Enhancement of HIV-1 infection by the capsular polysaccharide of Cryptococcus neoformans

Host defenses against cryptococcosis

The interaction of pathogenic Cryptococcus species with their various hosts is somewhat unique compared to other fungal pathogens such as Aspergillus fumigatus and Candida albicans. Cryptococcus shares an intimate association with host immune cells, leading to enhanced intracellular growth. Furthermore, unlike most other fungal pathogens, the signs and symptoms of cryptococcal disease are typically self-inflicted by the host during the host's attempt to clear this invader from sensitive organ systems such as the central nervous system. In this review, we will summarize the story of host-Cryptococcus interactions to date and explore strategies to exploit the current knowledge for treatment of cryptococcal infections.

Inhibition of HIV entry by extracellular glucuronoxylomannan of Cryptococcus neoformans

Cryptococcosis, caused by Cryptococcus neoformans, is the most common opportunistic fungal disease in HIV/AIDS patients. The prognosis of AIDS patients with Cryptococcus infection is very poor. One of the major characteristics in cryptococcosis patients is the presence of high concentrations of the cryptococcal capsule polysaccharide (CCP) in the serum and cerebrospinal fluid. CCP enhances HIV replication in H9 T-cells, but the mechanism is unknown. In this study, we tested whether extracellular glucuronoxylomannan (GXM), a major component of CCP, enhances HIV entry using replication-incompetent HIV and a cell line which expresses a stable amount of CD4 and both of the HIV co-receptors. Extracellular GXM had no effect on cell-cell fusion however; viral entry surprisingly was inhibited by GXM. Hence, any enhancement of replication must be due to an effect that occurs post-entry.

New insights on the pathogenesis of invasive Cryptococcus neoformans infection

Disseminated cryptococcosis begins with infection of the lungs via inhalation. This is followed by escape from the lungs and entry into the bloodstream allowing dissemination to the brain and central nervous system. We discuss the steps involved in dissemination and the host and microbial factors that influence each step. For the host, containment in the lung is accomplished with a combination of cell-mediated and antibody responses. Dissemination occurs when these systems fail and/or when phagocytic cells that fail to kill the yeast instead act as a niche for replication. One of the main microbial factors affecting dissemination is the polysaccharide capsule, a major virulence factor that promotes dissemination at every step. Secreted enzymes are important, including laccase and phospholipase B, which promote escape from the lungs, and urease, which contributes to crossing the blood-brain barrier. Lastly, a number of regulatory factors contribute, especially to growth of Cryptococcus neoformans in the brain.

Variables that influence HIV-1 cerebrospinal fluid viral load in cryptococcal meningitis: a linear regression analysis

Background

The central nervous system is considered a sanctuary site for HIV-1 replication. Variables associated with HIV cerebrospinal fluid (CSF) viral load in the context of opportunistic CNS infections are poorly understood. Our objective was to evaluate the relation between: (1) CSF HIV-1 viral load and CSF cytological and biochemical characteristics (leukocyte count, protein concentration, cryptococcal antigen titer); (2) CSF HIV-1 viral load and HIV-1 plasma viral load; and (3) CSF leukocyte count and the peripheral blood CD4+ T lymphocyte count.

Methods

Our approach was to use a prospective collection and analysis of pre-treatment, paired CSF and plasma samples from antiretroviral-naive HIV-positive patients with cryptococcal meningitis and assisted at the Francisco J Muñiz Hospital, Buenos Aires, Argentina (period: 2004 to 2006). We measured HIV CSF and plasma levels by polymerase chain reaction using the Cobas Amplicor HIV-1 Monitor Test version 1.5 (Roche). Data were processed with Statistix 7.0 software (linear regression analysis).

Results

Samples from 34 patients were analyzed. CSF leukocyte count showed statistically significant correlation with CSF HIV-1 viral load (r = 0.4, 95% CI = 0.13-0.63, p = 0.01). No correlation was found with the plasma viral load, CSF protein concentration and cryptococcal antigen titer. A positive correlation was found between peripheral blood CD4+ T lymphocyte count and the CSF leukocyte count (r = 0.44, 95% CI = 0.125-0.674, p = 0.0123).

Conclusion

Our study suggests that CSF leukocyte count influences CSF HIV-1 viral load in patients with meningitis caused by Cryptococcus neoformans.

Intravenous gammaglobulin treatment in HIV-1 infection

The two main indications for the use of intravenous gammaglobulin--antibody replacement therapy and immunomodulation--are pertinent only for a few scenarios in HIV-1 infection. The role of gammaglobulin in the treatment of HIV-1 infection has changed significantly with the introduction of highly active antiretroviral therapy. Antiretroviral drugs have not only controlled the progression of disease but also had far-reaching effects on HIV-1-induced immunologic aberrations. Complete or partial immunologic reconstitution and prevention of immunologic damage have been the hallmarks of success for highly active antiretroviral therapy. This article addresses the use of gammaglobulin before and after the era of effective antiretroviral therapies.

Human immunoglobulin G2 (IgG2) and IgG4, but not IgG1 or IgG3, protect mice against Cryptococcus neoformans infection

The encapsulated yeast Cryptococcus neoformans is a significant cause of meningitis and death in patients with AIDS. Some murine monoclonal antibodies (MAbs) against the glucuronoxylomannan (GXM) component of the C. neoformans capsular polysaccharide can prolong the lives of infected mice, while others have no effect or can even shorten survival. To date, no one has systematically compared the efficacies of antibodies with the same variable regions and different human constant regions with their unique combination of effector functions in providing protection against murine C. neoformans infection. In the present study, we examined the efficacies of anti-GXM MAbs of the four human immunoglobulin G (IgG) subclasses, which have identical variable regions but differ in their capacities to bind the three types of Fc receptors for IgG (FcgammaR), their abilities to activate complement, and their half-lives. IgG2 and IgG4 anti-GXM prolonged the lives of infected BALB/c mice, IgG3 anti-GXM did not affect animal survival, while mice treated with IgG1 anti-GXM died earlier than mice treated with phosphate-buffered saline or irrelevant isotype-matched MAbs. All MAbs decreased serum GXM in infected animals. Effector pathways traditionally believed to be important in defense against microbes, such as opsonophagocytosis and complement binding, negatively correlated with antibody efficacy. It is generally accepted that human IgG1 has the most favorable combination of effector functions for therapeutic use against infections. Therefore, our findings have significant implications for humanization of the mouse IgG1 currently in clinical trials for cryptococcal meningitis and for the design of antibody therapeutics to treat other infectious diseases as well.

