The prognostic factors of HIV-negative adult cryptococcal meningitis with a focus on cranial MRI-based neuroimaging findings

Reframing the clinical phenotype and management of cryptococcal meningitis

Cryptococcal meningitis is an important global health problem, resulting from infection with the yeast Cryptococcus, especially Cryptococcus neoformans and Cryptococcus gattii, which cause a spectrum of disease ranging from pulmonary and skin lesions to life-threatening central nervous system involvement. The diagnosis and management of cryptococcal meningitis have substantially changed in recent years. Cryptococcal meningitis often occurs in people living with advanced HIV infection, though in high-income countries with robust HIV detection and treatment programmes, it increasingly occurs in other groups, notably solid-organ transplant recipients, other immunosuppressed patients and even immunocompetent hosts. This review outlines the clinical presentation, management and prognosis of cryptococcal meningitis, including its salient differences in people living with HIV compared with HIV-negative patients. We discuss the importance of managing raised intracranial pressure and highlight the advantages of improved multidisciplinary team working involving neurologists, infectious disease specialists and neurosurgeons.

Clinical characteristics and aetiological analysis of combined central and pulmonary cryptococcal infection: Clinical cases

This paper presents a summary of seven cases of combined pulmonary and central cryptococcal infection and analyses of their clinical features, treatment and prognosis. No clear correlation was identified between the intracranial cryptococcal capsular antigen titre and either the intracranial pressure or the amount of protein in the cerebrospinal fluid. Pulmonary lesions may develop in any of the lung lobes and manifest in multiple forms. Infection at the central level is predominantly meningitis. As the central cerebrospinal fluid (CSF) capsular antigen titre can be considerably elevated even when serum capsular antigen titres are markedly low, lumbar puncture and subsequent analysis are essential for every case of pulmonary cryptococcal infection. Patients with renal insufficiency or who refused intravenous treatment opted for oral fluconazole therapy, and their prognoses were favourable.

Association between neuroimaging and clinical outcomes in individuals with central nervous system cryptococcosis

BACKGROUND

The radiological manifestations of central nervous system (CNS) cryptococcosis are diverse and often subtle. There is heterogeneity on how different neuroimaging patterns impact prognosis. This study aims to assess the association between the neuroimaging and clinical outcomes of CNS cryptococcosis.

METHODS

All patients with CNS cryptococcosis between July 2017 and April 2023 who underwent brain magnetic resonance imaging (MRI) were included. The primary outcome was mortality during hospitalisation. Secondary outcomes were readmission, ventricular shunting, duration of hospitalisation and time to the first negative cerebrospinal fluid culture. We compared the outcomes for each of the five main radiological findings on the brain MRI scan.

RESULTS

We included 46 proven CNS cryptococcosis cases. The two main comorbidity groups were HIV infection (20, 43%) and solid organ transplantation (10, 22%), respectively. Thirty-nine patients exhibited at least one radiological abnormality (85%), with the most common being meningeal enhancement (34, 74%). The mortality rates occurred at 11% (5/46) during hospitalisation. We found no significant disparities in mortality related to distinct radiological patterns. The presence of pseudocysts was significantly associated with the need for readmission (p = .027). The ventricular shunting was significantly associated with the presence of pseudocysts (p = .005) and hydrocephalus (p = .044).

CONCLUSION

In this study, there is no association between brain MRI findings and mortality. Larger studies are needed to evaluate this important issue.

Clinical treatment of cryptococcal meningitis: an evidence-based review on the emerging clinical data

Cryptococcal meningitis (CM) is a fatal fungal central nervous system (CNS) infection caused by Cryptococcus infecting the meninges and/or brain parenchyma, with fever, headache, neck stiffness, and visual disturbances as the primary clinical manifestations. Immunocompromised individuals with human immunodeficiency virus (HIV) infection or who have undergone organ transplantation, as well as immunocompetent people can both be susceptible to CM. Without treatment, patients with CM may have a mortality rate of up to 100% after hospital admission. Even after receiving therapy, CM patients may still suffer from problems such as difficulty to cure, poor prognosis, and high mortality. Therefore, timely and effective treatment is essential to improve the mortality and prognosis of CM patients. Currently, the clinical outcomes of CM are frequently unsatisfactory due to limited drug choices, severe adverse reactions, drug resistance, etc. Here, we review the research progress of CM treatment strategies and discuss the suitable options for managing CM, hoping to provide a reference for physicians to select the most appropriate treatment regimens for CM patients.

