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Liao WK, Hsieh MS, Hu SY, Huang SC, Tsai CA, Chang YZ, Tsai YC. Predictive Performance of Scoring Systems for Mortality Risk in Patients with Cryptococcemia: An Observational Study. J Pers Med 2023; 13:1358. [PMID: 37763126 PMCID: PMC10533170 DOI: 10.3390/jpm13091358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
Cryptococcal infection is usually diagnosed in immunocompromised individuals and those with meningeal involvement, accounting for most cryptococcosis. Cryptococcemia indicates a poor prognosis and prolongs the course of treatment. We use the scoring systems to predict the mortality risk of cryptococcal fungemia. This was a single hospital-based retrospective study on patients diagnosed with cryptococcal fungemia confirmed by at least one blood culture collected from the emergency department covering January 2012 and December 2020 from electronic medical records in the Taichung Veterans General Hospital. We enrolled 42 patients, including 28 (66.7%) males and 14 (33.3%) females with a mean age of 63.0 ± 19.7 years. The hospital stay ranged from 1 to 170 days (a mean stay of 44.4 days), and the overall mortality rate was 64.3% (27/42). In univariate analysis, the AUC of ROC for MEWS, RAPS, qSOFA, MEWS plus GCS, REMS, NEWS, and MEDS showed 0.833, 0.842, 0.848, 0.846, 0.846, 0.878, and 0.905. In the multivariate Cox regression analysis, all scoring systems, older age, lactate, MAP, and DBP, indicated significant differences between survivor and non-survivor groups. Our results show that all scoring systems could apply in predicting the outcome of patients with cryptococcal fungemia, and the MEDS displays the best performance. We recommend a further large-scale prospective study for patients with cryptococcal fungemia.
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Affiliation(s)
- Wei-Kai Liao
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
- School of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan;
| | - Ming-Shun Hsieh
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan;
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan 330, Taiwan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Sung-Yuan Hu
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan;
| | - Shih-Che Huang
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Lung Cancer Research Center, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Che-An Tsai
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Yan-Zin Chang
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- Department of Clinical Laboratory, Drug Testing Center, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Yi-Chun Tsai
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
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Lin K, Lai Y, Lin Y, Ho M, Chen Y, Chung W. Antifungal Susceptibility of the Clinical and Environmental Strains of
Cryptococcus gattii sensu lato
in Taiwan. Mycoses 2022; 66:13-24. [DOI: 10.1111/myc.13520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Kuo‐Hsi Lin
- Tungs’ Taichung MetroHarbor Hospital Taichung Taiwan
- National Chung Hsing University Taichung Taiwan
| | - Yi‐Chyi Lai
- Chung Shan Medical University Taichung Taiwan
| | - Yi‐Pei Lin
- Tungs’ Taichung MetroHarbor Hospital Taichung Taiwan
| | - Mao‐Wang Ho
- China Medical University Hospital Taichung Taiwan
| | | | - Wen‐Hsin Chung
- National Chung Hsing University Taichung Taiwan
- Innovation and Development center of sustainable Agriculture (IDCSA), Taichung Taiwan
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Su XH, Li WP, Liu JY, Wang YJ, Liu J, Xu XF, Yang L, Xia H, Jiang Y, Peng FH. Comparison of features and outcomes between HIV-negative patients with Cryptococcus gattii meningitis and Cryptococcus neoformans meningitis in South China. Mycoses 2022; 65:887-896. [PMID: 35793429 DOI: 10.1111/myc.13491] [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: 04/16/2022] [Revised: 06/16/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare the epidemiologic, clinical, laboratory, and imaging features, and outcomes in patients with Cryptococcus gattii meningitis (CGM) and Cryptococcus neoformans meningitis (CNM). METHODS We performed a retrospective study of HIV-negative patients with CGM and CNM (2015-2021) distinguished by metagenomic next-generation sequencing in cerebrospinal fluid in South China. RESULTS 81 patients (17 CGM, 64 CNM) were enrolled (72.8% male, median age 49 years, range 21-77 years), and CGM patients were younger (median, 43 vs 53 years, p = 0.005). Of 17 CGM, VGI and VGII accounted for 70.6% and 29.4%, respectively. CGM patients had less underlying diseases (7/17 [41.2%] vs 48/64 [75%], p=0.018) and focal neurologic deficit (3/17 [17.6%] vs 35/64 [54.7%], p = 0.022), had higher intracranial pressure (15/17 [88.2%] vs 25/64 [39.1%], p=0.002), more meningeal enhancement (14/17 [82.4%] vs 32/64 [50%], p = 0.034), less parenchymal involvement (median, 1 vs 3, p = 0.018), more lung cryptococcomas (6/12 [50%] vs 6/47 [12.8%], p = 0.014), faster CSF fungal clearance (p = 0.004), less complications (median, 1 vs 3, p < 0.001), and more favorable outcomes (16/17 [94.1%] vs 41/64 [64.1%], p =0.035). CONCLUSIONS This study demonstrated that species identification helps to guide therapy and predict outcomes.
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Affiliation(s)
- Xiao-Hong Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
| | - Wei-Peng Li
- Department of Neurology, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Jun-Yu Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
| | - Yi-Jie Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
| | - Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
| | - Xiao-Feng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
| | - Lu Yang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
| | - Han Xia
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, P. R. China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
| | - Fu-Hua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
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4
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de Oliveira L, Melhem MDSC, Buccheri R, Chagas OJ, Vidal JE, Diaz-Quijano FA. Early clinical and microbiological predictors of outcome in hospitalized patients with cryptococcal meningitis. BMC Infect Dis 2022; 22:138. [PMID: 35139801 PMCID: PMC8830130 DOI: 10.1186/s12879-022-07118-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cryptococcal meningitis causes high mortality in immunocompromised and immunocompetent patients. The objective of this study was to identify early predictors of clinical outcome, available at the first days of hospitalization, in patients with cryptococcal meningitis in a tertiary center in Brazil. Methods Ninety-six cases of cryptococcal meningitis with clinical, epidemiological and laboratory data, and identification and antifungal susceptibility of the strains were analyzed. Quantitative CSF yeast counts were performed by direct microscopic exam with a Fuchs-Rosenthal cell counting chamber using an institutional protocol. Univariable and multiple analyses using logistic regression were performed to identify predictors, available at the beginning of hospitalization, of in-hospital mortality. Moreover, we performed a secondary analysis for a composite outcome defined by hospital mortality and intensive care unit transfer. Results The species and the antifungal susceptibility were not associated with the outcomes evaluated. The variables significantly associated with the mortality were age (OR = 1.08, 95% CI 1.02–1.15), the cerebrospinal fluid (CSF) yeasts count (OR = 1.65, 95% CI 1.20–2.27), systemic arterial hypertension (OR = 22.63, 95% CI 1.64–312.91) and neurological impairment identified by computed tomography (OR = 41.73, 95% CI 3.10–561.65). At the secondary analysis, CSF yeast count was also associated with the composite outcome, in addition to the culture of Cryptococcus spp. from bloodstream and cerebral toxoplasmosis. The associations were consistent with survival models evaluated. Conclusions Age and CSF yeast count were independently associated with in-hospital mortality of patients with cryptococcal meningitis but Cryptococcus species identification and antifungal susceptibility were not associated with the outcomes. Quantitative CSF yeast counts used in this study can be evaluated and implemented in other low and middle-income settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07118-7.
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Affiliation(s)
- Lidiane de Oliveira
- Department of Epidemiology, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP, CEP 01246-904, Brazil.
| | - Marcia de Souza Carvalho Melhem
- Mycology Unit of Adolfo Lutz Institute, Public Health Reference Laboratory, Secretary of Health, Av. Dr.Arnaldo, 351, São Paulo, SP, CEP 05411-000, Brazil.,School of Medicine, Federal University of Mato Grosso do Sul, Bairro Universitário, Av. Costa e Silva, s/no, Campo Grande, MS, CEP 79070-900, Brazil
| | - Renata Buccheri
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil
| | - Oscar José Chagas
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil
| | - José Ernesto Vidal
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil.,Department of Infectious Diseases, Hospital das Clinicas, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 470, São Paulo, SP, CEP 01246-904, Brazil
| | - Fredi Alexander Diaz-Quijano
- Department of Epidemiology, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP, CEP 01246-904, Brazil
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5
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Li Y, Fang L, Chang FQ, Xu FZ, Zhang YB. Cryptococcus infection with asymptomatic diffuse pulmonary disease in an immunocompetent patient: A case report. World J Clin Cases 2021; 9:2619-2626. [PMID: 33889628 PMCID: PMC8040166 DOI: 10.12998/wjcc.v9.i11.2619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/09/2021] [Accepted: 02/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cryptococcus presenting as an opportunistic pathogen mainly affects immunocompromised patients, but the disseminated form of infection is rare among immunocompetent populations. The partial radiographic characteristics of pulmonary cryptococcosis mimic lung carcinoma, leading to unnecessary open chest exploratory surgery, and the lack of a gold-standard noninvasive diagnostic increases the risk of misdiagnosis. Positron emission tomography/computed tomography (PET/CT), a sensitive method for distinguishing malignant tumors, coupled with cryptococcal latex agglutination test showing a high positive rate may overcome these issues.
