2
|
Stack M, Hiles J, Valinetz E, Gupta SK, Butt S, Schneider JG. Cryptococcal Meningitis in Young, Immunocompetent Patients: A Single-Center Retrospective Case Series and Review of the Literature. Open Forum Infect Dis 2023; 10:ofad420. [PMID: 37636518 PMCID: PMC10456216 DOI: 10.1093/ofid/ofad420] [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: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
Background Cryptococcal meningitis is an uncommon but serious infection with high mortality and morbidity. Classically described in immunocompromised patients, including those with solid organ transplants or HIV/AIDS, cryptococcosis has also been reported in young and otherwise healthy patients, albeit rarely. Methods We retrospectively searched for all cases of cryptococcal meningitis in young (≤50 years) and previously healthy patients with no known immunocompromising conditions from January 2015 to January 2022 at Indiana University Health (IU Health). Additionally, a PubMed literature review was performed with the keywords "cryptococcal meningitis" and "immunocompetent" from January 1988 to January 2022. Clinical courses, including outcomes and treatment regimens, were evaluated. Results We identified 4 local cases of cryptococcal meningitis in otherwise healthy patients age ≤50 years. Three cases were due to Cryptococcus neoformans, with 1 experiencing a postinfectious inflammatory response syndrome (PIIRS). The PubMed search identified 51 additional cases, with 32 (63%) being caused by Cryptococcus neoformans and 8 (17%) by Cryptococcus gattii. Of the 51 cases, only 2 resulted in death directly due to cryptococcosis. Fifteen (29%) had PIIRS, with steroid treatment documented in 11 of 15. Antifungal induction regimens and duration were varied but predominately consisted of amphotericin and flucytosine, with a mean induction duration of 5.0 weeks. Conclusions Cryptococcal meningitis in young, previously healthy patients is likely under-recognized. PIIRS (akin to immune reconstitution inflammatory syndrome observed in HIV/AIDS) with prolonged recovery should be of concern. Determining risk factors for cryptococcosis in these patients remains elusive.
Collapse
Affiliation(s)
- Matthew Stack
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jon Hiles
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Health, Indianapolis, Indiana, USA
| | - Ethan Valinetz
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samir K Gupta
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Saira Butt
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jack G Schneider
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
3
|
Seetahal-Maraj P, Giddings S, Ramcharan K, Ramnarine N. Obstructive Hydrocephalus Secondary to Cryptococcal Meningitis in an Immunocompetent Adult. Cureus 2021; 13:e18975. [PMID: 34820230 PMCID: PMC8606177 DOI: 10.7759/cureus.18975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 11/10/2022] Open
Abstract
Cryptococcal infections of the central nervous system (CNS) are common opportunistic infections in immunocompromised hosts. They can occur in immunocompetent hosts, and this has been documented in isolated case reports. Rapid neurological deterioration can be seen, particularly with hydrocephalus, and diagnosis can be difficult without a high index of suspicion. Treatment arms include prolonged antifungal therapy and cerebrospinal fluid (CSF) diversion procedures. We present a case of a middle-aged immunocompetent male, who presented with an acute confusional state and papilledema. An urgent computed tomography (CT) and magnetic resonance imaging (MRI) revealed obstructive hydrocephalus, and an external ventricular drain was placed. CSF samples were collected, and analysis revealed cryptococcal infection. He was treated with antifungal therapy but failed external ventricular drain challenging. A ventriculoperitoneal shunt was placed after negative CSF studies were obtained. While uncommon, cryptococcal meningitis in immunocompetent hosts can present with obstructive hydrocephalus. It can result in rapid neurological decline and death. Emergent CSF diversion and antifungal therapy are the primary treatment modalities. CSF diversion may be permanently required in some cases.
Collapse
Affiliation(s)
| | - Stanley Giddings
- Faculty of Clinical Medical Sciences, The University of the West Indies, Trinidad, TTO
| | | | | |
Collapse
|
4
|
Fisher KM, Montrief T, Ramzy M, Koyfman A, Long B. Cryptococcal meningitis: a review for emergency clinicians. Intern Emerg Med 2021; 16:1031-1042. [PMID: 33420904 DOI: 10.1007/s11739-020-02619-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 12/23/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization. OBJECTIVE This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM. DISCUSSION This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS). CONCLUSIONS CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.