Construction and validation of a nomogram model to predict the poor prognosis in patients with pulmonary cryptococcosis

Background

Patients with poor prognosis of pulmonary cryptococcosis (PC) are prone to other complications such as meningeal infection, recurrence or even death. Therefore, this study aims to analyze the influencing factors in the poor prognosis of patients with PC, so as to build a predictive nomograph model of poor prognosis of PC, and verify the predictive performance of the model.

Methods

This retrospective study included 410 patients (78.1%) with improved prognosis of PC and 115 patients (21.9%) with poor prognosis of PC. The 525 patients with PC were randomly divided into the training set and validation set according to the ratio of 7:3. The Least Absolute Shrinkage and Selection Operator (LASSO) algorithm was used to screen the demographic information, including clinical characteristics, laboratory test indicators, comorbidity and treatment methods of patients, and other independent factors that affect the prognosis of PC. These factors were included in the multivariable logistic regression model to build a predictive nomograph. The receiver operating characteristic curve (ROC), calibration curve and decision curve analysis (DCA) were used to verify the accuracy and application value of the model.

Results

It was finally confirmed that psychological symptoms, cytotoxic drugs, white blood cell count, hematocrit, platelet count, CRP, PCT, albumin, and CD4/CD8 were independent predictors of poor prognosis of PC patients. The area under the curve (AUC) of the predictive model for poor prognosis in the training set and validation set were 0.851 (95% CI: 0.818-0.881) and 0.949, respectively. At the same time, calibration curve and DCA results confirmed the excellent performance of the nomogram in predicting poor prognosis of PC.

Conclusion

The nomograph model for predicting the poor prognosis of PC constructed in this study has good prediction ability, which is helpful for improving the prognosis of PC and further optimizing the clinical management strategy.

Cryptococcal meningitis in apparently immunocompetent patients

Cryptococcal meningitis (CM) is an invasive fungal disease that currently poses a threat to human health worldwide, with high morbidity and mortality, particularly in immunocompromised patients. Although CM mainly occurs in HIV-positive patients and other immunocompromised patients, it is also increasingly seen in seemingly immunocompetent hosts. The clinical characteristics of CM between immunocompromised and immunocompetent populations are different. However, few studies have focussed on CM in immunocompetent individuals. This review summarizes the clinical characteristics of apparently immunocompetent CM patients in terms of aetiology, immune pathogenesis, clinical presentation, laboratory data, imaging findings, treatment strategies and prognosis. It is of great significance to further understand the disease characteristics of CM, explore new treatment strategies and improve the prognosis of CM in immunocompetent individuals.

Neuroimaging of Cryptococcal Meningitis in Patients without Human Immunodeficiency Virus: Data from a Multi-Center Cohort Study

BACKGROUND

A clearer understanding is needed about the use of brain MRI in non-HIV patients with cryptococcal meningitis.

METHODS

Cerebral CT and MRI were studied in 62 patients in a multicenter study of cryptococcal meningitis in non-HIV patients. CT was performed in 51 and MRI in 44. MRI results are reported for the images read at NIH for 29 of the 44 patients. CT reports obtained from the original REDCap database were added to calculate the incidence of normal findings.

RESULTS

CTs were read as normal in 24 of 51 (47%), MRIs were normal in 10% (three of 29). The most characteristic lesions of cryptococcal meningitis on MRI were small basal ganglia lesions representing dilated perivascular spaces in 24% and basal ganglia lesions with restricted diffusion (infarcts) in 38%. In the 18 patients who received contrast, contrast-enhancing lesions, likely representing masses of cryptococci and inflammatory cells, were found in the basal ganglia in 22% and elsewhere in the brain in 22%. Meningeal enhancement was seen in 56%, ependymal enhancement in 24%, and choroid plexus enhancement in 11%. Hydrocephalus was found in five (18%), though increased intacranial pressure was not detected. Suboptimal imaging (n = 6), lack of contrast administration (n = 11) and lack of follow-up, however, markedly limited the accurate assessment of abnormalities in multiple cases.

CONCLUSION

MRI characteristics of non-HIV cryptococcal meningitis include hydrocephalus, meningeal and ependymal enhancement and basal ganglia lesions. Optimal imaging is, however, necessary to maximize the diagnostic and prognostic usefulness of MRI.

