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Chean D, Windsor C, Lafarge A, Dupont T, Nakaa S, Whiting L, Joseph A, Lemiale V, Azoulay E. Severe Community-Acquired Pneumonia in Immunocompromised Patients. Semin Respir Crit Care Med 2024; 45:255-265. [PMID: 38266998 DOI: 10.1055/s-0043-1778137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Due to higher survival rates with good quality of life, related to new treatments in the fields of oncology, hematology, and transplantation, the number of immunocompromised patients is increasing. But these patients are at high risk of intensive care unit admission because of numerous complications. Acute respiratory failure due to severe community-acquired pneumonia is one of the leading causes of admission. In this setting, the need for invasive mechanical ventilation is up to 60%, associated with a high hospital mortality rate of around 40 to 50%. A wide range of pathogens according to the reason of immunosuppression is associated with severe pneumonia in those patients: documented bacterial pneumonia represents a third of cases, viral and fungal pneumonia both account for up to 15% of cases. For patients with an undetermined etiology despite comprehensive diagnostic workup, the hospital mortality rate is very high. Thus, a standardized diagnosis strategy should be defined to increase the diagnosis rate and prescribe the appropriate treatment. This review focuses on the benefit-to-risk ratio of invasive or noninvasive strategies, in the era of omics, for the management of critically ill immunocompromised patients with severe pneumonia in terms of diagnosis and oxygenation.
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Affiliation(s)
- Dara Chean
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Camille Windsor
- Medical Intensive Care Unit, AP-HP Henri Mondor University Hospital, Créteil, France
| | - Antoine Lafarge
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Thibault Dupont
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Sabrine Nakaa
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Livia Whiting
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Adrien Joseph
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
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2
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Musubire A, Kagimu E, Mugabi T, Meya DB, Boulware DR, Bahr NC. Complex Decisions in HIV-Related Cryptococcosis: Addressing Second Episodes of Cryptococcal Meningitis. Curr HIV/AIDS Rep 2024; 21:75-85. [PMID: 38400871 PMCID: PMC11016006 DOI: 10.1007/s11904-024-00691-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE OF REVIEW This review highlights the difficulties in diagnosing and treating persons with a prior history of cryptococcal meningitis who improve but suffer from a recurrence of symptoms. This scenario is well known to those who frequently care for patients with cryptococcal meningitis but is not well understood. We highlight major gaps in knowledge. RECENT FINDINGS We recently summarized our experience with 28 persons with paradoxical immune reconstitution inflammatory syndrome (IRIS) and 81 persons with microbiological relapse. CD4 count and cerebrospinal fluid white blood cell count were higher in IRIS than relapse but neither was reliable enough to routinely differentiate these conditions. Second-episode cryptococcal meningitis remains a difficult clinical scenario as cryptococcal antigen, while excellent for initial diagnosis has no value in differentiating relapse of infection from other causes of recurrent symptoms. Updated research definitions are proposed and rapid, accurate diagnostic tests are urgently needed.
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Affiliation(s)
- Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, 66160 KS, USA.
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3
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Wang X, Long X, Jia S, Zhu J, Zhou Z, Ahmed S, Jiang Y, Jiang Y. In vitro and in vivo synergistic effects of hydroxychloroquine and itraconazole on Cryptococcus neoformans. Folia Microbiol (Praha) 2023:10.1007/s12223-023-01040-4. [PMID: 36753031 DOI: 10.1007/s12223-023-01040-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/26/2023] [Indexed: 02/09/2023]
Abstract
Cryptococcus neoformans is an opportunistic fungal pathogen that can cause life-threatening invasive fungal infections. As its prevalence and drug resistance continue to rise, cryptococcosis requires new treatment options. Tapping into the potential antifungal effects of traditional drugs or combination therapy has become one of the options. This study was the first to examine the interaction of hydroxychloroquine (HCQ) and itraconazole (ITR) on Cryptococcus neoformans in vitro and in vivo. Our results showed that HCQ alone and in combination with ITR exhibited antifungal activity against C. neoformans planktonic cells. When HCQ was combined with ITR, the minimal inhibitory concentration (MIC) value of HCQ decreased to 32 μg/mL, and the MIC value of ITR decreased from 0.25 μg/mL to 0.06-0.25 μg/mL. The time-killing curve showed that the combined application of HCQ and ITR significantly shortened the killing time, dynamically defining the antifungal activity. The minimum biofilm clearance concentration (MBEC) of HCQ was only 32 μg/mL, which was significantly lower than the MIC of HCQ for planktonic cells. When combined with ITR, the MBEC of ITR decreased from 128 μg/mL to 2-1 μg/mL, and the MBEC of HCQ decreased from 32 μg/mL to 4 μg/mL, indicating a synergistic antifungal biofilm effect. In comparison to ITR alone, the combination of HCQ and ITR treatment increased the survival of C. neoformans-infected Galleria mellonella larvae and decreased the fungal burden of infected larvae. Mechanistic investigations revealed that HCQ might damage C. neoformans cell membranes, impact the structure of fungal cells, cause extracellular material leakage, and have a potent affinity for attaching to the C. neoformans genomic DNA. In conclusion, HCQ has potential clinical application in the treatment of cryptococcosis.