CASE A 36-year-old man presented for general examination, without health complaints. Routine CT showed multiple pulmonary nodules and a mass with high maximum standardized uptake value. Initially, we suspected primary malignancy with hematogenous metastasis. Although his routine fungal analysis had been negative, subsequent CT-guided percutaneous core needle biopsy and histopathology examination indicated a diagnosis of pulmonary cryptococcosis. Fluconazole (200 mg/d) antifungal drug treatment was initiated, and 1 mo later the pulmonary mass had reduced in size markedly (on chest CT scan) without any complications.
CONCLUSION Serologic and PET/CT examinations may not rule out cryptococcosis, and percutaneous lung puncture is critical under all circumstances.
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Affiliation(s)
- Yong Li
- Department of Geriatric Respiratory and Critical Care, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
- Department of Tuberculosis, Anhui Medical University Clinical College of Chest & Anhui Chest Hospital, Hefei 230000, Anhui Province, China
| | - Lei Fang
- Department of Geriatric Respiratory and Critical Care, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Fang-Qun Chang
- Department of Geriatric Respiratory and Critical Care, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Fang-Zhou Xu
- Department of Geriatric Respiratory and Critical Care, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Yan-Bei Zhang
- Department of Geriatric Respiratory and Critical Care, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
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6
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Jin L, Cao JR, Xue XY, Wu H, Wang LF, Guo L, Shen DX. Clinical and microbiological characteristics of Cryptococcus gattii isolated from 7 hospitals in China. BMC Microbiol 2020; 20:73. [PMID: 32228457 PMCID: PMC7106762 DOI: 10.1186/s12866-020-01752-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/12/2020] [Indexed: 12/12/2022] Open
Abstract
Background Infection, even outbreak, caused by Cryptococcus gattii (C. gattii) has been reported in Canada and the United States, but there were sparsely-reported cases of C. gattii in China. Our interest in occurrence, clinical manifestation, laboratory identification and molecular characterization of Chinese C. gattii strains leads us to this research. Results Out of 254 clinical isolates, initially identified as Cryptococcus neoformans (C. neoformans), eight strains were re-identified as C. gattii. Multi-locus sequence typing (MLST) showed genotype VGI accounted for the most (6 / 8), the other two strains were genotype VGII (VGIIa and VGIIb respectively) with 3 specific spectra of molecular weight about 4342, 8686, 9611 Da by MALDI-TOF MS. The minimal inhibitory concentrations (MICs) of Fluconazole with Yeast one was 2~4 times higher than that with ATB fungus 3 and MICs of antifungal agents against VGII strains were higher than against VGI strains. Comparative proteome analysis showed that 329 and 180 proteins were highly expressed by C. gattii VGI and VGII respectively. The enrichment of differentially expressed proteins was directed to Golgi complex. Conclusions Infection by C. gattii in China occurred sparsely. Genotype VGI was predominant but VGII was more resistant to antifungal agents. There was significant difference in protein expression profile between isolates of VGI and VGII C. gattii.
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Affiliation(s)
- Liang Jin
- Medical laboratory center, First Medical Center of Chinese PLA General Hospital & Medical School of Chinese PLA, No.28 Fuxing Road, Haidian District, Beijing, 100853, China.,Department of Clinical Laboratory, the First Hospital of Qinhuangdao, Qinhuangdao, 066000, China
| | - Jing-Rong Cao
- Department of Clinical Laboratory, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Xin-Ying Xue
- Medical laboratory center, First Medical Center of Chinese PLA General Hospital & Medical School of Chinese PLA, No.28 Fuxing Road, Haidian District, Beijing, 100853, China.,Department of Respiratory and Critical Care Medicine, the Affiliated Beijing Shijitan Hospital of Capital Medical University, Beijing, 100038, China
| | - Hua Wu
- Department of Clinical Laboratory, Hainan General Hospital, Haikou, 570311, China
| | - Li-Feng Wang
- Medical laboratory center, First Medical Center of Chinese PLA General Hospital & Medical School of Chinese PLA, No.28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ling Guo
- Medical laboratory center, First Medical Center of Chinese PLA General Hospital & Medical School of Chinese PLA, No.28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ding-Xia Shen
- Medical laboratory center, First Medical Center of Chinese PLA General Hospital & Medical School of Chinese PLA, No.28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Pharkjaksu S, Chongtrakool P, Chayakulkeeree M, Mitrpant C, Angkasekwinai P, Bennett JE, Kwon-Chung KJ, Ngamskulrungroj P. Cryptococcus neoformans/gattii Species Complexes from Pre-HIV Pandemic Era Contain Unusually High Rate of Non-Wild-Type Isolates for Amphotericin B. Infect Drug Resist 2020; 13:673-681. [PMID: 32161475 PMCID: PMC7049752 DOI: 10.2147/idr.s235473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/11/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction The Cryptococcus neoformans/gattii species complexes are a leading cause of fatality among HIV-infected patients. Despite the unavailability of clinical breakpoints (CBPs) for antifungal agents, epidemiological cutoff values (ECVs) were recently proposed, and non-wild-type isolates for polyenes and azoles are being increasingly reported. However, the distributions of the susceptibility patterns for pre-HIV-era isolates have not been studied. Methods We determined the in vitro antifungal susceptibility patterns of 233 Cryptococcus isolates, collected at the National Institutes of Health, USA, in pre-HIV pandemic era, to study minimum inhibitory concentrations (MICs) to the important drugs for cryptococcosis and to compare the results with strain genotypes. Amphotericin B susceptibility was compared to published ECV of C. neoformans. Results The 233 Cryptococcus strains consisted of 89.7% C. neoformans species complex and 10.3% C. gattii species complex. Most were from clinical sources (189, 81.1%), and the major molecular type was VNI (146, 62.7%). The highest geometric mean (GM) was observed for fluconazole (GM = 0.96 µg/mL) while the lowest was for itraconazole (GM = 0.10 µg/mL). MICs to fluconazole in C. gattii species complex were significantly higher than C. neoformans species complex (p < 0.001). Moreover, C. neoformans/VNI strains showed significantly higher MICs than others such as C. neoformans/VNII to fluconazole (p < 0.0001) and C. deneoformans/VNIV to amphotericin B (p = 0.022) and fluconazole (p = 0.008). In our collection of 167 clinical C. neoformans species complex strains, 85 (50.9%), 24 (14.4%), and 3 (1.8%) strains had an amphotericin B (AMB)-MIC of 1, 2, and 4 µg/mL, respectively. The high percentage (66.9%, 79/118 strains) of non-wild-type clinical C. neoformans VNI strains, using an AMB-ECV of 0.5 µg/mL, was found. Moreover, 25 of 28 (89.3%) C. neoformans VNI strains from environmental and veterinary sources also had AMB-MICs above 0.5 µg/mL. In general, there was no significant difference in GM AMB-MIC of the clinical strains isolated from patients with (35 patients) and without (78 patients) prior AMB treatment (0.85 vs 0.76; p = 0.624). GM MIC of the environmental strains was not significantly different from that of the prior AMB-treatment strains (0.98 vs 0.76, p = 0.159) and the post-AMB-treatment strains (0.98 vs 0.85, p = 0.488). Conclusion The high rate of non-wild-type among these otherwise naive isolates to amphotericin B is unexpected. Confirmation with more strains from a later era is needed.
