblet cells and airway responsiveness, which are also features of reactive airway disease, were also present with pulmonary infection. An examination of lung cytokine levels in the context of active pulmonary infection revealed increased expression of interleukin (IL)-10, tumor necrosis factor- alpha , and IL-13, but not IL-12 or interferon- gamma . In contrast, systemic infection was associated with higher levels of interferon- gamma but lower levels of IL-13. Our studies highlight the potential for localized pulmonary C. neoformans infection to potentiate allergic responses and airway reactivity and suggest a potential role for subclinical pulmonary cryptococcosis in the pathogenesis of asthma.

The pro-apoptotic human BH3-only peptide harakiri is expressed in cryptococcus-infected perivascular macrophages in HIV-1 encephalitis patients

In the central nervous system (CNS), HIV-1 targets mainly microglia/macrophages. Like the CD4+ T cell depletion and neuronal loss in AIDS, apoptosis is thought to be involved in eliminating infected macrophages. In this study, we examined the expression of the pro-apoptotic BH3-peptide harakiri (Hrk) in brain tissues of AIDS patients. Immunoreactivity against Hrk was positive in perivascular macrophages infiltrated into some restricted lesions. Most of these immunopositive cells contained small inclusions positive for Grocott's methenamine silver staining. Confocal laser microscopy demonstrated that Hrk expression coincided with immunoreactivities against HIV-1 and Cryptococcus neoformans. Expression of Hrk mRNA was demonstrated in these cells by in situ hybridization, which indicated that Hrk is not phagocytosed material. Some pro-apoptotic bcl-family members, including Hrk, may contribute to the delayed hypersensitive reaction in AIDS, in macrophages eliminating opportunistic infection.

Campath-1H Induction and the Incidence of Infectious Complications in Adult Renal Transplantation

BACKGROUND

The purpose of this study was to evaluate adult renal transplantation patients who received a alemtuzumab (Campath-1H)-based induction protocol for the incidence of infectious complications.

METHODS

We began using 30 mg Campath-1H intravenously for induction therapy in May 2003. The patients were treated with a maintenance regimen of tacrolimus or mycophenolate mofetil (MMF), and rapidly tapered prednisone; valganciclovir was used for CMV prophylaxis. Forty-nine adult patients who received renal transplants between May 1, 2003 and June 7, 2004 were included. The mean follow-up time was 13.7 months with a range of 10-24 months. Data were collected via a retrospective chart review.

RESULTS

The infectious complications noted in the Campath-1H group were compared with a historical group of 56 patients receiving conventional immunosuppression. There was one case of cytomegalovirus (CMV) viremia and two cases of CMV disease (one pneumonitis and one enteritis). There were four cases of urinary tract infection and one extremity cellulitis. One patient developed Cryptococcal meningitis. Eight of the 49 (16%) patients in the Campath group had an infectious complication, compared to 18 out of 56 (32%) in the historical group.

CONCLUSION

Campath-1H induction for renal transplantation appears to have a low incidence of associated infectious complications when compared to historical regimens.

[Current topics in molecular medical mycology: new-stream Cryptococcus neoformans and other pathogenic fungi studies]

Model yeast Saccharomyces cerevisiae and human genome projects have been completed and proteomics is a major focus in postgenomic and postsequence research in biology and medicine. In 2004, the genome project on pathogenic yeast Candida albicans was completed, as was the Cryptococcus neoformans genome in 2005. The Aspergillus fumigatus genome project is currently under way. To use molecular data, such as phylogenic analysis, pathogenic factor analysis, and proteomics-based drug discovery/development, proteome analysis of pathogenic fungi has been conducted globally. I summarize up-to-date information on new-stream Cryptococcus neoformans and other pathogenic fungi studies based on molecular medical mycology.

Unusual presentation of central nervous system cryptococcal infection in an immunocompetent patient

The imaging findings of cryptococcosis affecting the brain in immunocompetent patients can be different from the more commonly described findings in immunocompromised patients. We report a case of an extremely unusual MR appearance of central nervous system cryptococcosis in a 49-year-old immunocompetent man.

Allograft Loss in Renal Transplant Recipients with Cryptococcus Neoformans Associated Immune Reconstitution Syndrome

This study describes the association of allograft loss and immune reconstitution syndrome (IRS) in the course of Cryptococcosis neoformans infection in renal transplant recipients. Patients comprised 54 renal allograft recipients with cryptococcosis in a prospective, multicenter study. IRS developed in 5.5% (3/54) of the renal transplant recipient with C. neoformans infection. The renal allograft was lost to chronic rejection in 66% (2/3) of the patients with cryptococcosis who developed IRS compared to 5.9% (3/51) of those who did not (P=0.012). Kaplan-Meier survival analysis showed that subsequent to cryptococcal infection the probability of allograft survival was significantly lower in patients who developed IRS compared to those who did not develop IRS (P=0.0004). Temporal association of graft loss with IRS suggests a common pathophysiologic basis for these entities with implications relevant for the optimal management of renal transplant recipients with cryptococcosis.

Antifungal Management Practices and Evolution of Infection in Organ Transplant Recipients with Cryptococcus Neoformans Infection

BACKGROUND

Therapeutic practices for Cryptococcus neoformans infection in transplant recipients vary, particularly with regards to antifungal agent employed, and duration of therapy. The risk of relapse and time to recurrence is not known. We assessed antifungal treatment practices for cryptococcosis in a cohort of prospectively followed organ transplant recipients.