Cerebral infarction in HIV-negative patients with cryptococcal meningitis: its predictors and impact on outcomes

Background

Descriptions of the patterns of acute/subacute cerebral infarction (ASCI) in HIV-negative patients with cryptococcal meningitis (CM) are scarce, and the predictors of ischemic stroke and outcomes following ASCI remain unclear.

Aim

To study the clinical characteristics and evaluate the predictors of ASCI in HIV-negative patients with CM and assess the impact of ischemic stroke on the outcomes of the patients.

Methods

We retrospectively analyzed the data of 61 HIV-negative patients with CM treated between January, 2016 and February, 2022, and among them, 53 patients with complete neuroimaging and cerebrospinal fluid (CSF) data were enrolled in this study. The cohort was stratified by the occurrence of ASCI diagnosed based on MRI evidences for comparison of the clinical characteristics (consciousness disturbance, GCS score, duration of symptoms, and treatment), CSF parameters, imaging findings (meningeal inflammation, hydrocephalus, posterior fossa exudates) and outcomes of the patients. A favorable outcome was defined as a modified Rankin scale (mRS) score ≤ 2 and a poor outcome as a mRS score > 2. Logistic regression analysis was used to identify the risk factors of ASCI in the HIV-negative patients with CM.

Results

Of the 53 HIV-negative patients with CM, 14 (26.4%) had ASCI. The incidences of fever, headache, neck stiffness, duration of symptoms, CSF parameters, meningeal enhancement in brain MRI and the treatment regimens were similar between the patients with and those without ASCI. Most of the infarcts (92.9%) were of the lacunar type, involving both the anterior and posterior territories. Basal ganglia-corona radiata and the brainstem-cerebellum were the most frequently involved sites. Univariate logistic regression analysis suggested that consciousness disturbance (P = 0.002), MRI evidence of hydrocephalus (P = 0.042) and posterior fossa exudates (P = 0.028) were predictors of ASCI in these HIV-negative patients with CM. Multivariate analysis identified consciousness disturbance as a significant predictor of ASCI (P = 0.020). Compared with the patients without ASCI, the HIV-negative patients with CM and ASCI had poorer outcomes (P = 0.001).

Conclusion

ASCI can occur in HIV-negative patients with CM, presented commonly as multiple lacunar infarctions involving all the cerebrovascular territories. The presence of consciousness disturbance, hydrocephalus and posterior fossa exudates may increase the risk of ASCI in patients with CM. ASCI is associated with a poor outcome of the HIV-negative patients with CM.

Cryptococcosis complicating diabetes mellitus: a scoping review

BACKGROUND

A better understanding of the epidemiology of cryptococcal infection in HIV-negative individuals is an international research interest. Immune dysfunction in diabetes mellitus (DM) significantly increases the risk of acquiring and reactivation of infection due to Cryptococcus neoformans. Risk factors and outcomes of cryptococcosis in DM are not well documented.

OBJECTIVE

The objective of this study was to determine the clinical characteristics and outcomes of cryptococcal infections in persons living with DM.

METHODS

MEDLINE (via PubMed), EMBASE, and the Cochrane Library databases were searched in November 2020. The searches covered the period between 1980 and 2020.We included studies that reported confirmed cryptococcosis in patients with DM. Reference lists of included articles were also searched, and additional studies were included if appropriate. No language restriction was applied. Single case reports, case series and original articles were included whereas review articles were excluded.

RESULTS

A total of 28 studies (24 single case reports, 4 retrospectives) were included involving 47 unique patients from Asia (17 cases), North America (six cases), South America (three cases) and Africa (two cases). Men constituted 75% (n = 18) of the cases. Median age was 60.5 (range: 27-79) years. The majority of the patients had cryptococcal meningitis (68.1%, n = 32) followed by disseminated cryptococcosis (6.4%, n = 7), and others (isolated cutaneous disease one, peritonitis one, pleural one, thyroid one, adrenal one). Diagnosis was achieved through either culture and microscopy (38/47), cryptococcal antigen tests (9/47) or histopathology (9/47) singly or in a combination. All-cause mortality was 38.3% (n = 18). Among those with meningitis mortality was 36.2%.

CONCLUSION

A wide spectrum of cryptococcal infections with varying severity occurs in DM. Mortality remains unacceptably high. There is a need for more studies to characterize better cryptococcal disease in DM.