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Affiliation(s)
- Sujiraphong Pharkjaksu
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piriyaporn Chongtrakool
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chalermchai Mitrpant
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pornpimon Angkasekwinai
- Department of Medical Technology, Faculty of Allied Health Sciences, Thammasat University, Pathumthani, Thailand
| | - John E Bennett
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Kyung J Kwon-Chung
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Popchai Ngamskulrungroj
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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8
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Huang SH, Chuang YC, Lee YC, Hung CC, Sheng WH, Su JJ, Sun HY, Chen YC, Chang SC. Lumbar puncture for non-HIV-infected non-transplant patients with cryptococcosis: Should it be mandatory for all? PLoS One 2019; 14:e0221657. [PMID: 31437259 PMCID: PMC6705819 DOI: 10.1371/journal.pone.0221657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The indications for lumbar puncture in non-HIV-infected, non-transplant (NHNT) patients with cryptococcosis without meningeal signs need to be more fully defined. OBJECTIVES This study was designed to determine the optimal predictors of central nervous system (CNS) involvement in adult NHNT patients with cryptococcosis. METHODS The study population consisted of adult NHNT patients with culture-confirmed cryptococcosis who sought care at a university hospital in Taiwan from 2002 to 2016. We used a case-control method to identify the clinical characteristics and laboratory findings associated with CNS involvement in patients who underwent a diagnostic lumbar puncture. In the sensitivity analysis, we included additional control patients who did not undergo lumbar puncture, but were followed beyond 12 months without the development of CNS involvement in the absence of exposure to any fungicidal agents. RESULTS We entered 270 NHNT adult patients into the study during the 15-year period. CNS involvement was confirmed in 66 (71.0%) of 93 patients who underwent lumbar puncture. A multivariable analysis revealed that presence of neurological manifestations and elevated serum CRAG titers were independently associated with a 23.97-fold (95% confidence interval [CI], 4.37-182.23) and 1.53-fold (per 2-fold increment, 95% CI 1.26-1.92) increased odds ratio for CNS involvement, respectively. Headache and focal neurologic signs were independently associated with CNS involvement. A cut-off serum CRAG titer of ≥1:64 provided the highest diagnostic performance by Youden index (sensitivity 83% and specificity 65%). Similar findings were noted in the sensitivity analysis including 198 (73%) patients. CONCLUSION Lumbar puncture is indicated for NHNT patients with cryptococcosis who have neurologic manifestations or a serum CRAG titer of ≥1:64.
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Affiliation(s)
- Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chien Lee
- Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei, Taiwan
| | - Chien-Ching Hung
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen Jen Su
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail:
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan
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9
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Tsai WC, Lien CY, Lee JJ, Huang CR, Tsai NW, Chang CC, Lu CH, Chang WN. The clinical characteristics of adult cryptococcal meningitis patients who died within one year of treatment with a focus on those with early mortality. J Clin Neurosci 2019; 67:80-84. [PMID: 31227408 DOI: 10.1016/j.jocn.2019.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/24/2019] [Accepted: 06/09/2019] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Wan-Chen Tsai
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Yi Lien
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jun-Jun Lee
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Information Management, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chi-Ren Huang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Nai-Wen Tsai
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiung-Chih Chang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Hsien Lu
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Neng Chang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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10
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Abstract
Invasive candidiasis (IC) remains the most common invasive fungal infection following solid-organ transplant (SOT), but risk factors are evolving. Current challenges include infection due to drug resistant non-albicans and emerging novel species such as Candida auris. Preventive antifungal use in SOT needs to be re-examined in light of these current challenges. Cryptococcosis is the second most common IFI following SOT. Cryptococcus gattii is an emerging pathogen that can have reduced in-vitro susceptibility to antifungal agents. Cryptococcus associated IRIS in SOT is a clinical entity that warrants heightened awareness for timely recognition and management.
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Affiliation(s)
- Sarah Taimur
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, One-Gustave L. Levy Place, New York, NY 10029, USA.
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11
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Lin SY, Lu PL, Tan BH, Chakrabarti A, Wu UI, Yang JH, Patel AK, Li RY, Watcharananan SP, Liu Z, Chindamporn A, Tan AL, Sun PL, Hsu LY, Chen YC. The epidemiology of non-Candida yeast isolated from blood: The Asia Surveillance Study. Mycoses 2018; 62:112-120. [PMID: 30230062 PMCID: PMC7379604 DOI: 10.1111/myc.12852] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 12/18/2022]
Abstract
Background Current guidelines recommend echinocandins as first‐line therapy for candidemia. However, several non‐Candida yeast are non‐susceptible to echinocandins (echinocandin non‐susceptible yeast, ENSY), including Cryptococcus, Geotrichum, Malassezia, Pseudozyma, Rhodotorula, Saprochaete, Sporobolomyces and Trichosporon. In laboratories that are not equipped with rapid diagnostic tools, it often takes several days to identify yeast, and this may lead to inappropriate presumptive use of echinocandins in patients with ENSY fungemia. The aim of this study was to determine the distribution of ENSY species during a 1‐year, laboratory surveillance programme in Asia. Methods Non‐duplicate yeast isolated from blood or bone marrow cultures at 25 hospitals in China, Hong Kong, India, Singapore, Taiwan and Thailand were analysed. Isolates were considered to be duplicative if they were obtained within 7 days from the same patient. Results Of 2155 yeast isolates evaluated, 175 (8.1%) were non‐Candida yeast. The majority of non‐Candida yeast were ENSY (146/175, 83.4%). These included Cryptococcus (109 isolates), Trichosporon (23), Rhodotorula (10) and Malassezia (4). The proportion of ENSY isolates (146/2155, 6.7%) differed between tropical (India, Thailand and Singapore; 51/593, 8.6%) and non‐tropical countries/regions (China, Hong Kong and Taiwan; 95/1562, 6.1%, P = 0.038). ENSY was common in outpatient clinics (25.0%) and emergency departments (17.8%) but rare in intensive care units (4.7%) and in haematology‐oncology units (2.9%). Cryptococcus accounted for the majority of the non‐Candida species in emergency departments (21/24, 87.5%) and outpatient clinics (4/5, 80.0%). Conclusions Isolation of non‐Candida yeast from blood cultures was not rare, and the frequency varied among medical units and countries.
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Affiliation(s)
- Shang-Yi Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Liang Lu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore City, Singapore
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Un-In Wu
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Jui-Hsuan Yang
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Atul K Patel
- Department of Infectious Diseases, Sterling Hospital, Ahmedabad, India
| | - Ruo Yu Li
- Department of Dermatology, Peking University First Hospital, Research Center for Medical Mycology, Peking University, Beijing, China
| | - Siriorn P Watcharananan
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | - Zhengyin Liu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Ariya Chindamporn
- Department of Microbiology, Faculty of Medicine, King Chulalongkorn Memorial Hospital Chulalongkorn University, Bangkok, Thailand
| | - Ai Ling Tan
- Department of Pathology, Singapore General Hospital, Singapore City, Singapore
| | - Pei-Lun Sun
- Department of Dermatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Li-Yin Hsu
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.,Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yee-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.,National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli, Taiwan
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12
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Abstract
Cryptococcus is among the most common invasive fungal pathogens globally and is one of the leading causes of acquired immunodeficiency virus-related deaths. Cryptococcus neoformans and Cryptococcus gattii are the most clinically relevant species and account for most cryptococcal disease. Pulmonary manifestations can range from mild symptoms to life-threatening infection. Treatment is tailored based on the severity of pulmonary infection, the presence of disseminated or central nervous system disease, and patient immune status. Amphotericin B and flucytosine followed by fluconazole remain the standard agents for the treatment of severe cryptococcal infection.
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Affiliation(s)
- Kate Skolnik
- Division of Respirology, Department of Internal Medicine, Rockyview General Hospital, University of Calgary, Respirology Offices, 7007 14th Street Southwest, Calgary, Alberta T2V 1P9, Canada
| | - Shaunna Huston
- Department of Physiology and Pharmacology, Health Research Innovation Centre, University of Calgary, Room 4AA08, 3330 Hospital Drive Northwest, Calgary, Alberta T2N 4N1, Canada
| | - Christopher H Mody
- Department of Microbiology and Infectious Diseases, Health Research Innovation Centre, University of Calgary, Room 4AA14, 3330 Hospital Drive Northwest, Calgary, Alberta T2N 4N1, Canada; Department of Internal Medicine, Health Research Innovation Centre, University of Calgary, Room 4AA14, 3330 Hospital Drive Northwest, Calgary, Alberta T2N 4N1, Canada.