Heat killed cells of Cryptococcus neoformans var. grubii induces protective immunity in rats: immunological and histopathological parameters

Different clinical parameters which included cell-mediated immune (CMI) response, were evaluated in a model of disseminated cryptococcosis in rats. The experimental animals were pretreated four days prior to their exposure to Cryptococcus neoformans var. grubii with either heat killed cells of this yeastlike pathogen (HKC) or capsular polysaccharide (CPS) emulsified in complete Freund adjuvant (CFA). Rats treated with HKC-CFA and intraperitoneally infected with C. neoformans var. grubii had significantly better clearance of yeasts from tissues, a lower concentration of the cryptococcal capsular polysaccharide, glucuronoxylomannan (GXM), in serum and tissues, and better histopathological parameters compared to unpretreated infected rats. In contrast, rats treated with CPS-CFA presented an exacerbation of infection with a significantly higher fungal burden in tissues, a higher concentration of GXM in serum, and worse histopathological parameters compared to similar unpretreated infected rats. In addition, HKC-CFA treatment produced a T helper 1 (Th1) profile with improvements in the spleen cell proliferative response, in the level of INFgamma production by CD4 T cells, and in the nitric oxide (NO) production by peritoneal cells. On the other hand, rats treated with CPS-CFA showed an increased level of the immunoregulatory cytokine IL10 production by CD4 T cells, but no modification in the NO production by peritoneal cells.

HIV-1 RNA levels in cerebrospinal fluid and plasma and their correlation with opportunistic neurological diseases in a Brazilian AIDS reference hospital

BACKGROUND: Plasma HIV RNA levels reflect systemic viral replication but in CNS it may occur relatively independent of systemic infection, yet clinical application of CSF HIV-1 RNA levels is less clear. OBJECTIVE: to compare CSF and plasma HIV-1 RNA levels of patients with different opportunistic neurological diseases to those without neurological disease, as well as to correlate these levels with the outcome of the disease and use of HAART. METHOD: 97 patients who had lumbar puncture for routine work up of suspected neurological diseases, were divided in 2 groups: without neurological disease (23) and with neurological disease (74). NASBA was used for plasma and CSF HIV RNA. RESULTS: Median CSF viral load was higher in toxoplasmic encephalitis, cryptococcal meningitis, HIV dementia and neurological diseases without a defined etiology when compared to patients without neurological disease. There was no difference between plasma viral load in patients with and without neurological diseases. Median viral load was higher in plasma and CSF among patients who died when compared to those successfully treated. CSF and plasma viral load were lower in patients with opportunistic diseases on HAART than without HAART. CONCLUSION: CSF viral load was higher in patients with any neurological disease, but this difference was not present in plasma viral load, suggesting that neurological disease influences more the CSF than plasma compartments. Notwithstanding different neurological diseases were not possible to be diferentiated by the levels of CSF HIV-1.

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.

Phase I evaluation of the safety and pharmacokinetics of murine-derived anticryptococcal antibody 18B7 in subjects with treated cryptococcal meningitis

A promising approach to improving outcomes in patients with cryptococcal meningitis is to use adjunctive passive immunotherapy with a monoclonal antibody (MAb) directed against the capsular polysaccharide of Cryptococcus neoformans. This is the first application of MAb therapy for the treatment of a fungal disease in humans. We determined the safety and maximum tolerated dose of the murine anticryptococcal MAb 18B7 in a phase I dose-escalation study. The subjects were human immunodeficiency virus-infected patients who had been successfully treated for cryptococcal meningitis. Six dosing cohorts received MAb 18B7 at 0.01 to 2 mg/kg of body weight as a single infusion. Three patients each received 0.01, 0.05, 0.2, and 0.5 mg of MAb 18B7 per kg without significant adverse events. Four of the subjects who received the 1-mg/kg dose had mild study drug-associated toxicity, including transient nausea, vomiting, back pain, and urticarial rash. Two of the subjects who received 2 mg/kg developed drug-associated mild to moderate nausea, vomiting, chills, and myalgias. One of the subjects who received 2 mg/kg developed intracranial hypertension 10 weeks after MAb 18B7 administration. Serum cryptococcal antigen titers in the cohorts receiving doses of 1 and 2 mg/kg declined by a median of twofold at 1 week and a median of threefold at 2 weeks postinfusion, but the titers subsequently returned toward the baseline values by week 12. The half-life of MAb 18B7 in serum was approximately 53 h, while the MAb was undetectable in the cerebrospinal fluid of all patients. These data support the continued investigation of MAb 18B7 at a maximum single dose of 1.0 mg/kg.

Pseudocystic cryptococcal meningitis complicated by transient periaqueductal obstruction in a child with HIV infection

We describe a 10-year-old human immune deficiency virus (HIV) infected girl who presented with pseudocystic cryptococcal meningitis complicated by hydrocephalus secondary to aqueductal obstruction. The neuroradiological features of this case are presented and we also postulate on the pathogenesis of the type of hydrocephalus encountered.

Changing incidence of central nervous system diseases in the EuroSIDA cohort

A drastic decrease in incidence has been observed for most human immunodeficiency virus (HIV)-related opportunistic manifestations after use of highly active antiretroviral therapy (HAART). We assessed the trend of incidence of central nervous system (CNS) diseases in a prospective multicenter observational study involving 9,803 patients across Europe in the period 1994 to 2002 and analyzed patient and treatment variables associated with these conditions. Overall, 568 patients (5.8%) received a diagnosis of a new CNS disease. Incidence decreased significantly from 5.9 per 100 person-year in 1994 to 0.5 in 2002. Overall, the decrease was 40% per calendar year, and it was similar to that of non-CNS diseases and less evident after year 1998. In multivariable models, low CD4 cell count and high plasma viral load, but not HAART or calendar year, were significantly associated with risk to develop CNS disease, indicating that the effect of HAART was likely mediated by both improved immunological conditions and inhibition of viral replication. In contrast, use of nucleoside reverse transcriptase inhibitors, irrespective of use of protease inhibitors or non-nucleoside reverse transcriptase inhibitors, appeared to protect specifically against acquired immunodeficiency disease syndrome dementia complex, suggesting that, in this condition, therapy might have a direct, additive effect in the CNS.

Facile syntheses of the hexasaccharide repeating unit of the exopolysaccharide from Cryptococcus neoformans serovar A

Two hexasaccharides, beta-D-Xylp-(1-->2)-alpha-D-Manp-(1-->3)-[beta-D-Xylp-(1-->2)-]alpha-D-Manp-(1-->3)-[beta-D-GlcpA-(1-->2)-]alpha-D-Manp and beta-D-GlcpA-(1-->2)-alpha-D-Manp-(1-->3)-[beta-D-Xylp-(1-->2)-]alpha-D-Manp-(1-->3)-[beta-D-Xylp-(1-->2)-]alpha-D-Manp, the repeating unit of the exopolysaccharide from Cryptococcus neoformans serovar A, were synthesized as their methyl glycosides in a regio- and stereoselective manner.