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Affiliation(s)
- Xue Wang
- Department of Dermatology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Microbiology, Basic Medical School, Guizhou Medical University, Guiyang, China
| | - Xuemei Long
- Department of Dermatology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Songgan Jia
- Department of Dermatology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jiali Zhu
- Department of Dermatology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Zhan Zhou
- Department of Dermatology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Sarah Ahmed
- Centre of Expertise in Mycology of Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Yinhui Jiang
- Laboratory of Medical Molecular Biology, Guizhou Medical University, Guiyang, China
| | - Yanping Jiang
- Department of Dermatology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China. .,Centre of Expertise in Mycology of Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, Netherlands.
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4
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Kuwahara M, Yurugi S, Ando J, Takeuchi M, Miyata R, Harada M, Masuda Y, Kanagawa S, Yoneda T, Fukumori T, Ogawa T, Nakamura-Uchiyama F, Kasahara K. A case of cryptococcal necrotizing fasciitis and immune reconstitution inflammatory syndrome in a renal transplantation recipient. Int J Surg Case Rep 2021; 85:106199. [PMID: 34280874 PMCID: PMC8318893 DOI: 10.1016/j.ijscr.2021.106199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Immunocompromised patients are at high risk of unexpectedly serious infections caused by uncommon bacteria or fungi. We experienced a case of Cryptococcus neoformans-induced necrotizing fasciitis (NF) of the lower extremities. The progress so far has been reported by the urology department [1]. Moreover, after the NF had been treated, the patient developed immune reconstitution inflammatory syndrome (IRIS). We report from surgeon's view point. CASE PRESENTATION A 51-year-old male renal transplant patient complained of pain in both lower extremities (LE). After the initial debridement, periodic acid-Schiff after diastase digestion (D-PAS) staining confirmed the diagnosis. No symptoms were seen in the lungs or cerebrospinal system. The patient was reluctant to undergo surgical treatment but several debridement improved patient's condition. After the LE wound healed, prednisolone was discontinued, then painful nodules appeared on both LE. Based on the negative culture results and the fact that the patient had been treated with flucytosine and fluconazole, we suspected that the nodules had been caused by IRIS. CLINICAL DISCUSSION It was difficult to diagnose Cryptococcus-induced NF and paradoxical IRIS. Cooperation from other specialists was essential. CONCLUSION We think this patient needed earlier and more definitive debridement. Fortunately, we were able to save the patient's life and maintain his LE function. In immunocompromised patients, cryptococcus can be a pathogen. In addition, IRIS can occur during treatment. Management of IRIS is the capital point of sepsis management, careful anti-inflammatory drug control by specialists is required.
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Affiliation(s)
- Masamitsu Kuwahara
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Satoshi Yurugi
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Junji Ando
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Mika Takeuchi
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Riyo Miyata
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Masayuki Harada
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Yasumitsu Masuda
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Saori Kanagawa
- Division of Plastic Surgery, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Tatsuo Yoneda
- Division of Dialysis Unit, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Tatsuya Fukumori
- Center for Infectious Diseases, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Taku Ogawa
- Center for Infectious Diseases, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
| | - Fukumi Nakamura-Uchiyama
- Center for Infectious Diseases, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan; Department of Infectious Diseases, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo 130-8575, Japan.
| | - Kei Kasahara
- Center for Infectious Diseases, Nara Medical University Hospital, 840 Shijocho, Kashihara, Nara 634-8522, Japan.