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13
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Ecoepidemiology of Cryptococcus gattii in Developing Countries. J Fungi (Basel) 2017; 3:jof3040062. [PMID: 29371578 PMCID: PMC5753164 DOI: 10.3390/jof3040062] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/28/2017] [Accepted: 10/30/2017] [Indexed: 01/06/2023] Open
Abstract
Cryptococcosis is a systemic infection caused by species of the encapsulated yeast Cryptococcus. The disease may occur in immunocompromised and immunocompetent hosts and is acquired by the inhalation of infectious propagules present in the environment. Cryptococcus is distributed in a plethora of ecological niches, such as soil, pigeon droppings, and tree hollows, and each year new reservoirs are discovered, which helps researchers to better understand the epidemiology of the disease. In this review, we describe the ecoepidemiology of the C. gattii species complex focusing on clinical cases and ecological reservoirs in developing countries from different continents. We also discuss some important aspects related to the antifungal susceptibility of different species within the C. gattii species complex and bring new insights on the revised Cryptococcus taxonomy.
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14
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Zhou HX, Lu L, Chu T, Wang T, Cao D, Li F, Ning G, Feng S. Skeletal cryptococcosis from 1977 to 2013. Front Microbiol 2015; 5:740. [PMID: 25642211 PMCID: PMC4294201 DOI: 10.3389/fmicb.2014.00740] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 12/05/2014] [Indexed: 12/18/2022] Open
Abstract
Skeletal cryptococcosis, an aspect of disseminated cryptococcal disease or isolated skeletal cryptococcal infection, is a rare but treatable disease. However, limited information is available regarding its clinical features, treatment, and prognosis. This systematic review examined all cases published between April 1977 and May 2013 with regard to the factors associated with this disease, including patient sex, age, and epidemiological history; affected sites; clinical symptoms; underlying diseases; laboratory tests; radiological manifestations; and delays in diagnosis, treatment, follow-up assessments, and outcomes. We found that immune abnormality is a risk factor but does not predict mortality; these observations are due to recent Cryptococcus neoformans var gattii (CNVG) outbreaks (Chaturvedi and Chaturvedi, 2011). Dissemination was irrespective of immune status and required combination therapy, and dissemination carried a worse prognosis. Therefore, a database of skeletal cryptococcosis cases should be created.
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Affiliation(s)
- Heng-Xing Zhou
- Department of Orthopaedics, Tianjin Medical University General Hospital Tianjin, China
| | - Lu Lu
- Department of Orthopaedics, Tianjin Medical University General Hospital Tianjin, China
| | - Tianci Chu
- Department of Orthopaedics, Tianjin Medical University General Hospital Tianjin, China
| | - Tianyi Wang
- Department of Orthopaedics, Tianjin Medical University General Hospital Tianjin, China
| | - Daigui Cao
- Department of Orthopaedics, Tianjin Medical University General Hospital Tianjin, China
| | - Fuyuan Li
- Department of Orthopaedics, Tianjin Medical University General Hospital Tianjin, China
| | - Guangzhi Ning
- Department of Orthopaedics, Tianjin Medical University General Hospital Tianjin, China
| | - Shiqing Feng
- Department of Orthopaedics, Tianjin Medical University General Hospital Tianjin, China
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15
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Primary cutaneous Cryptococcus neoformans serotype D presenting as painful ulcer and nodules on elbow of an immunocompetent patient. Ir J Med Sci 2014; 183:691-2. [DOI: 10.1007/s11845-014-1201-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 09/16/2014] [Indexed: 11/25/2022]
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16
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Hasimoto e Souza LK, Costa CR, Fernandes ODFL, Abrão FY, Silva TC, Treméa CM, Silva MDRR. Clinical and microbiological features of cryptococcal meningitis. Rev Soc Bras Med Trop 2014; 46:343-7. [PMID: 23856876 DOI: 10.1590/0037-8682-0061-2012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 05/21/2013] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION In this study, the clinical features, underlying diseases and clinical outcomes of patients with cryptococcosis were investigated. In addition, a molecular analysis of the Cryptococcus neoformans species complex isolated from these patients was performed. METHODS A prospective study of 62 cases of patients with cryptococcal infection was conducted at the Hospital de Doenças Tropicais de Goiás Dr. Anuar Auad from 2009-2010. Cryptococcal meningitis cases were diagnosed by direct examination and cerebrospinal fluid (CSF) sample culture. The profiling of these patients was assessed. The CSF samples were submitted to India ink preparation and cultured on Sabouraud dextrose agar, and C. neoformans was identified by the production of urease, a positive phenoloxidase test and assimilation of carbohydrates. C. neoformans and C. gattii isolates were distinguished by growth on L-canavanine-glycine-bromothymol blue medium, and molecular analysis was conducted via PCR fingerprinting reactions using M13 and (GACA)4 primers. RESULTS From the 62 patients with cryptococcosis, 71 isolates of CSF were obtained; 67 (94.4%) isolates were identified as C. neoformans var. grubii/VNI, and 4 (5.6%) were identified as C. gattii/VGII. Of these patients, 53 had an HIV diagnosis. The incidence of cryptococcosis was higher among patients 20-40 years of age, with 74.2% of the cases reported in males. Cryptococcus-related mortality was noted in 48.4% of the patients, and the symptoms were altered sensorium, headache, fever and stiff neck. CONCLUSIONS The high morbidity and mortality observed among patients with cryptococcosis demonstrate the importance of obtaining information regarding the epidemiological profile and clinical course of the disease in the State of Goiás, Brazil.
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Affiliation(s)
- Lúcia Kioko Hasimoto e Souza
- Laboratório de Micologia, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goias, Goiânia, GO, Brazil.
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17
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McMullan BJ, Sorrell TC, Chen SCA. Cryptococcus gattii infections: contemporary aspects of epidemiology, clinical manifestations and management of infection. Future Microbiol 2013; 8:1613-31. [DOI: 10.2217/fmb.13.123] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cryptococcus gattii is an important primary and opportunistic pathogen, predominantly causing meningoencephalitis and pulmonary disease with substantial mortality. Initially considered geographically restricted to immune-competent, highly exposed individuals in the tropics, an apparent epidemic in North America has led to new perspectives on its ecology, epidemiology and clinical associations, which are distinct from its sibling species Cryptococcus neoformans. The role of C. gattii molecular genotypes/subtypes in different settings is under investigation. Diagnostic and treatment strategies are similar to those for C. neoformans in immunocompetent hosts, although data indicate that more prolonged induction, as well as total duration of therapy, is required. Exclusion of CNS involvement is mandatory. Brain cryptococcomas are characteristic of C. gattii infection, and raised intracranial pressure is common, for which surgery is often required. Immune reconstitution syndrome may occur. Ongoing C. gattii research and greater awareness and availability of specific diagnostic tests are required to improve patient outcomes.
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Affiliation(s)
- Brendan Joseph McMullan
- Department of Immunology & Infectious Diseases, Sydney Children‘s Hospital, Randwick, New South Wales, Australia
- School of Women‘s & Children‘s Health, University of New South Wales, Kensington, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Tania Christine Sorrell
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney Emerging Infections Biosecurity Institute, University of Sydney, New South Wales, Australia
| | - Sharon Chih-Ann Chen
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
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18
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Lockhart SR, Iqbal N, Harris JR, Grossman NT, DeBess E, Wohrle R, Marsden-Haug N, Vugia DJ. Cryptococcus gattii in the United States: genotypic diversity of human and veterinary isolates. PLoS One 2013; 8:e74737. [PMID: 24019979 PMCID: PMC3760847 DOI: 10.1371/journal.pone.0074737] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 08/06/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cryptococcusgattii infections are being reported in the United States (US) with increasing frequency. Initially, US reports were primarily associated with an ongoing C. gattii outbreak in the Pacific Northwest (PNW) states of Washington and Oregon, starting in 2004. However, reports of C. gattii infections in patients from other US states have been increasing since 2009. Whether this is due to increasing frequency of disease, greater recognition within the clinical community, or both is currently unknown. METHODOLOGY/PRINCIPAL FINDINGS During 2005-2013, a total of 273 C. gattii isolates from human and veterinary sources in 16 US states were collected. Of these, 214 (78%) were from the Pacific Northwest (PNW) and comprised primarily the clonal C. gattii genotypes VGIIa (64%), VGIIc (21%) and VGIIb (9%). The 59 isolates from outside the PNW were predominantly molecular types VGIII (44%) and VGI (41%). Genotyping using multilocus sequence typing revealed small clusters, including a cluster of VGI isolates from the southeastern US, and an unrelated cluster of VGI isolates and a large cluster of VGIII isolates from California. Most of the isolates were mating type MATα, including all of the VGII isolates, but one VGI and three VGIII isolates were mating type MATa. CONCLUSIONS/SIGNIFICANCE We provide the most comprehensive report to date of genotypic diversity of US C. gattii isolates both inside and outside of the PNW. C. gattii may have multiple endemic regions in the US, including a previously-unrecognized endemic region in the southeast. Regional clusters exist both in California and the Southeastern US. VGII strains associated with the PNW outbreak do not appear to have spread substantially beyond the PNW.