Collapse
Affiliation(s)
- Kathryn Marie Fisher
- Department of Emergency Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Tim Montrief
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace St., Pittsburgh, PA, 15261, USA
| | - Mark Ramzy
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace St., Pittsburgh, PA, 15261, USA
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.
| |
Collapse
|
5
|
Erturk Sengel B, Tukenmez Tigen E, Can Sarinoglu R, Midi I, Cerikcioglu N, Odabasi Z. Cryptococcus meningitis presented with multiple cerebral infarcts in an immunocompetent patient. IDCases 2021; 24:e01154. [PMID: 34026541 PMCID: PMC8131984 DOI: 10.1016/j.idcr.2021.e01154] [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: 06/11/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 11/30/2022] Open
Abstract
Cryptococcus neoformans is generally observed with immunosuppressive conditions. Rarely, it may be seen in immunocompetent individuals and presented with non-specific conditions. We described an immunocompetent case of cryptococcal meningitis presented with multiple cerebral infarcts. Despite the late diagnosis and emergence of hydrocephalus during treatment, the patient was recovered without any sequelae. In immunocompetent patients, the conventional diagnostics tests may be negative because of the low fungal load. If it is available, the Biofire FilmArray meningitis panel has high sensitivity and specificity for diagnosis.
Collapse
Affiliation(s)
- Buket Erturk Sengel
- Marmara University, Faculty of Medicine, Infectious Disease and Clinical Microbiology, Istanbul, Turkey
- Corresponding author at: Marmara Üniversitesi Pendik Eğitim ve Araştırma Hastanesi, Fevzi Çakmak Mah. Muhsin Yazıcıoğlu Cad. No:10, Pendik, İstanbul, Turkey.
| | - Elif Tukenmez Tigen
- Marmara University, Faculty of Medicine, Infectious Disease and Clinical Microbiology, Istanbul, Turkey
| | - Rabia Can Sarinoglu
- Marmara University, Faculty of Medicine, Medical Microbiology, Istanbul, Turkey
| | - Ipek Midi
- Marmara University, Faculty of Medicine, Neurology, Istanbul, Turkey
| | - Nilgun Cerikcioglu
- Marmara University, Faculty of Medicine, Medical Microbiology, Istanbul, Turkey
| | - Zekaver Odabasi
- Marmara University, Faculty of Medicine, Infectious Disease and Clinical Microbiology, Istanbul, Turkey
| |
Collapse
|
7
|
Khattab A, Patruni S, Sealey ML. Rare presentation of cryptococcal meningitis in an immunocompetent patient. BMJ Case Rep 2019; 12:12/5/e230003. [PMID: 31142492 DOI: 10.1136/bcr-2019-230003] [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] [Indexed: 01/15/2023] Open
Abstract
Cryptococcal meningitis is an opportunistic infection predominantly affecting immunocompromised patients but rarely can affect the immunocompetent. We describe a 53-year-old Caucasian man who presented complaining of a 2-week history of severe bilateral eye pain and diplopia. His only known risk factor was that he lived in a horse farm and recently shot bats and pigeons in his barn. He visited an outside hospital during this time without a diagnosis established. After further deliberation, we obtained a lumbar puncture (LP) which revealed an opening pressure (OP) of 27 cm H2O. Cerebrospinal fluid (CSF) and fungal cultures confirmed the presence of Cryptococcus neoformans The patient was diagnosed with C. neoformans-mediated meningoencephalitis and was initiated on the appropriate induction anti-fungal therapy. This case emphasises the need for clinicians to remain vigilant and consider cryptococcal meningitis in immunocompetent individuals even when classic symptoms of meningitis are absent.