Synthesis of a hexasaccharide, the repeating unit of O-deacetylated GXM of C. neoformans serotype A

beta-D-GlcpA-(1-->2)-alpha-D-Manp-(1-->3)-[beta-D-Xylp-(1-->2)]-alpha-D-Manp-(1-->3)[-beta-D-Xylp-(1-->2)]-alpha-D-Manp, the repeating unit of the exopolysaccharide from Cryptococcus neoformans serovar A, was synthesized as its allyl glycoside. Thus, 3-O-selective acetylation of allyl 4,6-O-benzylidene-alpha-D-mannopyranoside afforded 2, and subsequent glycosylation of 2 with 2,3,4-tri-O-benzoyl-D-xylopyranosyl trichloroacetimidate furnished the beta-(1-->2)-linked disaccharide 4. Debenzylidenation followed by benzoylation gave allyl 2,3,4-tri-O-benzoyl-beta-D-xylopyranosyl-(1-->2)-3-O-acetyl-4,6-di-O-benzoyl-alpha-D-mannopyranoside (5), and selective 3-O-deacetylation gave the disaccharide acceptor 6. Coupling of 6 with 2-O-acetyl-3,4,6-tri-O-benzoyl-alpha-D-mannopyranosyl trichloroacetimidate yielded the trisaccharide 8, and subsequent deallylation and trichloroacetimidation gave 2,3,4-tri-O-benzoyl-beta-D-xylopyranosyl-(1-->2)-[2-O-acetyl-3,4,6-tri-O-benzoyl-alpha-D-mannopyranosyl-(1-->3)]-4,6-di-O-benzoyl-alpha-D-mannopyranosyl trichloroacetimidate (9). Condensation of the trisaccharide donor 9 with the disaccharide acceptor 6 gave the pentasaccharide 10 whose 2-O-deacetylation gave the acceptor 11. Glycosylation of 11 with methyl 2,3,4-tri-O-acetyl-alpha-D-glucopyranosyluronate trichloroacetimidate and subsequent deprotection gave the target hexasaccharide.

Antigenic and biological characteristics of mutant strains of Cryptococcus neoformans lacking capsular O acetylation or xylosyl side chains

Cryptococcus neoformans is surrounded by an antiphagocytic polysaccharide capsule whose primary constituent is glucuronoxylomannan (GXM). Three prominent structural features of GXM are single xylosyl and glucuronosyl side chains and O acetylation of the mannose backbone. Isogenic pairs of O-acetyl-positive and O-acetyl-negative strains (cas1 Delta) as well as xylose-positive and xylose-negative strains (uxs1 Delta) of serotype D have been reported. The cas1 Delta strains were hypervirulent, and the uxs1 Delta strains were avirulent. The goal of this study was to examine the effects of the cas1 Delta and uxs1 Delta mutations on the following: (i) binding of anti-GXM monoclonal antibodies (MAbs) in capsular quellung reactions, (ii) activation of the complement system and binding of C3, (iii) phagocytosis by neutrophils, and (iv) clearance of GXM in vivo. The results showed that loss of O acetylation produced dramatic changes in the reactivities of five of seven anti-GXM MAbs. In contrast, loss of xylosylation produced a substantive alteration in the binding behavior of only one MAb. O-acetyl-negative strains showed no alteration in activation and binding of C3 from normal serum. Xylose-negative strains exhibited accelerated kinetics for C3 deposition. Loss of O acetylation or xylosylation had no effect on phagocytosis of serum-opsonized yeast cells by human neutrophils. Finally, loss of O acetylation or xylosylation altered the kinetics for clearance of GXM from serum and accumulation of GXM in the liver and spleen. These results show that O acetylation and/or xylosylation are important for binding of anti-GXM MAbs, for complement activation, and for tissue accumulation of GXM but do not impact phagocytosis by neutrophils.

Antifungal therapy--state of the art at the beginning of the 21st century

The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.

The relationship of preventable opportunistic infections, HIV-1 RNA, and CD4 Cell counts to chronic mortality

BACKGROUND

Both HIV-1 RNA and absolute CD4 cell counts have been identified as important predictors of HIV-1 disease progression and mortality. The independent impact of opportunistic infections on the risk of chronic mortality, defined as death beyond 30 days of an opportunistic infection, has not been studied when controlling for HIV-1 RNA. Our objective was to determine the relationship between a history of any of five preventable opportunistic infections (Pneumocystis carinii pneumonia, Mycobacterium avium complex, toxoplasmosis, cytomegalovirus, and candida esophagitis) and chronic mortality.

METHODS

Using the Multicenter AIDS Cohort Study (MACS) public use data set of 2193 HIV-infected men in four U.S. cities, we employed a Cox regression model to estimate the impact of a history of preventable opportunistic infection on chronic mortality while controlling for maximum HIV-1 RNA, CD4 cell count, use of antiretroviral drugs, and age.

FINDINGS

The chronic mortality rate among individuals with a history of preventable opportunistic infection was 66.7 per 100 person-years compared with 2.3 per 100 person-years for those without a history of preventable opportunistic infection (RR = 28.4, 95% CI: 24.7-32.8). In the adjusted analysis, the relative hazard of death for those with a history of preventable opportunistic infections was 7.0 (5.8-8.3), whereas antiretroviral therapy was associated with a decreased risk of death (0.37 [0.30-0.44]). We found no association between maximum HIV-1 RNA and chronic mortality. There was statistically significant effect modification between preventable opportunistic infections and CD4 cell count (p <.0001).

INTERPRETATION

Preventable opportunistic infections cause not only short-term mortality in HIV-1 disease but appear to have a major impact on chronic mortality.

Immunoglobulin G monoclonal antibodies to Cryptococcus neoformans protect mice deficient in complement component C3

Passive administration of monoclonal antibodies (MAbs) to the capsular polysaccharide of Cryptococcus neoformans can alter the course of infection in mice. In a murine model of cryptococcal infection, immunoglobulin G1 (IgG1), IgG2a, and IgG2b switch variants of the anti-capsular 3E5 MAb prolong the survival of lethally infected mice, whereas the 3E5 IgG3 MAb does not protect and in some cases enhances infection, shortening the life spans of infected mice. We examined the role of complement component C3 in Ab-mediated protection by determining the efficacy of the four mouse IgG subclasses against C. neoformans in mice genetically deficient in factor C3 as well as mice acutely depleted of C3. Similar to other complement-deficient animal models, C3(-/-) mice and mice depleted of C3 by cobra venom factor were more susceptible to C. neoformans infection than control mice, providing further evidence that complement is important in the host defense against the fungus. In the absence of C3, all IgG isotypes prolonged the lives of mice infected with C. neoformans, indicating that protection by IgG does not require the complement pathways. Furthermore, we observed protection with IgG3 in the complement-deficient mice, suggesting that complement is involved in the lack of protection observed with IgG3 in other mouse models.