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Affiliation(s)
- Shawn R. Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Naureen Iqbal
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Julie R. Harris
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Nina T. Grossman
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Emilio DeBess
- Oregon Department of Human Services, Portland, Oregon, United States of America
| | - Ron Wohrle
- 3 Washington State Department of Health, Tumwater, Washington, United States of America
| | - Nicola Marsden-Haug
- 3 Washington State Department of Health, Tumwater, Washington, United States of America
| | - Duc J. Vugia
- California Department of Public Health, Richmond, California, United States of America
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19
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Isavuconazole activity against Aspergillus lentulus, Neosartorya udagawae, and Cryptococcus gattii, emerging fungal pathogens with reduced azole susceptibility. J Clin Microbiol 2013; 51:3090-3. [PMID: 23804388 DOI: 10.1128/jcm.01190-13] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Isavuconazole is an extended-spectrum triazole with in vitro activity against a wide variety of fungal pathogens. Clinical isolates of molds Aspergillus lentulus and Neosartorya udagawae and yeast Cryptococcus gattii VGII (implicated in the outbreak in the Pacific Northwest, North America) exhibit reduced susceptibilities to several azoles but higher susceptibilities to isavuconazole.
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20
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Tseng HK, Liu CP, Ho MW, Lu PL, Lo HJ, Lin YH, Cho WL, Chen YC. Microbiological, epidemiological, and clinical characteristics and outcomes of patients with cryptococcosis in Taiwan, 1997-2010. PLoS One 2013; 8:e61921. [PMID: 23613973 PMCID: PMC3629109 DOI: 10.1371/journal.pone.0061921] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 03/15/2013] [Indexed: 01/24/2023] Open
Abstract
Background Among members of Cryptococcus neoformans- Cryptococcus gattii species complex, C. neoformans is distributed worldwide whereas C. gattii is considered to be more prevalent in the subtropics and tropics including Taiwan. This nationwide study was undertaken to determine the distribution of genotypes, clinical characteristics and outcomes of 219 patients with proven cryptococcosis at 20 hospitals representative of all geographic areas in Taiwan during 1997–2010. Methods and Findings Of 219 isolates analyzed, C. neoformans accounted for 210 isolates (95.9%); nine isolates were C. gattii (4.1%). The predominant genotype was VNI (206 isolates). The other genotypes included VNII (4 isolates), VGI (3 isolates) and VGII (6 isolates). Antifungal minimal inhibition concentrations higher than epidemiologic cutoff values (ECVs) were found in nine VNI isolates (7 for amphotericin B). HIV infection was the most common underlying condition (54/219, 24.6%). Among HIV-negative patients, liver diseases (HBV carrier or cirrhosis) were common (30.2%) and 15.4% did not have any underlying condition. Meningoencephalitis was the most common presentation (58.9%), followed by pulmonary infection (19.6%) and “others” (predominantly cryptococcemia) (18.7%). The independent risk factors for 10-week mortality, by multivariate analysis, were cirrhosis of liver (P = 0.014) and CSF cryptococcal antigen titer ≥512 (P = 0.020). All except one of 54 HIV-infected patients were infected by VNI genotype (98.1%). Of the 13 isolates of genotypes other than VNI, 12 (92.3%) were isolated from HIV-negative patients. HIV-infected patients compared to HIV-negative patients were more likely to have meningoencephalitis and serum cryptococcal antigen ≥1∶512. Patients infected with C. gattii compared to C. neoformans were younger, more likely to have meningoencephalitis (100% vs. 57%), reside in Central Taiwan (56% vs. 31%), and higher 10-week crude mortality (44.4% vs. 22.2%). Conclusions Cryptococcus neoformans in Taiwan, more prevalent than C. gatii, has a predominant VNI genotype. Isolates with antifungal MIC higher than ECVs were rare.
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Affiliation(s)
- Hsiang-Kuang Tseng
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, Mackay Memorial Hospital, Zhongshan District, Taipei, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan
- Mackay Medicine Nursing and Management College, Taipei, Taiwan
| | - Chang-Pan Liu
- Division of Infectious Diseases, Department of Internal Medicine, Mackay Memorial Hospital, Zhongshan District, Taipei, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan
- Mackay Medicine Nursing and Management College, Taipei, Taiwan
| | - Mao-Wang Ho
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Po-Liang Lu
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiu-Jung Lo
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli, Taiwan
- School of Dentistry, China Medical University, Taichung, Taiwan
| | - Yu-Hui Lin
- Division of Infectious Diseases, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Long Cho
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan
- * E-mail: (YCC); (WLC)
| | - Yee-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- * E-mail: (YCC); (WLC)
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21
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Lockhart SR, Iqbal N, Bolden CB, DeBess EE, Marsden-Haug N, Worhle R, Thakur R, Harris JR. Epidemiologic cutoff values for triazole drugs in Cryptococcus gattii: correlation of molecular type and in vitro susceptibility. Diagn Microbiol Infect Dis 2012; 73:144-8. [PMID: 22494557 DOI: 10.1016/j.diagmicrobio.2012.02.018] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 02/21/2012] [Accepted: 02/21/2012] [Indexed: 01/12/2023]
Abstract
Cryptococcus gattii causes infection in tropical and subtropical regions worldwide but has garnered increased attention since its 1999 emergence in North America. C. gattii can be divided into 4 molecular types that may represent cryptic species. Recent evidence has shown that azole antifungal MIC values differ among these molecular types. We tested a large collection of C. gattii isolates for susceptibility to 4 azole drugs. We found that isolates of molecular type VGII have the highest geometric mean (GM) fluconazole MIC values (8.6 μg/mL), while isolates of molecular type VGI have the lowest (1.7 μg/mL). For fluconazole, itraconazole, and voriconazole GM MIC values, VGI < VGIII < VGIV < VGII. The GM MIC values for posaconazole were similarly represented across molecular types, with the exception that VGII < VGIII and VGIV. We used the MIC values to establish preliminary epidemiologic cutoff values for each azole and molecular type of C. gattii.
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Affiliation(s)
- Shawn R Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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22
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Li M, Liao Y, Chen M, Pan W, Weng L. Antifungal susceptibilities of Cryptococcus species complex isolates from AIDS and non-AIDS patients in Southeast China. Braz J Infect Dis 2012; 16:175-9. [DOI: 10.1016/s1413-8670(12)70301-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 12/11/2011] [Indexed: 11/29/2022] Open
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23
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Silva DC, Martins MA, Szeszs MW, Bonfietti LX, Matos D, Melhem MSC. Susceptibility to antifungal agents and genotypes of Brazilian clinical and environmental Cryptococcus gattii strains. Diagn Microbiol Infect Dis 2012; 72:332-9. [PMID: 22341512 DOI: 10.1016/j.diagmicrobio.2011.11.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 11/21/2011] [Accepted: 11/23/2011] [Indexed: 11/26/2022]
Abstract
There are few reports concerning the in vitro antifungal susceptibility of clinical and environmental Cryptococcus gattii isolates. In this study, we performed polymerase chain reaction-restriction fragment length polymorphism to investigate the molecular subtypes of 50 clinical and 4 environmental Brazilian isolates of C. gattii and assessed their antifungal susceptibility for fluconazole (FLU) and amphotericin B (Amb) according to recent recommendations proposed for antifungal susceptibility testing of nonfermentative yeasts. Time-kill curve studies were performed using RPMI 1640 medium to analyze the fungicidal effect of AmB. We found 47 VGII (94%) molecular types and 3 VGI (6%) types among the clinical isolates. The environmental isolates were VGII (75%) subtype and VGI (25%) subtype. The FLU-MIC ranged from 1 to 64 mg L(-1), and MIC(50)/MIC(90) values were, respectively, 8/16 mg L(-1). For AmB, the MICs were low and homogeneous, ranging from 0.12 to 0.5 mg L(-1), for VGI or VGII. The time required to reach the fungicidal end point (99.9% killing) was 6 h for the majority of strains (64%), but viable cells of VGII were still present after 48 h of exposition. We pointed out the occurrence of high FLU-MICs for C. gattii isolates with highest values for VGII. Our data also suggest that the rate of killing of C. gattii by AmB is strain dependent, and viable cells of VGII genotype strains were still observed after an extended incubation time, addressing future studies to determine whether the in vitro fungicidal activity could be clinically relevant.