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5
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Immune reconstitution inflammatory syndrome in the lung in non-human immunodeficiency virus patients. Respir Investig 2019; 58:36-44. [PMID: 31791908 DOI: 10.1016/j.resinv.2019.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/30/2019] [Accepted: 11/05/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND We evaluated immune reconstitution inflammatory syndrome (IRIS) in the lung in non-human immunodeficiency virus (HIV) patients. METHODS We reviewed articles related to IRIS occurrence in the lung in non-HIV patients using a PubMed search. The keywords used for the search were "immune reconstitution syndrome" and "non-HIV." Only patients with lung involvement were included. Those with suggested IRIS caused by white blood cell recovery were excluded. RESULTS There were 37 cases of IRIS in the lung in non-HIV patients. Complicating infections included tuberculosis (n = 17), histoplasmosis (n = 9), aspergillosis (n = 5), cryptococcosis (n = 4), and Pneumocystis pneumonia (n = 2). We also evaluated the underlying diseases, IRIS pathogenesis, management, and prognosis. IRIS was most commonly encountered in patients treated with anti-tumor necrosis factor (TNF) antibody who developed disseminated or extrapulmonary tuberculosis, leading to treatment discontinuation. CONCLUSIONS The diagnosis and management of IRIS in the lung in non-HIV patients should be investigated further, especially in the era of anti-TNF treatment.
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6
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Wu X, Shen Y. Management of human immunodeficiency virus-associated cryptococcal meningitis: Current status and future directions. Mycoses 2019; 62:874-882. [PMID: 31365770 DOI: 10.1111/myc.12977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 12/30/2022]
Abstract
Cryptococcal meningitis (CM) is one of the most common opportunistic infections of acquired immunodeficiency syndrome (AIDS), as well as an important cause of hospitalisation and death. In recent years, the mortality of CM has remained high in HIV/AIDS population, with up to 30%, including within developed countries. The treatment usually encompasses controls of Cryptococcus, HIV, and increased intracranial pressure. Recent progress on the management of HIV-associated CM mainly centres in optimising induction regimens, looking for appropriate timing of initiating antiretroviral therapy and prevention of symptomatic onset and adverse consequences. This review compared several international guidelines combined with the results from some clinical researches to illustrate the similarities, differences and potential in CM treatment. The present practice is still far from satisfactory, and there remains much to explore due to our limited understanding of the pathogenesis of HIV-associated CM. Thus, screening and monitoring should be strengthened, and better therapies in line with the actual situation of each country should be discovered.
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Affiliation(s)
- Xueyun Wu
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
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7
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Abstract
: Neurological conditions associated with HIV remain major contributors to morbidity and mortality and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence shows that the central nervous system (CNS) may serve as a reservoir for viral replication, which has major implications for HIV eradication strategies. Although there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of neurological conditions associated with HIV infection, significant scientific gaps remain. In many resource-limited settings, antiretrovirals considered second or third line in the United States, which carry substantial neurotoxicity, remain mainstays of treatment, and patients continue to present with severe immunosuppression and CNS opportunistic infections. Despite this, increased global access to cART has coincided with an aging HIV-positive population with cognitive sequelae, cerebrovascular disease, and peripheral neuropathy. Further neurological research in low-income and middle-income countries (LMICs) is needed to address the burden of neurological complications in HIV-positive patients, particularly regarding CNS viral reservoirs and their effects on eradication.
