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Li X, Paccoud O, Chan KH, Yuen KY, Manchon R, Lanternier F, Slavin MA, van de Veerdonk FL, Bicanic T, Lortholary O. Cryptococcosis Associated With Biologic Therapy: A Narrative Review. Open Forum Infect Dis 2024; 11:ofae316. [PMID: 38947739 PMCID: PMC11212009 DOI: 10.1093/ofid/ofae316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/17/2024] [Indexed: 07/02/2024] Open
Abstract
Cryptococcus is an opportunistic fungal pathogen that can cause disseminated infection with predominant central nervous system involvement in patients with compromised immunity. Biologics are increasingly used in the treatment of neoplasms and autoimmune/inflammatory conditions and the prevention of transplant rejection, which may affect human defense mechanisms against cryptococcosis. In this review, we comprehensively investigate the association between cryptococcosis and various biologics, highlighting their risks of infection, clinical manifestations, and clinical outcomes. Clinicians should remain vigilant for the risk of cryptococcosis in patients receiving biologics that affect the Th1/macrophage activation pathways, such as tumor necrosis factor α antagonists, Bruton tyrosine kinase inhibitors, fingolimod, JAK/STAT inhibitors (Janus kinase/signal transducer and activator of transcription), and monoclonal antibody against CD52. Other risk factors-such as age, underlying condition, and concurrent immunosuppressants, especially corticosteroids-should also be taken into account during risk stratification.
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Affiliation(s)
- Xin Li
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Olivier Paccoud
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Koon-Ho Chan
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Kwok-Yung Yuen
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Romain Manchon
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Fanny Lanternier
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, Mycology Department, Université Paris Cité, Paris, France
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Olivier Lortholary
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, Mycology Department, Université Paris Cité, Paris, France
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Chey SY, O’Sullivan NA, Beer T, Leong WK, Kermode AG. Cutaneous presentation of cryptococcal infection with subclinical central nervous system involvement secondary to fingolimod therapy. Mult Scler J Exp Transl Clin 2023; 9:20552173231197132. [PMID: 37674981 PMCID: PMC10478555 DOI: 10.1177/20552173231197132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/08/2023] [Indexed: 09/08/2023] Open
Abstract
Fingolimod is a multiple sclerosis disease-modifying therapy which sequestrates lymphocytes in the lymph nodes, thereby reducing peripheral blood lymphocytes. Cryptococcal infection is an important adverse effect which should be recognised. We report a case of cutaneous and central nervous system infection who presented with isolated cutaneous symptoms in the absence of neurological or systemic manifestations.
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Affiliation(s)
- Shin Yee Chey
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Perron Institute for Neurological and Translational Sciences, QE II Medical Centre, Perth, Australia
| | | | - Trevor Beer
- Clinipath Pathology, Osborne Park, Australia
| | - Wai K Leong
- Department of Neurology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Allan G Kermode
- Perron Institute for Neurological and Translational Sciences, QE II Medical Centre, Perth, Australia
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Carpenter K, Etemady-Deylamy A, Costello V, Khasawneh M, Chamberland R, Tian K, Donlin M, Moreira-Walsh B, Reisenbichler E, Abate G. Cryptococcal chest wall mass and rib osteomyelitis associated with the use of fingolimod: A case report and literature review. Front Med (Lausanne) 2022; 9:942751. [PMID: 36160166 PMCID: PMC9491343 DOI: 10.3389/fmed.2022.942751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022] Open
Abstract
Being introduced in 2010, fingolimod was among the first oral therapies for relapsing multiple sclerosis (MS). Since that time, postmarketing surveillance has noted several case reports of various cryptococcal infections associated with fingolimod use. To date, approximately 15 such case reports have been published. We present the first and unique case of cryptococcal chest wall mass and rib osteomyelitis associated with fingolimod use. The patient presented with left-side chest pain and was found to have a lower left chest wall mass. Computerized tomography (CT) showed chest wall mass with the destruction of left 7th rib. Aspirate from the mass grew Cryptococcus neoformans. The isolate was serotype A. Fingolimod was stopped. The patient received liposomal amphotericin B for 2 weeks and started on fluconazole with a plan to continue for 6–12 months. The follow-up CT in 6 weeks showed a marked decrease in the size of the chest wall mass. In conclusion, our case highlights the atypical and aggressive form of cryptococcal infection possibly related to immunosuppression from fingolimod use.
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Affiliation(s)
- Kent Carpenter
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Ali Etemady-Deylamy
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Victoria Costello
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Mohammad Khasawneh
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Robin Chamberland
- SSM Saint Louis Network Microbiology, Saint Louis, MO, United States
- Department of Pathology, Saint Louis University, Saint Louis, MO, United States
| | - Katherine Tian
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Maureen Donlin
- Department of Molecular Microbiology and Immunology, Saint Louis University, Saint Louis, MO, United States
| | - Brenda Moreira-Walsh
- Department of Molecular Microbiology and Immunology, Saint Louis University, Saint Louis, MO, United States
| | - Emily Reisenbichler
- Department of Pathology, Saint Louis University, Saint Louis, MO, United States
| | - Getahun Abate
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
- *Correspondence: Getahun Abate
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4
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A comprehensive review of varicella-zoster virus, herpes simplex virus and cryptococcal infections associated with sphingosine-1-phosphate receptor modulators in multiple sclerosis patients. Mult Scler Relat Disord 2022; 59:103675. [DOI: 10.1016/j.msard.2022.103675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/22/2022] [Accepted: 02/06/2022] [Indexed: 12/30/2022]
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Dahshan D, Dessie SA, Cuda J, Khalil E. Primary Cutaneous Cryptococcosis in a Patient on Fingolimod: A Case Report. Cureus 2021; 13:e16444. [PMID: 34422475 PMCID: PMC8367091 DOI: 10.7759/cureus.16444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 11/11/2022] Open
Abstract
Primary cutaneous cryptococcosis is an uncommon condition. Patients with immunosuppression and those of older age are more susceptible to infection, warranting investigations into underlying systemic disease. We report the case of a 49-year-old male with multiple sclerosis in remission on fingolimod who presented with a non-healing skin lesion on his upper thigh for a duration of two years. Skin biopsy showed dermal parasitized histiocytes, and serum antigens for histoplasmosis and Cryptococcus were negative. Further investigation with polymerase chain reaction (PCR) demonstrated cutaneous cryptococcal infection, with no associated systemic signs or symptoms. This case report highlights an uncommon presentation of cutaneous cryptococcosis on an unexposed skin surface with successful and rapid improvement following fluconazole therapy without fingolimod discontinuation.