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Affiliation(s)
- Dayane C Silva
- Mycology Unit of Adolfo Lutz Institute, Public Health Reference Laboratory, Secretary of Health, São Paulo-SP, 01246-902, Brazil
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24
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Araújo BS, Bay M, Reichert R, Goldani LZ. Intra-abdominal cryptococcosis by Cryptococcus gattii: case report and review. Mycopathologia 2012; 174:81-5. [PMID: 22246960 DOI: 10.1007/s11046-011-9517-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 12/16/2011] [Indexed: 12/11/2022]
Abstract
Although abdominal cryptococcomas and visceral cryptococcal lymphadenitis as part of disseminated fungal infection have been reported mostly in HIV-infected patients, localized intra-abdominal involvement due to Cryptococcus gattii has not been previously described in non-HIV-infected patients. In general, a smaller proportion of cryptococcosis is caused by C. gattii. We report here on a type II diabetic HIV-negative patient who presented with a localized intra-abdominal cryptococcal mass due to C. gattii. In addition, we review the general aspects of intra-abdominal and gastrointestinal involvement by Cryptococcus neoformans in the literature and discuss the importance of identifying the C. neoformans varieties and C. gattii in routine laboratories.
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Affiliation(s)
- Bruno S Araújo
- Section of Infectious Diseases, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, 90640-002, Brazil
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Abstract
Infections caused by the emerging pathogen Cryptococcus gattii are increasing in frequency in North America. During the past decade, interest in the pathogen has continued to grow, not only in North America but also in other areas of the world where infections have recently been documented. This review synthesizes existing data and raises issues that remain to be addressed.
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Affiliation(s)
- Julie Harris
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS C-09, Atlanta, GA 30309 USA.
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Guinea J, Hagen F, Peláez T, Boekhout T, Tahoune H, Torres-Narbona M, Bouza E. Antifungal susceptibility, serotyping, and genotyping of clinicalCryptococcus neoformansisolates collected during 18 years in a single institution in Madrid, Spain. Med Mycol 2010; 48:942-8. [DOI: 10.3109/13693781003690067] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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In vitro susceptibility of the yeast pathogen cryptococcus to fluconazole and other azoles varies with molecular genotype. J Clin Microbiol 2010; 48:4115-20. [PMID: 20844209 DOI: 10.1128/jcm.01271-10] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cryptococcosis is primarily caused by Cryptococcus neoformans and Cryptococcus gattii. These two pathogenic species each divide into four distinct molecular genotypes. In this study, we examined whether genotype influenced susceptibility to antifungal drugs used to treat cryptococcosis using the broth microdilution method described by the Clinical and Laboratory Standards Institute. C. gattii isolates belonging to molecular genotype VGII had significantly higher MIC values for flucytosine and all azole antifungal agents tested, particularly fluconazole, than isolates of other C. gattii genotypes. In an extended analysis of fluconazole susceptibility, VGII isolates from the north and west of Australia required higher drug levels for inhibition than those from Vancouver Island, Canada. Within C. neoformans, genotype VNII had significantly lower geometric mean MICs for fluconazole than genotype VNI. These results indicate that cryptococcal species, molecular genotype, and region of origin may be important when deciding treatment options for cryptococcosis.
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Antifungal therapy in a murine model of disseminated infection by Cryptococcus gattii. Antimicrob Agents Chemother 2010; 54:4074-7. [PMID: 20625150 DOI: 10.1128/aac.00172-10] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
We have evaluated the efficacy of posaconazole (PSC), voriconazole (VRC), and amphotericin B (AMB) in a murine model of systemic infection by Cryptococcus gattii using immunocompromised animals and three clinical strains of the fungus. AMB was the most effective drug in prolonging the survival of mice and also in reducing tissue burden in all organs tested. To a lesser degree, VRC at 60 mg/kg of body weight in lung tissue and PSC at 40 mg/kg also in spleen demonstrated good efficacy in reducing the fungal load. The PSC and VRC levels in serum and brain tissue, determined by an agar diffusion bioassay method at 4 h after the last dose of the therapy, were above the corresponding MIC values. However, these drugs were not able to reduce the fungal load in brain tissue. Our results demonstrated that PSC and, to a lesser degree, VRC, have fungistatic activity and potential for the treatment of human pulmonary cryptococcosis.
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29
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Chau TT, Mai NH, Phu NH, Nghia HD, Chuong LV, Sinh DX, Duong VA, Diep PT, Campbell JI, Baker S, Hien TT, Lalloo DG, Farrar JJ, Day JN. A prospective descriptive study of cryptococcal meningitis in HIV uninfected patients in Vietnam - high prevalence of Cryptococcus neoformans var grubii in the absence of underlying disease. BMC Infect Dis 2010; 10:199. [PMID: 20618932 PMCID: PMC2910700 DOI: 10.1186/1471-2334-10-199] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 07/09/2010] [Indexed: 11/14/2022] Open
Abstract
Background Most cases of cryptococcal meningitis occur in patients with HIV infection: the course and outcome of disease in the apparently immunocompetent is much more poorly understood. We describe a cohort of HIV uninfected Vietnamese patients with cryptococcal meningitis in whom underlying disease is uncommon, and relate presenting features of patients and the characteristics of the infecting species to outcome. Methods A prospective descriptive study of HIV negative patients with cryptococcal meningitis based at the Hospital for Tropical Diseases, Ho Chi Minh City. All patients had comprehensive clinical assessment at baseline, were cared for by a dedicated study team, and were followed up for 2 years. Clinical presentation was compared by infecting isolate and outcome. Results 57 patients were studied. Cryptococcus neoformans var grubii molecular type VN1 caused 70% of infections; C. gattii accounted for the rest. Most patients did not have underlying disease (81%), and the rate of underlying disease did not differ by infecting species. 11 patients died while in-patients (19.3%). Independent predictors of death were age ≥ 60 years and a history of convulsions (odds ratios and 95% confidence intervals 8.7 (1 - 76), and 16.1 (1.6 - 161) respectively). Residual visual impairment was common, affecting 25 of 46 survivors (54.3%). Infecting species did not influence clinical phenotype or outcome. The minimum inhibitory concentrations of flucytosine and amphotericin B were significantly higher for C. neoformans var grubii compared with C. gattii (p < 0.001 and p = 0.01 respectively). Conclusion In HIV uninfected individuals in Vietnam, cryptococcal meningitis occurs predominantly in people with no clear predisposing factor and is most commonly due to C. neoformans var grubii. The rates of mortality and visual loss are high and independent of infecting species. There are detectable differences in susceptibility to commonly used antifungal drugs between species, but the clinical significance of this is not clear.
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Affiliation(s)
- Tran Th Chau
- Hospital for Tropical Diseases, Quan, Ho Chi Minh City, Vietnam
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Correlation of genotype and in vitro susceptibilities of Cryptococcus gattii strains from the Pacific Northwest of the United States. J Clin Microbiol 2009; 48:539-44. [PMID: 20007380 DOI: 10.1128/jcm.01505-09] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cryptococcus gattii emerged in North America in 1999 as a human and veterinary pathogen on Vancouver Island, British Columbia. The emergent subtype, VGIIa, and the closely related subtype VGIIb can now be found in the United States in Washington, Oregon, and California. We performed multilocus sequence typing and antifungal susceptibility testing on 43 isolates of C. gattii from human patients in Oregon, Washington, California, and Idaho. In contrast to Vancouver Island, VGIIa was the most frequent but not the predominant subtype in the northwest United States. Antifungal susceptibility testing showed statistically significant differences in MICs between the subtypes. This is the first study to apply antifungal susceptibility testing to C. gattii isolates from the Pacific Northwest and the first to make direct comparisons between subtypes.
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Datta K, Bartlett KH, Baer R, Byrnes E, Galanis E, Heitman J, Hoang L, Leslie MJ, MacDougall L, Magill SS, Morshed MG, Marr KA. Spread of Cryptococcus gattii into Pacific Northwest region of the United States. Emerg Infect Dis 2009; 15:1185-91. [PMID: 19757550 PMCID: PMC2815957 DOI: 10.3201/eid1508.081384] [Citation(s) in RCA: 206] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This organism should be recognized as an emerging pathogen in the United States. Cryptococcus gattii has emerged as a human and animal pathogen in the Pacific Northwest. First recognized on Vancouver Island, British Columbia, Canada, it now involves mainland British Columbia, and Washington and Oregon in the United States. In Canada, the incidence of disease has been one of the highest worldwide. In the United States, lack of cryptococcal species identification and case surveillance limit our knowledge of C. gattii epidemiology. Infections in the Pacific Northwest are caused by multiple genotypes, but the major strain is genetically novel and may have emerged recently in association with unique mating or environmental changes. C. gattii disease affects immunocompromised and immunocompetent persons, causing substantial illness and death. Successful management requires an aggressive medical and surgical approach and consideration of potentially variable antifungal drug susceptibilities. We summarize the study results of a group of investigators and review current knowledge with the goal of increasing awareness and highlighting areas where further knowledge is required.