METHODS

The patients comprised 83 transplant recipients with cryptococcosis followed for a median of 2.1 and up to 5.2 years.

RESULTS

Patients with central nervous system infection (69% vs. 16%, P = 0.00001), disseminated infection (82.7% vs. 20%, P = 0.00001), and fungemia (29% vs. 8%, P = 0.046) were more likely to receive regimens containing amphotericin B than fluconazole as primary therapy. The use of fluconazole, on the other hand, was more likely for infection limited to the lungs (64% vs. 14%, P = 0.00002). Survival at 6 months tended to be lower in patients whose CSF cultures at 2 weeks were positive compared to those whose CSF cultures were negative (50% vs. 91%, P = 0.06). Maintenance therapy was employed in 68% (54/79) of the patients who survived >3 weeks. The median duration of maintenance therapy was 183 days; 55% received maintenance for > or = 6 months and 25% for >1 year. Relapse was documented in 1.3% (1/79) of the patients.

CONCLUSIONS

A majority of the organ transplant recipients with cryptococcosis receive maintenance antifungal therapy for 6 months with low risk of relapse. These data can assist in trials to assess the optimal therapeutic approach and duration of therapy for cryptococcosis in transplant recipients.

Evidence for human immunodeficiency virus and Cryptococcus neoformans interactions in the pro-inflammatory and anti-inflammatory responses in blood during AIDS-associated cryptococcosis

Tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, -8 and-10 and soluble TNF receptor II (sTNFR II) levels were measured at baseline, and after antifungal therapy for 2 weeks and 3 months, in plasma from 75 human immunodeficiency virus (HIV)-positive and 14 HIV-negative patients with cryptococcosis, and in plasma from 14 HIV-positive controls. At baseline, TNF-alpha, IL-6 and sTNFR II levels, and cryptococcal antigen titres, were increased in patients with fungaemia compared to controls (p < 0.02). The mediator levels were not influenced by the severity of the disease or subsequent death, but sTNFR II and IL-10 levels were reduced, together with virus load, in patients receiving anti-retroviral agents (p < 0.01). During antifungal therapy, sTNFR II levels decreased (p 0.003) in parallel with the virus load and with an increase in CD4 T-cell numbers.

The immune response to fungal infections

During the past two decades, invasive fungal infections have emerged as a major threat to immunocompromised hosts. Patients with neoplastic diseases are at significant risk for such infections as a result of their underlying illness and its therapy. Aspergillus, Candida, Cryptococcus and emerging pathogens, such as the zygomycetes, dark walled fungi, Trichosporon and Fusarium, are largely opportunists, causing infection when host defences are breached. The immune response varies with respect to the fungal species and morphotype encountered. The risk for particular infections differs, depending upon which aspect of immunity is impaired. This article reviews the current understanding of the role and relative importance of innate and adaptive immunity to common and emerging fungal pathogens. An understanding of the host response to these organisms is important in decisions regarding use of currently available antifungal therapies and in the design of new therapeutic modalities.

July 2004: 40-year-old man with headaches and dyspnea

A 40-year-old man had a 6-week history of severe frontal headaches and dry cough. Chest x-ray showed hilar adenopathy with bilateral parenchymal infiltrates. A diagnosis of atypical pneumonia was made. Four weeks later he was admitted with persistent headache. Infectious screen was negative. Brain MR post contrast, revealed cerebellar enhancement and swelling with moderate tonsillar herniation; findings which precluded the performance of a lumbar puncture. High resolution CT thorax confirmed hilar abnormalities; shown by microscopy to represent non caseating granulomata. A presumptive diagnosis of sarcoidosis was reached. Despite an initial symptomatic improvement his headache persisted. Repeat MRI, eleven days after admission, showed reduced cerebellar enhancement and swelling with no change in the degree of tonsillar herniation. He deteriorated acutely and died two weeks after admission. Autopsy revealed cerebral oedema with tonsillar herniation secondary to cryptococcal meningitis variety neoformans. There was no evidence of neurosarcoid. Active and inactive sarcoid was identified in the lungs and hilar nodes with no evidence of systemic sarcoid. Focal evidence of cryptococcal pneumonitis was present in the lung as a necrotic focus. A strong index of clinical suspicion is necessary to diagnose the rare association of cryptococcus complicating sarcoidosis.

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.

Initial treatment of cryptococcal meningitis in AIDS

The comparison of initial treatment with amphotericin B (0.7 mg/kg/d) plus rifampin (600 mg/d) with amphotericin B (0.7 mg/kg/d) alone for 2 weeks, both followed by fluconazole (400 mg/ d) for 8 weeks in the acute treatment of cryptococcal meningitis in AIDS by an open- randomized, controlled, prospective clinical trial is reported. Twenty patients were enrolled in each group. There were no significant differences between the groups in regard to a negative CSF culture for Cryptococcus neoformans in the 2nd and 10th weeks of treatment, time until normal body temperature after treatment, number of patients who died, and persistence of high CSF pressure after completion of treatment. Elevated intracranial pressure was an important factor associated with the patients who died. These results indicate that the combination of amphotericin B plus rifampin is not superior to amphotericin B alone.