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Affiliation(s)
- Deena Dahshan
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Sofanit A Dessie
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Jonathan Cuda
- Pathology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Elie Khalil
- Infectious Diseases, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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Scotto R, Reia A, Buonomo AR, Moccia M, Viceconte G, Pisano E, Zappulo E, Brescia Morra V, Gentile I. Risk of invasive fungal infections among patients treated with disease modifying treatments for multiple sclerosis: a comprehensive review. Expert Opin Drug Saf 2021; 20:925-936. [PMID: 33880975 DOI: 10.1080/14740338.2021.1918673] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Disease modifying treatments are commonly used in the treatment of multiple sclerosis. As different opportunistic infections have been reported, concerns are also raised regarding the risk of invasive fungal infections.Areas covered: Both clinical trials and observational studies on safety and efficacy of diseases modifying treatment for multiple sclerosis were reviewed and data regarding the occurrence of invasive fungal infections were reported. Papers evaluating the following drugs were reviewed: rituximab, ocrelizumab, alemtuzumab, fingolimod, natalizumab, dimethyl fumarate, interferon, glatiramer acetate, cladribine, teriflunomide.Expert opinion: Overall, the occurrence of invasive fungal infections was low, with most infective events reported among patients treated with monoclonal antibodies and fingolimod. Aspergillosis and cryptococcal meningitidis were the most representative fungal infections. Although not common, these infections may be difficult to diagnose and their fatality rate is often high. For this reason, screening protocols for fungal infections must be implemented in the clinical practice when managing patients with MS.
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Affiliation(s)
- R Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - A Reia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - A R Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - M Moccia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - G Viceconte
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - E Pisano
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - E Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - V Brescia Morra
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - I Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
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Kolodziej MA, Al Barim B, Nagl J, Weigand MA, Uhl E, Uhle F, Di Fazio P, Schwarm FP, Stein M. Sphingosine‑1‑phosphate analogue FTY720 exhibits a potent anti‑proliferative effect on glioblastoma cells. Int J Oncol 2020; 57:1039-1046. [PMID: 32945397 DOI: 10.3892/ijo.2020.5114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023] Open
Abstract
Sphingosine‑1‑phosphate (S1P) plays a key role in cell survival, growth, migration, and in angiogenesis. In glioma, it triggers the activity of the S1P‑receptor 1 and of the sphingosine kinase 1; thus influencing the survival rate of patients. The aim of the present study was to investigate the anti‑proliferative effect of the S1P analogue FTY720 (fingolimod) in glioblastoma (GBM) cells. A172, G28, and U87 cells were incubated with micromolar concentrations of FTY720 or temozolomide (TMZ) for 24 to 72 h. Proliferation and half maximal inhibitory concentration (IC50) were determined by using the xCELLigence system. FACS analysis was performed to check the cell cycle distribution of the cells after a 72‑h incubation with FTY720. This was then compared to TMZ‑incubated and to untreated cells. Gene expression was detected by RT‑qPCR in A172, G28, U87 and three primary GBM‑derived cell lines. FTY720 was able to reduce the number of viable cells. The IC50 value was 4.6 µM in A172 cells, 17.3 µM in G28 cells, and 25.2 µM in U87 cells. FTY720 caused a significant arrest of the cell cycle in all cells and stabilized or over‑expressed the level of AKT1, MAPK1, PKCE, RAC1, and ROCK1 transcripts. The TP53 transcript level remained stable or was downregulated after treatment with FTY720. FTY720 may be a promising target drug for the treatment of GBM, as it has a strong anti‑proliferative effect on GBM cells.
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Affiliation(s)
- M A Kolodziej
- Department of Neurosurgery, Justus Liebig University Giessen, D‑35392 Giessen, Germany
| | - B Al Barim
- Department of Neurosurgery, University Hospital Muenster, D‑48149 Muenster, Germany
| | - J Nagl
- Department of Neurosurgery, Justus Liebig University Giessen, D‑35392 Giessen, Germany
| | - M A Weigand
- Department of Anesthesiology, University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - E Uhl
- Department of Neurosurgery, Justus Liebig University Giessen, D‑35392 Giessen, Germany
| | - F Uhle
- Department of Anesthesiology, University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - P Di Fazio
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, D‑35034 Marburg, Germany
| | - F P Schwarm
- Department of Neurosurgery, Justus Liebig University Giessen, D‑35392 Giessen, Germany
| | - M Stein
- Department of Neurosurgery, Justus Liebig University Giessen, D‑35392 Giessen, Germany
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