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8
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Wright EJ, Thakur KT, Bearden D, Birbeck GL. Global developments in HIV neurology. HANDBOOK OF CLINICAL NEUROLOGY 2018; 152:265-287. [PMID: 29604981 DOI: 10.1016/b978-0-444-63849-6.00019-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neurologic conditions associated with HIV remain major contributors to morbidity and mortality, and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence suggests that the central nervous system (CNS) serves as a reservoir for viral replication with major implications for human immunodeficiency virus (HIV) eradication strategies. Though there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of HIV-associated neurologic conditions, significant scientific gaps remain. In many low-income settings, second- and third-line cART regimens that carry substantial neurotoxicity remain treatment mainstays. Further, patients continue to present severely immunosuppressed with CNS opportunistic infections. Public health efforts should emphasize improvements in access and optimizing treatment of HIV-positive patients, specifically in resource-limited settings, to reduce the risk of neurologic sequelae.
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Affiliation(s)
- Edwina J Wright
- Department of Infectious Diseases, Alfred Health, Monash University, Melbourne, Australia; The Burnet Institute, Melbourne, Australia; Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.
| | - Kiran T Thakur
- Division of Critical Care and Hospitalist Neurology, Columbia University Medical Center, New York, NY, United States
| | - David Bearden
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Gretchen L Birbeck
- Strong Epilepsy Center, Department of Neurology, University of Rochester, Rochester, NY, United States; Chikankata Epilepsy Care Team, Chikankata Hospital, Mazabuka, Zambia
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9
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Huong NTC, Altibi AMA, Hoa NM, Tuan LA, Salman S, Morsy S, Lien NTB, Truong NT, Mai NTH, Hoa PTL, Thang NB, Trung VT. Progressive cutaneous Cryptococcosis complicated with meningitis in a myasthenia gravis patient on long-term immunosuppressive therapy - a case report. BMC Infect Dis 2017; 17:311. [PMID: 28446137 PMCID: PMC5406963 DOI: 10.1186/s12879-017-2415-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus neoformans and most remarkably manifests in HIV-infected individuals, especially in the settings of very low CD4 count. Development of cryptococcosis in HIV-uninfected individuals is exceedingly rare and usually signifies a marked immunodeficiency. Cryptococcosis in association with myasthenia gravis or thymoma has been previously documented in only very few cases in the literature. CASE PRESENTATION We reported a complicated case of severe cutaneous cryptococcosis in a 39-year-old Vietnamese male patient with myasthenia gravis on long-term immunosuppressive therapy. The patient presented with a five month history of recurrent and progressive skin lesions that later on progressed into cryptococcal meningitis. CONCLUSION Through this case, we aimed to emphasize the importance of including cutaneous cryptococcosis in the differential diagnosis of cutaneous lesions in patients on chronic immunosuppressive therapy. The cutaneous manifestations of cryptococcosis can be the first clue for a disseminated disease, which makes early recognition crucial and life-saving.
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Affiliation(s)
- Nguyen Thi Cam Huong
- Department of Infectious Diseases, University of Medicine and Pharmacy at Ho Chi Minh City , Ho Chi Minh city, Vietnam. .,The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
| | | | - Nguyen My Hoa
- Department of Infectious Diseases, University of Medicine and Pharmacy at Ho Chi Minh City , Ho Chi Minh city, Vietnam.,The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Le Anh Tuan
- Department of Infectious Diseases, University of Medicine and Pharmacy at Ho Chi Minh City , Ho Chi Minh city, Vietnam.,The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Samar Salman
- Dermatology and Venereology Department, Tanta University Hospital, Tanta, Egypt
| | - Sara Morsy
- Biochemistry Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | | | - Nguyen Thi Hoang Mai
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Pham Thi Le Hoa
- Department of Infectious Diseases, University of Medicine and Pharmacy at Ho Chi Minh City , Ho Chi Minh city, Vietnam.,The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Ba Thang
- Department of Neurology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Van The Trung
- Department of Dermatology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
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10
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Srichatrapimuk S, Sungkanuparph S. Integrated therapy for HIV and cryptococcosis. AIDS Res Ther 2016; 13:42. [PMID: 27906037 PMCID: PMC5127046 DOI: 10.1186/s12981-016-0126-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/16/2016] [Indexed: 12/27/2022] Open
Abstract