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Affiliation(s)
- Kausik Datta
- Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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32
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Liaw SJ, Wu HC, Hsueh PR. Microbiological characteristics of clinical isolates of Cryptococcus neoformans in Taiwan: serotypes, mating types, molecular types, virulence factors, and antifungal susceptibility. Clin Microbiol Infect 2009; 16:696-703. [PMID: 19694765 DOI: 10.1111/j.1469-0691.2009.02930.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study investigated the microbiological characteristics of 100 clinical isolates of Cryptococcus neoformans species complex, including serotypes, mating types, molecular types, antifungal susceptibility and virulence. The isolates were collected at National Taiwan University Hospital from 1999 to 2004. Eight isolates of C. neoformans from pigeon droppings were also evaluated. Among these isolates, 99 were C. neoformans var. grubii serotype A and one was C. neoformans var. gattii serotype B. All of these isolates were alpha mating types. PCR fingerprinting, generated by primers M13 and (GACA)(4), and URA5 gene restriction fragment length polymorphism analysis revealed that C. neoformans var. grubii isolates belonged to the VNI (98 isolates) and the VNII (one isolate) types, and the single C. neoformans var. gattii was VGI type. The similar profiles of clinical and environmental isolates suggest that patients might acquire these yeasts from the environment. The MIC(90) for fluconazole, itraconazole, 5-flucytosine, voriconazole and amphotericin B against all C. neoformans isolates were 8, 0.5, 4, 0.125 and 0.5 mg/L, respectively. All clinical isolates produced urease, phospholipase, capsule and melanin, but these activities varied with individual isolates. Analysis of six clinical and two environmental isolates with various levels of phospholipase activity indicated a correlation between phospholipase activity and the ability to adhere to the lung epithelial cell line, A549. The extent of cell damage, as indicated by lactate dehydrogenase release, also paralleled the phospholipase activity of these isolates. In addition, production of melanin contributed significant protection against amphotericin B killing of the isolates tested.
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Affiliation(s)
- S-J Liaw
- Department and Graduate Institute of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taiwan, China
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33
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Wiederhold NP. Pharmacology, in vitro activity, and in vivo efficacy of new antifungal agents. CURRENT FUNGAL INFECTION REPORTS 2009. [DOI: 10.1007/s12281-009-0011-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Khan ZU, Randhawa HS, Chehadeh W, Chowdhary A, Kowshik T, Chandy R. Cryptococcus neoformans serotype A and Cryptococcus gattii serotype B isolates differ in their susceptibilities to fluconazole and voriconazole. Int J Antimicrob Agents 2009; 33:559-63. [PMID: 19195846 DOI: 10.1016/j.ijantimicag.2008.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Revised: 11/11/2008] [Accepted: 11/11/2008] [Indexed: 11/27/2022]
Abstract
This study presents antifungal susceptibility data for environmental isolates of Cryptococcus neoformans serotype A (n=32) and Cryptococcus gattii serotype B (n=18) to fluconazole and voriconazole employing disc diffusion and Etest methods. The disc diffusion test was performed on Mueller-Hinton agar as recommended by the Clinical and Laboratory Standards Institute (CLSI). For comparison, the disc diffusion test and Etest were also performed on RPMI-1640 agar supplemented with 2% glucose. The plates were incubated at 35 degrees C and read after 48h. Comparison of geometric mean inhibition zone diameters revealed that C. gattii isolates were significantly less susceptible than C. neoformans isolates to fluconazole (P=0.001) and voriconazole (P<0.0001). Similar results were obtained on RPMI agar by disc diffusion test and Etest, showing significantly reduced susceptibility for C. gattii isolates. Notwithstanding differences in the susceptibilities of the two species to fluconazole and voriconazole, they appeared susceptible according to the CLSI breakpoints recommended for some Candida spp. To what extent these differences in the susceptibilities of C. neoformans and C. gattii impact on the therapeutic management of cryptococcosis is unclear, although some studies have reported less favourable response in cases caused by the latter species.
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Affiliation(s)
- Z U Khan
- Department of Microbiology, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait.
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35
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Trilles L, Lazéra MDS, Wanke B, Oliveira RV, Barbosa GG, Nishikawa MM, Morales BP, Meyer W. Regional pattern of the molecular types of Cryptococcus neoformans and Cryptococcus gattii in Brazil. Mem Inst Oswaldo Cruz 2008; 103:455-62. [PMID: 18797758 DOI: 10.1590/s0074-02762008000500008] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 07/09/2008] [Indexed: 11/22/2022] Open
Abstract
The molecular types of 443 Brazilian isolates of Cryptococcus neoformans and Cryptococcus gattii were analyzed to determine their geographic distribution within Brazil and their underlying host conditions. The following data, imported from previous epidemiological studies as well as two culture collections, were analyzed for: place of isolation, source (clinical or environmental), host risk factors, species, serotype, mating type, and molecular type. Molecular typing by PCR-fingerprinting using primers for the minisatellite-specific core sequence of the wild-type phage M13 or microsatellites [(GACA)4, (GTG)5], restriction fragment length polymorphism of URA5 gene analysis, and/or amplified fragment length polymorphism (AFLP) identified eight major genotypes: VNI/AFLP1, VNII/AFLP1A, VNIII/AFLP2, and VNIV/AFLP3 for C. neoformans, and VGI/AFLP4, VGII/AFLP6, VGIII/AFLP5, and VGIV/AFLP7 for C. gattii. The most common molecular type found in Brazil was VNI (64%), followed by VGII (21%), VNII (5%), VGIII (4%), VGI and VNIV (3% each), and VNIII (< 1%). Primary cryptococcosis caused by the molecular type VGII (serotype B, MAT alpha) prevails in immunocompetent hosts in the North and Northeast regions, disclosing an endemic regional pattern for this specific molecular type in the Northern Brazil.
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Affiliation(s)
- Luciana Trilles
- Molecular Mycology Research Laboratory, Center for Infectious Diseases and Microbiology, Westmead Hospital, Westmead Millennium Institute, Western Clinical School, University of Sydney, Sydney, Austrália.
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36
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Antifungal susceptibilities among different serotypes of Cryptococcus gattii and Cryptococcus neoformans. Antimicrob Agents Chemother 2008; 53:309-11. [PMID: 18955539 DOI: 10.1128/aac.01216-08] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We measured antifungal activity against 128 cryptococcal isolates (86 of C. neoformans and 42 of C. gattii) to determine if differences in serotype susceptibility exist. Contrary to previous results, we found no serotype susceptibility differences. Isavuconazole, posaconazole, and voriconazole demonstrated excellent potency against each isolate and serotype, including isolates with reduced fluconazole susceptibilities.