Toll-like receptor 4 mediates intracellular signaling without TNF-alpha release in response to Cryptococcus neoformans polysaccharide capsule

Toll-like receptors (TLR) 2 and 4 are cell surface receptors that in association with CD14 enable phagocytic inflammatory responses to a variety of microbial products. Activation via these receptors triggers signaling cascades, resulting in nuclear translocation of NF-kappa B and a proinflammatory response including TNF-alpha production. We investigated whether TLRs participate in the host response to Cryptococcus neoformans glucuronoxylomannan (GXM), the major capsular polysaccharide of this fungus. Chinese hamster ovary fibroblasts transfected with human TLR2, TLR4, and/or CD14 bound fluorescently labeled GXM. The transfected Chinese hamster ovary cells were challenged with GXM, and activation of an NF-kappa B-dependent reporter construct was evaluated. Activation was observed in cells transfected with both CD14 and TLR4. GXM also stimulated nuclear NF-kappa B translocation in PBMC and RAW 264.7 cells. However, stimulation of these cells with GXM resulted in neither TNF-alpha secretion nor activation of the extracellular signal-regulated kinase 1/2, p38, and stress-activated protein kinase/c-Jun N-terminal kinase mitogen-activated protein kinase pathways. These findings suggest that TLRs, in conjunction with CD14, function as pattern recognition receptors for GXM. Furthermore, whereas GXM stimulates cells to translocate NF-kappa B to the nucleus, it does not induce activation of mitogen-activated protein kinase pathways or release of TNF-alpha. Taken together, these observations suggest a novel scenario whereby GXM stimulates cells via CD14 and TLR4, resulting in an incomplete activation of pathways necessary for TNF-alpha production.

Treatment of experimental Cryptococcus neoformans infection in newborn rabbits by airway instillation of specific antibody and surfactant

Cryptococcosis in AIDS patients has a slow response to antifungal chemotherapy, and passive antibody treatment has thus been considered as an adjunct. Polyclonal anticryptococcal IgG dissolved in a suspension of modified natural surfactant was given intratracheally to near-term rabbits. Killing of Cryptococcus neoformans within the lungs was determined by counting the colony forming units (cfu). After 5 h a significant decrease in cfu was observed in rabbits treated with the IgG-surfactant mixture compared with control animals receiving saline. In conjunction with conventional therapy, the combined treatment of IgG-surfactant given by bronchoscopy might be used in high-risk patients to enhance killing of the yeast within the lungs.

Cryptococcal Meningitis in HIV-Infected Patients

Cryptococcosis is a fungal infection that is potentially deadly for and common among AIDS patients, in the United States and worldwide. Subacute meningitis and meningoencephalitis are typical, clinically. This article will review relevant aspects of cryptococcal meningitis in AIDS, focusing on the most recent information pertaining to pathogenesis, epidemiology, clinical syndromes, and treatment of this devastating disease.

HIV type 1 envelope glycoprotein gp120 induces development of a T helper type 2 response to Cryptococcus neoformans

OBJECTIVE

To analyse the contribution of HIV type 1 envelope glycoprotein gp120 to regulation of a T-cell response to Cryptococcus neoformans.

DESIGN

Monocytes treated with recombinant gp120 and exposed to C. neoformans were used as antigen presenting cells (APC) in coculture with autologous T lymphocytes.

METHODS

Costimulatory and major histocompatibility complex class II molecules were evaluated on APC by flow cytometry analysis. T-cell proliferation was determined as 3H thymidine incorporation. Cytokine production was analysed by enzyme-linked immunosorbent assay.

RESULTS

gp120 had multiple effects on APC and the T-cell response including: (i) up-regulation of major histocompatibility complex class II antigens on the APC surface resulting from both redistribution of molecules from the intracellular pool and synthesis of new molecules; (ii) up-regulation of B7-2 molecules on the APC surface; (iii) altered T-cell proliferation; and (iv) promotion of interleukin-4 and inhibition of interferon-gamma synthesis and release.

CONCLUSIONS

These data indicate that gp120 alters the normal T-cell response to C. neoformans, promoting a T-helper type 2 response. The altered T-cell response produced by gp120 may play an important role in the pathogenesis of cryptococcosis in the patient with AIDS.

Microscopy and latex antigen negative cryptococcal meningitis

A HIV-positive patient presented with cryptococcal meningitis that was not detected by cerebrospinal fluid (CSF) latex antigen and direct microscopy. The diagnosis was confirmed by culture of the CSF and subsequent urine culture, both of which yielded an apparently acapsular strain of Cryptococcus neoformans. After 19 months the patient relapsed and capsulated yeasts were observed on this occasion on direct microscopy of the CSF. The latex antigen test was strongly positive. Culture again yielded an apparently acapsular isolate. Retrospective culture of all isolates obtained from this patient in sterile CSF resulted in the formation of capsules. This was confirmed by the requirement of normal non heat inactivated serum for neutrophil-cryptococcus attachment to occur in vitro. Although antigen and direct microscopy are frequently relied upon to diagnose cryptococcal meningitis, a negative result does not exclude the condition.

Specific antibody to Cryptococcus neoformans alters human leukocyte cytokine synthesis and promotes T-cell proliferation

Addition of a monoclonal antibody which binds the Cryptococcus neoformans capsule to suspensions of human monocytes, T lymphocytes, and cryptococcal cells (i) enhances interleukin-1beta (IL-1beta), tumor necrosis factor alpha, and IL-2 production; (ii) reduces IL-10 secretion; and (iii) promotes T-cell proliferation. The ability of specific antibody to influence cytokine production and lymphoproliferation suggests a mechanism by which humoral immunity can influence cell-mediated immunity.