Cryptococcosis has been one of the most common opportunistic infections and causes of mortality among HIV-infected patients, especially in resource-limited countries. Cryptococcal meningitis is the most common form of cryptococcosis. Laboratory diagnosis of cryptococcosis includes direct microscopic examination, isolation of Cryptococcus from a clinical specimen, and detection of cryptococcal antigen. Without appropriate treatment, cryptococcosis is fatal. Early diagnosis and treatment is the key to treatment success. Treatment of cryptococcosis consists of three main aspects: antifungal therapy, intracranial pressure management for cryptococcal meningitis, and restoration of immune function with antiretroviral therapy (ART). Optimal integration of these three aspects is crucial to achieving successful treatment and reducing the mortality. Antifungal therapy consists of three phases: induction, consolidation, and maintenance. A combination of two drugs, i.e. amphotericin B plus flucytosine or fluconazole, is preferred in the induction phase. Fluconazole monotherapy is recommended during consolidation and maintenance phases. In cryptococcal meningitis, intracranial pressure rises along with CSF fungal burden and is associated with morbidity and mortality. Aggressive control of intracranial pressure should be done. Management options include therapeutic lumbar puncture, lumbar drain insertion, ventriculostomy, or ventriculoperitoneal shunt. Medical treatment such as corticosteroids, mannitol, and acetazolamide are ineffective and should not be used. ART has proven to have a great impact on survival rates among HIV-infected patients with cryptococcosis. The time to start ART in HIV-infected patients with cryptococcosis has to be deferred until 5 weeks after the start of antifungal therapy. In general, any effective ART regimen is acceptable. Potential drug interactions between antiretroviral agents and amphotericin B, flucytosine, and fluconazole are minimal. Of most potential clinical relevance is the concomitant use of fluconazole and nevirapine. Concomitant use of these two drugs should be cautious, and patients should be monitored closely for nevirapine-associated adverse events, including hepatotoxicity. Overlapping toxicities of antifungal and antiretroviral drugs and immune reconstitution inflammatory syndrome are not uncommon. Early recognition and appropriate management of these consequences can reinforce the successful integrated therapy in HIV-infected patients with cryptococcosis.
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11
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Abstract
Cryptococcosis is an invasive mycosis caused by pathogenic encapsulated yeasts in the genus Cryptococcus. Cryptococcus gained prominence as a pathogen capable of widespread disease outbreaks in vulnerable populations. We have gained insight into the pathobiology of Cryptococcus, including the yeast' s capacity to adapt to environmental pressures, exploit new geographic environments, and cause disease in both immunocompromised and apparently immunocompetent hosts. Inexpensive, point-of-care testing makes diagnosis more feasible than ever. The associated worldwide burden and mortality remains unacceptably high. Novel screening strategies and preemptive therapy offer promise at making a sustained and much needed impact on this sugar-coated opportunistic mycosis.
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Affiliation(s)
- Eileen K Maziarz
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, DUMC Box 102359, 315 Trent Drive, Durham, NC 27710, USA.
| | - John R Perfect
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, DUMC Box 102359, 315 Trent Drive, Durham, NC 27710, USA
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12
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Coelho C, Casadevall A. Cryptococcal therapies and drug targets: the old, the new and the promising. Cell Microbiol 2016; 18:792-9. [PMID: 26990050 DOI: 10.1111/cmi.12590] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 02/28/2016] [Accepted: 03/08/2016] [Indexed: 01/09/2023]
Abstract
Half a century after the introduction of Amphotericin B the management of cryptococcosis remains unsatisfactory. The disease, caused primarily by the two fungal species Cryptococcus neoformans and Cryptococcus gattii, remains responsible for considerable morbidity and mortality despite standard medical care. Current therapeutic options are limited to Amphotericin B, azoles and 5-flucytosine. However, this organism has numerous well-characterized virulence mechanisms that are amenable to pharmacological interference and are thus potential therapeutic targets. Here, we discuss existing approved antifungal drugs, resistance mechanisms to these drugs and non-standard antifungal drugs that have potential in treatment of cryptococcosis, including immunomodulatory strategies that synergize with antifungal drugs, such as cytokine administration or monoclonal antibodies. Finally, we summarize attempts to target well-described virulence factors of Cryptococcus, the capsule or fungal melanin. This review emphasizes the pressing need for new therapeutic alternatives for cryptococcosis.