Collapse
Affiliation(s)
- Ahmed Khattab
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sunita Patruni
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Mary L Sealey
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
8
|
Cogliati M, Desnos-Ollivier M, McCormick-Smith I, Rickerts V, Ferreira-Paim K, Meyer W, Boekhout T, Hagen F, Theelen B, Inácio J, Alonso B, Colom MF, Trilles L, Montagna MT, De Donno A, Susever S, Ergin C, Velegraki A, Ellabib MS, Nardoni S, Macci C, Trovato L, Dipineto L, Akcaglar S, Mlinaric-Missoni E, Bertout S, Vencá ACF, Sampaio AC, Criseo G, Ranque S, Çerikçioğlu N, Marchese A, Vezzulli L, Ilkit M, Pasquale V, Polacheck I, Lockhart SR. Genotypes and population genetics of cryptococcus neoformans and cryptococcus gattii species complexes in Europe and the mediterranean area. Fungal Genet Biol 2019; 129:16-29. [PMID: 30953839 DOI: 10.1016/j.fgb.2019.04.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 02/06/2023]
Abstract
A total of 476 European isolates (310 Cryptococcus neoformans var. grubii, 150 C. neoformans var. neoformans, and 16 C. gattii species complex) from both clinical and environmental sources were analyzed by multi-locus sequence typing. Phylogenetic and population genetic analyses were performed. Sequence analysis identified 74 sequence types among C. neoformans var. neoformans (VNIV), 65 among C. neoformans var. grubii (56 VNI, 8 VNII, 1 VNB), and 5 among the C. gattii species complex (4 VGI and 1 VGIV) isolates. ST23 was the most frequent genotype (22%) among VNI isolates which were mostly grouped in a large clonal cluster including 50% of isolates. Among VNIV isolates, a predominant genotype was not identified. A high percentage of autochthonous STs were identified in both VNI (71%) and VNIV (96%) group of isolates. The 16 European C. gattii species complex isolates analyzed in the present study originated all from the environment and all belonged to a large cluster endemic in the Mediterranean area. Population genetic analysis confirmed that VNI group of isolates were characterized by low variability and clonal expansion while VNIV by a higher variability and a number of recombination events. However, when VNI and VNIV environmental isolates were compared, they showed a similar population structure with a high percentage of shared mutations and the absence of fixed mutations. Also linkage disequilibrium analysis reveals differences between clinical and environmental isolates showing a key role of PLB1 allele combinations in host infection as well as the key role of LAC1 allele combinations for survival of the fungus in the environment. The present study shows that genetic comparison of clinical and environmental isolates represents a first step to understand the genetic characteristics that cause the shift of some genotypes from a saprophytic to a parasitic life style.
Collapse
Affiliation(s)
- Massimo Cogliati
- Dip. Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy.
| | - Marie Desnos-Ollivier
- Institut Pasteur, Molecular Mycology Unit, National Reference Center for Invasive Mycoses & Antifungal, CNRS UMR2000, Paris, France
| | | | | | - Kennio Ferreira-Paim
- Molecular Mycology Research Laboratory, Center for Infectious Diseases, Faculty of Medicine and Health, Sydney Medical School, Westmead Clinical School, Marie Bashier Institute for Emerging Infectious Diseases and Biosecurity, University of Sydney, Westmead Hospital, (Research and Educational Network) Westmead Institute for Medical Research, Westmead, NSW, Australia; Department of Microbiology, Federal University of Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Center for Infectious Diseases, Faculty of Medicine and Health, Sydney Medical School, Westmead Clinical School, Marie Bashier Institute for Emerging Infectious Diseases and Biosecurity, University of Sydney, Westmead Hospital, (Research and Educational Network) Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Teun Boekhout
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands; Institute of Biodiversity and Ecosystem Dynamic (IBED), University of Amsterdam, Amsterdam, the Netherlands
| | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | - Bart Theelen
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | - Joäo Inácio
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK
| | - Beatriz Alonso
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK; Instituto de Investigación Sanitaria Gregorio Marañón (IisGM), Hospital Gegorio Marañón, Madrid, Spain
| | | | | | | | | | | | | | - Aristea Velegraki
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Cristina Macci
- National Research Council, Research Institute on Terrestrial Ecosystems (IRET), Pisa, Italy
| | | | | | | | | | - Sebastien Bertout
- Unité Mixte Internationale "Recherches Translationnelles sur l'infection à VIH et les Maladies Infectieuses", Université de Montpellier, Montpellier, France
| | - Ana C F Vencá
- Instituto de Higiene e Medicina Tropical, Lisbon, Portugal
| | - Ana C Sampaio
- Universidade de Trás-os-Montes e Alto Douro, CITAB, Quinta dos Prados, Vila Real, Portugal
| | - Giuseppe Criseo
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Italy
| | - Stéphane Ranque
- Aix-Marseille University, IRD, APHM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France
| | | | - Anna Marchese
- Sezione di Microbiologia del DISC, Università di Genova-IRCCS Policlinico San Martino Genova, Genova, Italy
| | - Luigi Vezzulli
- Dipartimento di Scienze della Terra, dell'Ambiente e della Vita (DISTAV), Università di Genova, Genova, Italy
| | - Macit Ilkit
- University of Çukurova Sarıçam, Adana, Turkey
| | | | | | | |
Collapse
|