Cryptococcus neoformans chemotyping by quantitative analysis of 1H nuclear magnetic resonance spectra of glucuronoxylomannans with a computer-simulated artificial neural network

The complete assignment of the proton chemical shifts obtained by nuclear magnetic resonance (NMR) spectroscopy of de-O-acetylated glucuronoxylomannans (GXMs) from Cryptococcus neoformans permitted the high-resolution determination of the total structure of any GXM. Six structural motifs based on an alpha-(1-->3)-mannotriose substituted with variable quantities of 2-O-beta- and 4-O-beta-xylopyranosyl and 2-O-beta-glucopyranosyluronic acid were identified. The chemical shifts of only the anomeric protons of the mannosyl residues served as structure reporter groups (SRG) for the identification and quantitation of the six triads present in any GXM. The assigned protons for the mannosyl residues resonated at clearly distinguishable positions in the spectrum and supplied all the information essential for the assignment of the complete GXM structure. This technique for assigning structure is referred to as the SRG concept. The SRG concept was used to analyze the distribution of the six mannosyl triads of GXMs obtained from 106 isolates of C. neoformans. The six mannosyl triads occurred singularly or in combination with one or more of the other triads. The identification and quantitation of the SRG were simplified by using a computer-simulated artificial neural network (ANN) to automatically analyze the SRG region of the one-dimensional proton NMR spectra. The occurrence and relative distribution of the six mannosyl triads were used to chemotype C. neoformans on the basis of subtle variations in GXM structure determined by analysis of the SRG region of the proton NMR spectrum by the ANN. The data for the distribution of the six SRGs from GXMs of 106 isolates of C. neoformans yielded eight chemotypes, Chem1 through Chem8.

Cryptococcus neoformans infection in mice previously infected with LP-BM5 MuLV, the agent of murine AIDS (MAIDS)

We studied susceptibility to experimental systemic cryptococcosis in mice previously infected with the retroviral complex LP-BM5 (responsible for murine AIDS). LP-BM5 was inoculated to C57B1/6 mice by intravenous (i.v.) injection 8 weeks before an i.v. challenge with 4 x 10(3) CFU of Cryptococcus neoformans. Uninfected and singly infected mice were used as controls. LP-BM5 infection did not result in a significant increase in fungal burdens in the lungs or brains of co-infected animals compared to mice infected with C. neoformans alone. However, mortality was enhanced in the co-infected animals. The kinetics of splenocyte subsets differed in co-infected mice and LP-BM5-infected mice; the increase in CD4+, CD8+ and Ly5+ cells was only moderate in the former. Cytokine production by concanavalin A (Con A)-stimulated splenocytes from co-infected mice showed a marked decrease in the Th1 response (IFN-gamma, IL-2) and an increase in the Th2 response (IL-4, IL-10). Furthermore, cryptococcosis altered the course of MAIDS, inhibiting splenomegaly. This effect was not related to a decrease in ecotropic virus titres in the spleen or to improved in vitro responsiveness of spleen cells to Con A. The marked decrease in IFN-gamma production in co-infected animals could partly explain the inhibition of LP-BM5-induced splenomegaly. This model of murine retroviral infection does not seem to be suitable for studying cryptococcosis in immunosuppressed animals, but remains valuable for investigating in vivo interactions between two pathogens.

Secretion of the C3 component of complement by peritoneal cells cultured with encapsulated Cryptococcus neoformans

Two isolates of Cryptococcus neoformans were identified as being widely divergent in pathogenic potential after intratracheal infection of mice. These isolates differed in their ability to upregulate capsule synthesis when grown under tissue culture conditions, and this property correlated with virulence. We postulated that differential capsule synthesis may cause differential stimulation of macrophages to produce products such as complement components. To test this hypothesis, heat-killed yeast cells were incubated with normal mouse peritoneal cells (PC) before the level of C3 secreted was determined. Cryptococcal stimulants were grown on mycological agar, which does not promote capsule synthesis, or in RPMI 1640 at 37 degrees C in an atmosphere of 5% CO2, which stimulates capsule synthesis, to determine the role that the capsule plays in the induction of C3 secretion. C3 levels were elevated in cultures containing cryptococci grown in RPMI 1640 at 37 degrees C in an atmosphere of 5% CO2, and the level of C3 detected was correlated with the amount of capsule expressed by the yeast cell stimulant. Nonencapsulated mutants of C. neoformans did not stimulate C3 secretion. Purified capsular polysaccharide (glucuronoxylomannan [GXM]) also stimulated the PC to secrete C3. Two signals were required before GXM stimulated C3 secretion. The second signal was identified as endotoxin present in small amounts (0.06 ng per ml) in tissue medium. Endotoxin may provide a priming stimulus for PC to express receptors or other cytokines needed for effective stimulation of C3. These experiments show that enhancement of C3 secretion by C. neoformans is due to GXM and is correlated with the virulence of the cryptococcal isolate.

Structure of the 13C-enriched O-deacetylated glucuronoxylomannan of Cryptococcus neoformans serotype A determined by NMR spectroscopy

The complete assignment of 1H and 13C chemical shifts for 99% uniformly 13C-labeled O-deacetylated glucuronoxylomannan (GXM) of Cryptococcus neoformans serotype A isolate 9759-Mu-1 was accomplished by the analysis of HCCH-TOCSY and HCCH-COSY spectra. The sequence of the glycosyl residues was determined by a GHMBC experiment using 20% uniformly 13C-labeled GXM; GXM was prepared by a novel procedure that insured the virtual exclusion of adjacent 13C-labeled carbon atoms. For each residue in the GXM of 9759-Mu-1 we determined its linkage position, its anomeric configuration, and its position in the repeating sequence as follows: [sequence: see text]

Acute lethal toxicity following passive immunization for treatment of murine cryptococcosis

Passive immunization with monoclonal antibodies (MAbs) specific for the major capsular polysaccharide of Cryptococcus neoformans alters the course of murine cryptococcosis. During studies of passive immunization for treatment of murine cryptococcosis, we noted the occurrence of an acute, lethal toxicity. Toxicity was characterized by scratching, lethargy, respiratory distress, collapse, and death within 20 to 60 min after injection of antibody. The toxic effect was observed only in mice with a cryptococcal infection and was reduced or absent in the early and late stages of disease. The clinical course and histopathology were consistent with those for shock. There was considerable variation between mouse strains in susceptibility to toxicity. Swiss Webster mice from the Charles River colony were most susceptible, followed by C3H/He, BALB/c, and C57BL/6 mice. DBA/2 mice and Swiss Webster mice from the Simonsen colony were resistant. Acute toxicity was mimicked by injection of preformed complexes of MAb and purified polysaccharide. The toxic effect was also produced by injection of MAbs into mice that were preloaded with polysaccharide. The toxic effect was not blocked by treatment of mice with chloropheniramine or anti-tumor necrosis factor alpha antibodies or by depletion of complement components via pretreatment with cobra venom factor. Toxicity was reduced by treatment of mice with high doses of epinephrine, dexamethasone, or chlorpromazine. Finally, the toxic effect was completely blocked by treatment of mice with the platelet-activating factor antagonist WEB 2170 BS or by pretreatment of mice with the liposome-encapsulated drug dichloromethylene diphosphonate, a procedure which depletes macrophages from the spleen and liver.