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Affiliation(s)
- Carolina Coelho
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Arturo Casadevall
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Deshayes S, Bouvier N, Chatelet V, Hurault de Ligny B, Dargère S, Bonhomme J, Béchade C. Severe cryptococcal-associated neurological immune reconstitution inflammatory syndrome in a renal transplant recipient treated with adalimumab. Transpl Infect Dis 2016; 18:461-465. [PMID: 26929435 DOI: 10.1111/tid.12522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/09/2016] [Accepted: 02/13/2016] [Indexed: 12/18/2022]
Abstract
Cryptococcosis is a major concern in organ transplant recipients. A decrease in immunosuppressants following the initiation of antifungal therapy is currently recommended, but can occasionally be complicated by the onset of immune reconstitution inflammatory syndrome (IRIS). We report on a case of cryptococcosis in a kidney transplant recipient, compounded by severe neurological IRIS, the outcome of which was unfavorable despite the use of anti-tumor necrosis factor-alpha monoclonal antibodies.
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Affiliation(s)
- S Deshayes
- Department of Internal Medicine, CHU de Caen, Caen, France
| | - N Bouvier
- Department of Nephrology, CHU de Caen, Caen, France
| | - V Chatelet
- Department of Nephrology, CHU de Caen, Caen, France
| | | | - S Dargère
- Department of Infectious Diseases, CHU de Caen, Caen, France
| | - J Bonhomme
- Department of Microbiology, CHU de Caen, Caen, France
| | - C Béchade
- Department of Nephrology, CHU de Caen, Caen, France
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14
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Cryptococcosis. DIAGNOSIS AND TREATMENT OF FUNGAL INFECTIONS 2015. [PMCID: PMC7122569 DOI: 10.1007/978-3-319-13090-3_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cryptococcosis is an infectious disease caused by the encapsulated fungi Cryptococcus neoformans and Cryptococcus gattii. Once a relatively uncommon cause of human disease, cryptococcal infection can develop in apparently immunocompetent hosts and has emerged as an important opportunistic infection in humans over the past several decades as immunocompromised populations expand in the setting of HIV/AIDS, organ transplantation, malignancies, and treatment for other conditions. Clinical manifestations are myriad but pulmonary and central nervous system (CNS) infections are the most common. Improvements in diagnostic testing and standardized approaches to antifungal therapy, when available, have made considerable impact in the management of this infection. While the widespread use of highly active antiretroviral therapy (HAART) has improved the outcome of cryptococcosis in many HIV-infected patients, cryptococcosis remains an entity of considerable morbidity and mortality in many parts of the world, and restoration of host immunity can present management challenges that require individualized management. As immunocompromised populations continue to expand, it is likely that cryptococcosis will remain an important opportunistic fungal infection of humans requiring ongoing investigation.
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Bahr NC, Wallace J, Frosch AEP, Boulware DR. Unmasking Cryptococcal Meningitis Immune Reconstitution Inflammatory Syndrome due to Granulocyte Colony-Stimulating Factor Use in a Patient with a Poorly Differentiated Germ Cell Neoplasm. Case Rep Oncol 2014; 7:1-5. [PMID: 24575007 PMCID: PMC3934776 DOI: 10.1159/000357666] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cryptococcal meningitis immune reconstitution inflammatory syndrome (IRIS) is frequently seen in patients with HIV and less frequently in patients on immune suppressive medications for other conditions. Here, we describe the first reported case of unmasking cryptococcal IRIS due to granulocyte colony-stimulating factor used in an HIV-negative patient with chemotherapy-induced neutropenia.