Cryptococcal meningitis presented as sudden hearing loss: A case study

BACKGROUND

This case report emphasizes that cryptococcal meningitis could be uncommonly presented to otolaryngologists as sudden onset of hearing loss, especially in patients with underlying diseases that could cause immunocompromise, and highlights the importance of differentiated diagnosis on sudden hearing loss before steroid therapy. It also demonstrates that prompt and sufficient fungicidal therapy with appropriate supportive treatment is crucial for a good prognosis on cryptococcal meningitis.

CASE PRESENTATION

A diabetic adult with untreated chronic hepatitis B was admitted complaining of sudden onset of left-sided hearing loss, following unexpected aggravating headache with meningeal signs after hospitalization with days of intratympanic steroid therapy. Cryptococcal meningitis was confirmed through lumbar puncture showing positive India ink staining and microbial culture of the cerebrospinal fluid (CSF). Fortunately, the patient recovered after prompt and adequate fungicidal therapy plus appropriate supportive treatment at last, though persistent hearing loss remained.

CONCLUSIONS

Cryptococcal meningitis could be presented in a very concealed way as sudden hearing loss, especially in patients with underlying diseases that could cause immunosuppression. Differentiated diagnosis on sudden hearing loss before steroid therapy is important.

The clinical characteristics of adult cryptococcal meningitis patients who died within one year of treatment with a focus on those with early mortality

Cryptococcal meningitis (CM) is a serious infectious disease of the central nervous system, and associated brain injuries can be found in the very early stage of disease. In this study, 92 adult CM patients (59 men, 33 women; median age 54.66 years, range 20-86 years) were enrolled, and their clinical, laboratory, neuroimaging features and therapeutic outcomes were analyzed. Two main clinical comparative analyses of the clinical characteristics and laboratory and neuroimaging features were made in this study. The first compared clinical differences between the survivors and non-survivors of all enrolled patients, and the second compared differences between the following three groups: Group I, the patients who died within 14 days of initiating treatment; Group II, the patients who died within 15 days to 1 year of initiating treatment, and Group III, the patients who survived for more than 1 year after initiating treatment. Prognostic factors including initial altered consciousness, increased cerebrospinal fluid (CSF) lactate level and the presence of cryptococcemia were significantly different between the different groups. The patients with early mortality had a higher CSF lactate level and higher rate of cryptococcemia. The presence of cryptococcemia was an important prognostic factor, and the patients with cryptococcemia had a higher incidence of positive CSF India ink stain. Further large-scale studies are needed to delineate the clinical and laboratory features of CM patients with early mortality.

The clinical characteristics and therapeutic outcomes of cryptococcal meningitis in elderly patients: a hospital-based study

BACKGROUND

The elderly, and especially those with an immuno-compromised status, are vulnerable to infectious diseases. The purpose of this study was to examine the clinical characteristics and therapeutic outcomes of cryptococcal meningitis (CM) in elderly patients in Taiwan.

METHODS

Ninety-nine adult patients with CM were identified during a 15-year study period (2002-2016), of whom 38 elderly (≥ 65 years) patients (16 men and 22 women, median age 72.9 years; range 65-86 years) were included for analysis. The clinical characteristics and therapeutic outcomes of these patients were analyzed and compared to non-elderly adult patients (< 65 years) with CM.

RESULTS

Among the 38 patients, diabetes mellitus was the most common underlying condition (15), followed by adrenal insufficiency (7), malignancy (6), hematologic disorders (5), chronic obstructive pulmonary disease (5), autoimmune diseases (3), liver cirrhosis (3) and acquired immunodeficiency syndrome (1). Altered consciousness (29), fever (21) and headache (17) were the leading clinical manifestations. Positive cerebrospinal fluid and blood cultures for Cryptococcus (C.) neoformans were found in 26 and 9 patients, respectively. There were significant differences in gender, altered consciousness and recent cerebral infarction between the elderly and non-elderly groups. The elderly group had a high mortality rate (36.8%, 14/38), and the presence of cryptococcemia was the most significant prognostic factor.

CONCLUSIONS

This study offers a preliminary view of the clinical characteristics of CM in the elderly. The results suggest that elderly patients (≥ 65 years) are more vulnerable to CM than adults aged < 65 years. Compared to the non-elderly group, the elderly group had female predominance, higher rates of altered consciousness and recent cerebral infarction as the clinical presentation. The presence of cryptococcemia was a significant prognostic factor in the elderly group. This study is limited by the small number of patients, and further large-scale studies are needed to better delineate this specific infectious syndrome.