Epitope location in the Cryptococcus neoformans capsule is a determinant of antibody efficacy

Monoclonal antibodies (mAbs) to the polysaccharide capsule of Cryptococcus neoformans can prolong survival in mice. However, the properties of antibodies that mediate protection are not fully understood. The IgM mAbs 12A1 and 13F1 originated from the same B cell and differ only by somatic mutations in their variable regions; yet mAb 12A1 protects against serotype D infection, while mAb 13F1 does not. Phage peptide display libraries were used to analyze the fine specificity of these two mAbs. The selection of distinct peptide motifs from identical libraries confirmed that mAbs 12A1 and 13F1 bound to two distinct epitopes. Immunofluorescence and immunoelectron microscopy studies revealed differences in antibody localization within the capsule of serotype D strain; mAb 12A1 bound to the outer rim of the capsule resulting in an annular pattern, whereas mAb 13F1 bound throughout the capsule and had a punctate appearance. The difference in the binding pattern of mAb 12A1 and 13F1 was not observed on serotype A organisms, where both mAbs bound to the capsule with an annular fluorescence pattern. The fluorescence pattern of binding correlated with protective efficacy; mAb 13F1 prolonged survival of mice infected with the J11 serotype A strain (annular fluorescence), but not serotype D strains (punctate pattern). Annular binding, but not punctate binding, was associated with increased opsonic efficacy for phagocytosis of C. neoformans by J774.16 macrophage-like cells. The correlation between capsular binding pattern, opsonic activity, and ability to prolong survival suggests that the efficacy of anticryptococcal antibodies is dependent upon where they bind in the polysaccharide capsule.

Reactivity patterns and epitope specificities of anti-Cryptococcus neoformans monoclonal antibodies by enzyme-linked immunosorbent assay and dot enzyme assay

Cryptococcus neoformans glucuronoxylomannans (GXM) are capsular polysaccharides important for virulence in cryptococcosis. This study used dot enzyme assays (DEA) and enzyme-linked immunosorbent assays (ELISA) to determine the reactivity patterns of 21 murine monoclonal antibodies (MAbs) with structurally defined GXMs from five serotypes. The MAbs were categorized into eight groups on the basis of DEA and five groups on the basis of ELISA. MAbs 302, 339, and 439 were studied extensively for their binding to various native and chemically modified GXMs. Quantitative variation in the inhibitory effects of GXMs on the binding of MAbs 302, 339, and 439 were observed by competitive ELISA. O-Deacetylation of serotype A, B, and D GXM resulted in the complete loss of their inhibitory properties. Carboxyl group reduction of GXMs from serotypes A and D resulted in a significant decrease of inhibitory activity for MAb. Xylomannans and methyl glycosides exhibited no detectable inhibitory activity on MAb binding to GXM. The results indicate (i) the existence of five to eight MAb-defined distinct epitopes in C. neoformans GXM that can elicit antibody responses, (ii) MAb detection of antigenic variation within GXMs assigned to a particular serotype, (iii) good correspondence between the patterns of MAb reactivities and polyclonal rabbit factor sera, (iv) good agreement between MAb molecular structure and serotype reactivity, and (v) a dependence of the serotype reactivity profile for a given MAb on the technique used to measure binding.

Cryptococcus neoformans and cryptococcal glucuronoxylomannan, galactoxylomannan, and mannoprotein induce different levels of tumor necrosis factor alpha in human peripheral blood mononuclear cells

Tumor necrosis factor alpha (TNF-alpha) release by peripheral blood mononuclear cells (PBMC) during disseminated infection by Cryptococcus neoformans may initiate and amplify the immune response of the host, leading to elimination of the fungus. The ability to induce TNF-alpha in PBMC by four clinical strains of C. neoformans, a laboratory strain (NIH 37), and the purified cryptococcal components glucuronoxylomannan (GXM), galactoxylomannan (GalXM), and mannoproteins (MP1 and MP2) were investigated under different opsonic conditions. In the absence of serum, the levels of TNF-alpha induced by all strains and cryptococcal components were not above background levels. Normal human serum (NHS) enhanced TNF-alpha induction by whole cryptococci and the different cryptococcal components, with MP2 being the most potent TNF-alpha inducer. Inactivation of complement (HI NHS) almost abrogated the ability of whole cryptococci and the GXMs to induce TNF-alpha. In contrast, when MP1, MP2, and GalXM were incubated with HI NHS, 48, 71, and 44%, respectively, of the original TNF-alpha levels remained. MPs incubated with heat-inactivated immunoglobulin G (IgG)-depleted serum still induced 50% of the levels of TNF-alpha induced by components incubated with HI NHS. Both these sera contained the same very low levels of anti-MP IgG antibodies, indicating the opsonic effect of a heat-stable factor other than antibody. Two anti-CD14 monoclonal antibodies (60BCA and 3C10) inhibited the production of TNF-alpha induced by MP2. The results indicate that (i) induction of TNF-alpha by C. neoformans and GXMs strongly depends on complement, (ii) MP1 and MP2 induction of TNF-alpha is facilitated by a heat-stable serum factor other than Ig, and (iii) CD14 may be involved in the induction of TNF-alpha by MP2.

Fungal infections

Fungal infections have increased in frequency in the last decades because of the growing number of immunocompromised patients who survive longer periods of time than in the past, the widespread use of immunosuppressive drugs, a large aging population with increased numbers of malignancies, and the spread of AIDS. Although fungi are present everywhere, some mycoses predominate in the tropics, not only in view of warm temperature and humid climate, which favor their growth, but also because of inadequate hygienic and working conditions brought about by poverty. Mycotic diseases in the brain are usually secondary to infections elsewhere in the body, usually the lungs, less often from other extracranial sites, and in the vast majority of the cases spread via blood circulation. Only occasionally they result from direct extensions from infections of the sinuses or bone, and less frequently from prosthetic heart valves. Candida may be endogenous in origin, inhabiting the digestive tract. Most fungi cause basal meningitis or intraparenchymal abscesses. Direct extension from the cribriform plate cause necro-hemorrhagic lesions in the base of the frontal lobe. Although fungi are common in our environment, few are pathogenic. In this paper mycotic infections are divided into opportunistic and pathogenic; although most of the latter have also been described in immunosuppressed patients, some of those caused by opportunistic organisms, have also occurred in the absence of predisposing factors.