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Affiliation(s)
- Nathan C Bahr
- Department of MedicineCenter for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Center for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minn., USA
| | - James Wallace
- Department of MedicineCenter for Infectious Diseases and Microbiology Translational Research, Minn., USA
| | - Anne E P Frosch
- Department of MedicineCenter for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Center for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minn., USA
| | - David R Boulware
- Department of MedicineCenter for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Center for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minn., USA
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16
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Bahr N, Boulware DR, Marais S, Scriven J, Wilkinson RJ, Meintjes G. Central nervous system immune reconstitution inflammatory syndrome. Curr Infect Dis Rep 2013; 15:583-93. [PMID: 24173584 PMCID: PMC3883050 DOI: 10.1007/s11908-013-0378-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Central nervous system immune reconstitution inflammatory syndrome (CNS-IRIS) develops in 9 %-47 % of persons with HIV infection and a CNS opportunistic infection who start antiretroviral therapy and is associated with a mortality rate of 13 %-75 %. These rates vary according to the causative pathogen. Common CNS-IRIS events occur in relation to Cryptococcus, tuberculosis (TB), and JC virus, but several other mycobacteria, fungi, and viruses have been associated with IRIS. IRIS symptoms often mimic the original infection, and diagnosis necessitates consideration of treatment failure, microbial resistance, and an additional neurological infection. These diagnostic challenges often delay IRIS diagnosis and treatment. Corticosteroids have been used to treat CNS-IRIS, with variable responses; the best supportive evidence exists for the treatment of TB-IRIS. Pathogenic mechanisms vary: Cryptococcal IRIS is characterized by a paucity of cerebrospinal inflammation prior to antiretroviral therapy, whereas higher levels of inflammatory markers at baseline predispose to TB meningitis IRIS. This review focuses on advances in the understanding of CNS-IRIS over the past 2 years.
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Affiliation(s)
- Nathan Bahr
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, MTRF 3-222, 2001 6th Street SE, Minneapolis, MN 55455, USA
| | - David R. Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, MTRF 3-222, 2001 6th Street SE, Minneapolis, MN 55455, USA
| | - Suzaan Marais
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - James Scriven
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- Liverpool School of Tropical Medicine, Liverpool University, Liverpool, UK
| | - Robert J. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- Department of Medicine, Imperial College London, London W2 1PG, UK
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
- National Institute of Medical Research, London, UK
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- Department of Medicine, Imperial College London, London W2 1PG, UK
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
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17
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Demoruelle MK, Kahr A, Verilhac K, Deane K, Fischer A, West S. Recent-onset systemic lupus erythematosus complicated by acute respiratory failure. Arthritis Care Res (Hoboken) 2013; 65:314-23. [PMID: 22972558 DOI: 10.1002/acr.21857] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/31/2012] [Indexed: 01/15/2023]
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18
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Young BE, Yeo TR, Lim HT, Vong KY, Tan K, Lye DC, Lee CC. Progressive Multifocal Leukoencephalopathy with Immune Reconstitution Inflammatory Syndrome (PML-IRIS): Two Case Reports of Successful Treatment with Mefloquine and a Review of the Literature. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2012. [DOI: 10.47102/annals-acadmedsg.v41n12p620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Hui Ting Lim
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Kiat Yee Vong
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Kevin Tan
- National Neuroscience Institute, Singapore
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19
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[Immune reconstitution syndrome]. Z Rheumatol 2012; 71:187-98. [PMID: 22527213 DOI: 10.1007/s00393-011-0858-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) represents a heterogeneous group of conditions. Whilst they typically present in HIV-infected patients with advanced immunodeficiency, IRIS have also been described in HIV-negative patients with immune reconstitution due to other causes of immunosuppression. Frequently IRIS results from an immune response against underlying infection (pathogen-associated IRIS). However, IRIS might become evident during immune reconstitution without an underlying pathogen such as a sarcoid-like illness or an autoimmune thyropathy. Here we report on the epidemiology and risk factors of IRIS along with diagnosis and management of this clinically important inflammatory syndrome.
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20
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Maziarz EK, Perfect JR. IRIS and Fungal Infections: What Have We Learned? CURRENT FUNGAL INFECTION REPORTS 2012. [DOI: 10.1007/s12281-011-0075-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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21
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Current world literature. Curr Opin Organ Transplant 2011; 16:650-60. [PMID: 22068023 DOI: 10.1097/mot.0b013e32834dd969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Yong L. Cryptococcal immune reconstitution syndrome in HIV-negative patients. Int J Infect Dis 2011; 15:e884. [PMID: 21982695 DOI: 10.1016/j.ijid.2011.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 09/01/2011] [Indexed: 11/28/2022] Open
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