Virulence factors of medically important fungi

Human fungal pathogens have become an increasingly important medical problem with the explosion in the number of immunocompromised patients as a result of cancer, steroid therapy, chemotherapy, and AIDS. Additionally, the globalization of travel and expansion of humankind into previously undisturbed habitats have led to the reemergence of old fungi and new exposure to previously undescribed fungi. Until recently, relatively little was known about virulence factors for the medically important fungi. With the advent of molecular genetics, rapid progress has now been made in understanding the basis of pathogenicity for organisms such as Aspergillus species and Cryptococcus neoformans. The twin technologies of genetic transformation and "knockout" deletion construction allowed for genetic tests of virulence factors in these organisms. Such knowledge will prove invaluable for the rational design of antifungal therapies. Putative virulence factors and attributes are reviewed for Aspergillus species, C. neoformans, the dimorphic fungal pathogens, and others, with a focus upon a molecular genetic approach. Candida species are excluded from coverage, having been the subject of numerous recent reviews. This growing body of knowledge about fungal pathogens and their virulence factors will significantly aid efforts to treat the serious diseases they cause.

Cryptococcus neoformans: paradigm for the role of antibody immunity against fungi?

Cryptococcus neoformans is an encapsulated fungus that is a frequent cause of life-threatening infections in patients with AIDS. C. neoformans has many similarities with encapsulated bacteria such as S. pneumoniae and H. influenzae for which antibody immunity is important in protection. However the role of antibody immunity in protection against C. neoformans has been controversial. Experiments with polyclonal sera have produced conflicting evidence for and against the importance of antibody immunity in host defense. Experiments with monoclonal antibodies (mAb) to the C. neoformans capsular polysaccharide (CPS) have revealed the existence of protective, non-protective and disease-enhancing mAbs, suggesting that the divergent results obtained with polyclonal preparations may be a result of relative proportion of protective and non-protective antibodies in immune sera. Administration of protective mAbs can prolong survival, decrease organ fungal burden, and reduce serum polysaccharide antigen. In vitro experiments suggests that protective mAbs modify the course of infection by enhancing effector cell function against C. neoformans. Addition of mAb to antifungal drugs enhances their efficacy against C. neoformans in vivo and in vitro. Human-mouse chimeric antibodies with activity against C. neoformans have been constructed. A highly immunogenic capsular polysaccharide-protein vaccine has been synthesized that elicits protective antibodies in mice. Antibody immunity elicited by conjugate vaccines or provided by passive administration may be useful in the prevention treatment of human cryptococcal infections.

Pathology of cryptococcal meningoencephalitis: analysis of 27 patients with pathogenetic implications

In this autopsy series of cryptococcal meningoencephalitis (CME), the authors analyzed neuropathologic lesions in 13 human immunodeficiency virus (HIV) and 14 non-HIV-related cases. Most non-HIV patients did not have immunosuppressive predisposing illness. Analysis of pathological findings revealed significant differences in the inflammatory response to CME in patients with and without HIV infection. None of the acquired immunodeficiency syndrome (AIDS) patients had granulomatous inflammation, whereas most non-HIV-associated cases had granulomas, supporting a role for cell-mediated immunity in CME. Lymphocytic infiltrate in both groups consisted of T cells (CD45RO+). In some non-HIV-associated cases, CME was undiagnosed and untreated. In most HIV-associated cases, CME had an encephalitic component, resulting in grossly or microscopically visible accumulations of fungi within the brain parenchyma, whereas in non-HIV-associated cases, CME was often confined to the subarachnoid space and large perivascular spaces (Virchow-Robin spaces). In non-HIV-associated cases, yeast forms were fewer and showed a more limited distribution. In contrast, many extracellular fungi were present in many cases of HIV-associated CME. The principal reactive cell in CME in AIDS was brain macrophages and microglia, especially those in the perivascular and juxtavascular locations. Reactive astrocytes were limited to large destructive lesions and subpial regions. In several patients with HIV-associated CME, large parenchymal cryptococcomas contained Crytococcus neoformans (CN) with cell wall pigmentation, suggestive of melanin. The authors suggest that in AIDS patients altered immune functions allow CN to accumulate within the brain, predominantly extracellularly, and that deficient macrophage/microglial effector function may be responsible for the altered pathology. In addition, coexisting CNS processes in HIV-associated CME may contribute to the altered pathology. The authors conclude that cryptococcal meningitis is not a disease limited to the cerebrospinal fluid (CSF) space but affects the brain more significantly than suspected. Therapeutic strategies that enhance the effector function of glial cells at the CNS-CSF barrier may be useful for improving the response to therapy.

Immunoglobulin G3 blocking antibodies to the fungal pathogen Cryptococcus neoformans

Vaccination and infection can elicit protective and nonprotective antibodies to the fungus Cryptococcus neoformans in mice. The effect of nonprotective antibodies on host defense is unknown. In this study we used mixtures of protective and nonprotective monoclonal antibodies (mAbs) to determine if nonprotective mAbs blocked the activity of the protective mAbs. Antibody isotype and epitope specificity are important in determining the ability to prolong survival in mice given a lethal C. neoformans infection. Three different nonprotective immunoglobulin (Ig) G23 mAbs to cryptococcal capsular polysaccharide were used to study the interaction between the IgG3 isotype and protective IgG1 and IgG2a mAbs in murine cryptococcal infection. One IgG3 mAb reduced the protective efficacy of an IgG1 with identical epitope specificity. A second IgG3 mAb with different epitope specificity also reduced the protection provided by the IgG1 mAb. The protective efficacy of an IgG2a mAb was also dramatically decreased by still another IgG3 mAb. To our knowledge this is the first report of blocking antibodies to a fungal pathogen. The results have important implications for the development of vaccines and passive antibody therapy against C. neoformans.

Structure of the O-deacetylated glucuronoxylomannan from Cryptococcus neoformans Cap70 as determined by 2D NMR spectroscopy

Cryptococcus neoformans, an opportunistic pathogen, is the fourth leading cause of death among AIDS patients. The yeast's capsule is a major virulence factor, and serotype is related to the chemical structure of glucuronoxylomannan (GXM), its capsular polysaccharide. The GXM from Cap70, a hypocapsular mutant of serotype D isolate B-3501, was investigated by chemical analysis and 2D NMR spectroscopy. The assignment of 1H and 13C chemical shifts for the O-deacetylated polysaccharide was accomplished from the analysis of DQF-COSY, TOCSY, and gradient-enhanced HSQC spectra. The sequence and linkage positions of glycosyl residues were determined by NOESY and ROESY spectra. Two repeating polysaccharide components were identified as having the following structures in approximately equal proportions: [formula: see text] It is not known if these repeating units comprise a single or two separate polymer chains. Pentasaccharide 2 has been known to be the major GXM polymer of B-3501 and other serotype D isolates. Hexasaccharide 1 is identified for the first time although it has subsequently been identified in other C. neoformans isolates. The presence of 1 in the GXM of Cap70 is consistent with the extra xylose found relative to that in isolate B-3501. The mannose:xylose:glucuronic acid:O-acetyl molar ratio of Cap70 GXM is 3.00:1.73:0.78:1.75, while the same ratio for B-3501 and other serotype D isolates is approximately 3.00:1.00:0.80:1.75. Methylation analysis confirmed that the GXM of Cap70 contains unsubstituted, monosubstituted (2-linked), and disubstituted (2- and 4-linked) mannose in a ratio of 0.87:1.75:0.38. Dot blot immunoassay indicates that Cap70 is a serotype D isolate like its parent strain.

Serotypes of Cryptococcus neoformans isolated from patients prior to and during the AIDS era in Thailand

One hundred and eighty-seven strains of Cryptococcus neoformans isolated from patients in Thailand were characterized by biochemical varieties relating to serogroups. Canavanine-glycine-bromothymol blue (CGB) agar was used for differentiating the varieties of C. neoformans. Slide agglutination tests were performed with Crypto Check (Iatron, Inc., Tokyo) to determine their serotypes. Fifty-five percent (10 out of 18) of the pre-AIDS isolates were serotype B, 28% were serotype A, 5% were serotype D, and an unexpected 11% (2 out of 18) were serotype C. These are the first to be recorded in Asia. In contrast, among the 169 clinical isolates obtained between January 1993 and March 1995 (AIDS epidemic), serotype A was outstandingly predominant--93% (157 out of 169), serotype B was relatively low (3.6%) and both serotypes D and AD were 1.8%. The pattern of serotypes of the 59 isolates from known HIV-positive patients was closely similar to the total isolates during the AIDS epidemic. In determining the varieties of C. neoformans by CGB, only 1 of the 187 isolates gave a false reaction. On the basis of our findings, we believe that in the pre-AIDS era either C. neoformans var. gattii serotype B or serotype C were the common causative agents of cryptococcosis in Thailand. The advent of AIDS changed the pattern of serotypes with serotype A becoming predominant as has been reported world wide.

Antibody immunity andCryptococcus neoformans

Recently there has been renewed interest in the potential of antibody immunity for the prevention and therapy of human Cryptococcus neoformans infections. Historically, the role of antibody immunity in protection against C. neoformans has been controversial. Experiments with polyclonal sera have produced evidence for and against the importance of antibody immunity in host defence. However, three groups have now shown that administration of monoclonal antibody (mAb) to the C. neoformans capsular polysaccharide (CPS) can modify the course of infection in mice. The quantity, isotype, and specificity of mAb appear to be important parameters of antibody efficacy against C. neoformans. Protective and nonprotective mAbs to CPS have been identified, suggesting a possible explanation for the divergent results obtained with polyclonal preparations, which presumably contain both types of antibodies. mAb administration has been shown to prolong survival, decrease organ fungal burden, and reduce serum polysaccharide antigen. The mechanism(s) by which mAb modify the course of infection is uncertain. In vitro experiments strongly suggest that antibodies mediate protection by enhancing effector cell function. The combination of antibody and amphotericin B is more effective than either agent alone for the treatment of murine cryptococcosis. Human–mouse chimeric antibodies with activity against C. neoformans have been constructed that may have advantages over mouse mAbs for therapy of human infections. A highly immunogenic capsular polysaccharide–protein vaccine has been made that can elicit protective antibodies in mice. Antibody immunity can modify the course of infection to the benefit of the host and may be useful in the prevention and treatment of human cryptococcosis. Key words: antibody, Cryptococcus neoformans, macrophage, vaccine, AIDS.

Cryptococcosis in the era of AIDS--100 years after the discovery of Cryptococcus neoformans

Although Cryptococcus neoformans and cryptococcosis have existed for several millennia, a century has passed since the discovery of this encapsulated yeast and its devastating disease. With the advent of the AIDS pandemic, cryptococcal meningitis has emerged as a leading cause of infectious morbidity and mortality and a frequently life-threatening opportunistic mycosis among patients with AIDS. Both basic and clinical research have accelerated in the 1990s, and this review attempts to highlight some of these advances. The discussion covers recent findings, current concepts, controversies, and unresolved issues related to the ecology and genetics of C. neoformans; the surface structure of the yeast; and the mechanisms of host defense. Regarding cell-mediated immunity, CD4+ T cells are crucial for successful resistance, but CD8+ T cells may also participate significantly in the cytokine-mediated activation of anticryptococcal effector cells. In addition to cell-mediated immunity, monoclonal antibodies to the major capsular polysaccharide, the glucuronoxylomannan, offer some protection in murine models of cryptococcosis. Clinical concepts are presented that relate to the distinctive features of cryptococcosis in patients with AIDS and the diagnosis, treatment, and prevention of cryptococcosis in AIDS patients.

Tissue localization of Cryptococcus neoformans glucuronoxylomannan in the presence and absence of specific antibody

During infection, Cryptococcus neoformans capsular glucuronoxylomannan (GXM) is released into tissues, where it may be associated with a variety of deleterious immunological effects. Relatively little is known about the organ distribution and cellular localization of GXM antigen. Intravenous administration of GXM to rats resulted in persistent serum levels which declined with a half-life of 14.3 h in the first 74 h and 3 h thereafter, coincident with the appearance of serum antibodies to GXM. GXM was sequestered primarily in spleen tissue, with localization to marginal zone and follicular cells. Administration of the murine immunoglobulin G1 monoclonal antibody (MAb) 2H1 resulted in > 99% reduction in serum GXM level within 3 h. MAb 2H1 administration resulted in liver GXM deposition, with cellular localization primarily to Kupffer cells. GXM was also found in the spleens of MAb 2H1-treated rats, with localization to the marginal zones and follicles. Endotracheal administration of GXM resulted in low serum levels, with lung tissue having the highest GXM organ levels, localized primarily to alveolar macrophages. The results indicate that (i) intravenous administration to rats produced persistent serum GXM levels with a half-life similar to that found in mice and rabbits; (ii) endotracheal administration of GXM resulted in low serum levels; (iii) in the absence of specific antibody, GXM organ deposition occurs primarily in the spleen and is localized primarily to marginal zone macrophages; (iv) in the presence of specific immunoglobulin G1 antibody, GXM organ deposition occurs primarily in the liver and is localized primarily to Kupffer cells; and (vi) reticuloendothelial cells sequester GXM in the presence and absence of specific antibody.