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37
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Solla I, Morano LE, Vasallo F, Cuenca-Estrella M. [Cryptococcus gattii meningitis: observation in a Spanish patient]. Enferm Infecc Microbiol Clin 2008; 26:395-6. [PMID: 18588823 DOI: 10.1157/13123846] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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38
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Gomez-Lopez A, Zaragoza O, Dos Anjos Martins M, Melhem M, Rodriguez-Tudela J, Cuenca-Estrella M. In vitro susceptibility of Cryptococcus gattii clinical isolates. Clin Microbiol Infect 2008; 14:727-30. [DOI: 10.1111/j.1469-0691.2008.02021.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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39
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Khan ZU, Randhawa HS, Kowshik T, Chowdhary A, Chandy R. Antifungal susceptibility of Cryptococcus neoformans and Cryptococcus gattii isolates from decayed wood of trunk hollows of Ficus religiosa and Syzygium cumini trees in north-western India. J Antimicrob Chemother 2007; 60:312-6. [PMID: 17553813 DOI: 10.1093/jac/dkm192] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We present antifungal susceptibility data on environmental isolates of Cryptococcus neoformans (serotype A, n=117) and Cryptococcus gattii (serotype B, n=65) cultured from decayed wood of trunk hollows of Ficus religiosa and Syzygium cumini trees. METHODS Susceptibilities to amphotericin B, fluconazole, ketoconazole, itraconazole and voriconazole were determined by using Etest. The MICs were read after 48 h as per the guidelines provided by the manufacturer. RESULTS The MIC90s and susceptibility ranges for C. neoformans isolates were as follows: 0.094 (0.004-0.25) mg/L for amphotericin B, 4 (0.032-12) mg/L for fluconazole, 0.094 (0.004-0.75) mg/L for itraconazole, 0.064 (0.002-0.19) mg/L for ketoconazole, and 0.047 (0.006-0.125) mg/L for voriconazole, whereas for C. gattii isolates these were 0.125 (0.023-0.5) mg/L for amphotericin B, 8 (0.032-16) mg/L for fluconazole, 0.75 (0.006-2) mg/L for itraconazole, 0.125 (0.003-0.19) mg/L for ketoconazole, and 0.094 (0.004-0.125) mg/L for voriconazole. A comparison of the geometric means of MICs (mg/L) revealed that C. gattii was less susceptible than C. neoformans to amphotericin B (0.075 versus 0.051, P=0.0003), fluconazole (2.912 versus 2.316, P=0.003), itraconazole (0.198 versus 0.0344, P<0.0001), ketoconazole (0.072 versus 0.037, P<0.0001), and voriconazole (0.045 versus 0.023, P<0.0001). CONCLUSIONS The antifungal susceptibility data obtained in this study indicate that the occurrence of primary resistance among environmental isolates of C. neoformans serotype A and C. gattii serotype B is rare, and serotype B isolates are less susceptible than serotype A isolates.
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Affiliation(s)
- Zia U Khan
- Mycology Reference Laboratory, Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait.
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40
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Enache-Angoulvant A, Chandenier J, Symoens F, Lacube P, Bolognini J, Douchet C, Poirot JL, Hennequin C. Molecular identification of Cryptococcus neoformans serotypes. J Clin Microbiol 2007; 45:1261-5. [PMID: 17287323 PMCID: PMC1865818 DOI: 10.1128/jcm.01839-06] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Cryptococcus neoformans is a fungal pathogen that causes life-threatening infections primarily in immunocompromised hosts. Based on the genetic characteristics and serologic properties of capsular polysaccharides, three varieties and five serotypes have been defined: C. neoformans var. neoformans (serotype D), C. neoformans var. grubii (serotype A), hybrid serotype AD, and C. neoformans var. gattii (serotypes B and C). Epidemiologic features, such as geographic distribution and ecologic niche, and clinical characteristics have been shown to be associated with serotypes. At the present time, serotyping is based on agglutination tests with either commercial or "homemade" antisera or on immunofluorescence assays using a monoclonal antibody directed against the capsule polysaccharide. In this paper, we describe two molecular methods (PCR-restriction enzyme analysis and length polymorphism analysis) for C. neoformans serotype identification. Both are based on the sequence characteristics of a fragment of the CAP59 gene required for capsule biosynthesis. Testing of 72 C. neoformans strains including representatives of the five serotypes demonstrated the reliability of these methods.
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Affiliation(s)
- A Enache-Angoulvant
- Laboratoire de Parasitologie-Mycologie, Faculté de Médecine Pierre et Marie Curie, site St. Antoine, 27 rue de Chaligny, 75012 Paris, France
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41
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Morgan J, McCarthy KM, Gould S, Fan K, Arthington-Skaggs B, Iqbal N, Stamey K, Hajjeh RA, Brandt ME. Cryptococcus gattii infection: characteristics and epidemiology of cases identified in a South African province with high HIV seroprevalence, 2002-2004. Clin Infect Dis 2006; 43:1077-80. [PMID: 16983624 DOI: 10.1086/507897] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Accepted: 06/13/2006] [Indexed: 11/03/2022] Open
Abstract
We describe 46 Cryptococcus gattii-infected persons identified by population-based surveillance conducted in South Africa. Most patients with C. gattii infection presented with meningitis. The mortality rate during hospitalization was 36%. We found no significant differences between persons with and persons without C. gattii infection with regard to clinical presentation, acquired immunodeficiency syndrome diagnosis, concomitant conditions, or prior opportunistic infections. C. gattii isolates had low MICs to the tested antifungal drugs.
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Affiliation(s)
- Juliette Morgan
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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42
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Dannaoui E, Abdul M, Arpin M, Michel-Nguyen A, Piens MA, Favel A, Lortholary O, Dromer F. Results obtained with various antifungal susceptibility testing methods do not predict early clinical outcome in patients with cryptococcosis. Antimicrob Agents Chemother 2006; 50:2464-70. [PMID: 16801427 PMCID: PMC1489793 DOI: 10.1128/aac.01520-05] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The in vitro susceptibilities of Cryptococcus neoformans isolates from consecutive human immunodeficiency virus-positive and -negative patients to the antifungal agents fluconazole, amphotericin B, and flucytosine were determined by different techniques, including the CLSI method, Etest, and broth microdilution in yeast nitrogen base (YNB) medium, during a multicenter prospective study in France. The relationship between the in vitro data and the clinical outcome 2 weeks after the initiation of antifungal therapy was assessed. In addition, the correlation between the strain serotype and the in vitro activities of the antifungals was determined, and the susceptibility results obtained with the different techniques were also compared. Thirty-seven patients received a combination of amphotericin B with flucytosine as first-line therapy, 22 were treated with amphotericin B alone, and 15 received fluconazole alone. Whatever the antifungal tested, there was no trend toward higher MICs for strains isolated from patients who failed to respond to a given therapy compared to those from patients who did not with either the CLSI method, Etest, or broth microdilution in YNB medium. The MICs obtained by the CLSI or Etest method were significantly lower for serotype D strains than for serotype A strains for both fluconazole and amphotericin B, while flucytosine MICs were not different according to serotype. These findings suggest that the in vitro antifungal susceptibility of C. neoformans, as determined with the techniques used, is not able to predict the early clinical outcome in patients with cryptococcosis.
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Affiliation(s)
- E Dannaoui
- Centre National de Référence Mycologie et Antifongiques, Unité de Mycologie Moléculaire, CNRS FRE2849, Institut Pasteur, 25, rue du Dr. Roux, 75724 Paris Cedex 15, France.
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Tay ST, Tanty Haryanty T, Ng KP, Rohani MY, Hamimah H. In vitro susceptibilities of Malaysian clinical isolates of Cryptococcus neoformans var. grubii and Cryptococcus gattii to five antifungal drugs. Mycoses 2006; 49:324-30. [PMID: 16784448 DOI: 10.1111/j.1439-0507.2006.01242.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The in vitro susceptibilities of Malaysian clinical isolates of Cryptococcus neoformans var. grubii and C . gattii to five antifungal drugs (amphotericin B, flucytosine, fluconazole, itraconazole and ketoconazole) were determined using the Etest method. None of the Malaysian isolates was resistant to amphotericin B and ketoconazole. Isolates resistant to flucytosine, fluconazole and itraconazole were observed in this study. Minimum inhibition concentrations (MICs) of > or = 32 microg ml(-1) against flucytosine, > or = 64 microg ml(-1) against fluconazole and > or = 1 microg ml(-1) against itraconazole were noted in four (8.3%), two (4.2%) and one (2.1%) isolates respectively. There was no significant difference in the MICs for both Cryptococcus species (P > 0.05), indicating that C. gattii was as susceptible as var. grubii to all the antifungal drugs tested. No significant difference in the MICs for both Cryptococcus species collected from 1980 to 1990 and 2002 to 2004 were observed (P > 0.05).
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Affiliation(s)
- S T Tay
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur.
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Trilles L, Fernández-Torres B, Lazéra MDS, Wanke B, Guarro J. In vitro antifungal susceptibility of Cryptococcus gattii. J Clin Microbiol 2004; 42:4815-7. [PMID: 15472349 PMCID: PMC522305 DOI: 10.1128/jcm.42.10.4815-4817.2004] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
We have determined the in vitro susceptibilities of 57 strains of Cryptococcus gattii to nine antifungal agents and have compared the MICs for these strains with those for C. neoformans. MICs were determined by a microdilution reference method. Albaconazole and ravuconazole (MICs of 0.04 and 0.05 microg/ml, respectively) showed the best activities. Micafungin showed no activity (MIC of >128 microg/ml). In general, C. gattii was less susceptible than C. neoformans to all drugs tested, with the exception of amphotericin B and flucytosine.
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Affiliation(s)
- Luciana Trilles
- Serviçio de Micología Médica, Instituto de Pesquisa Clínica Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
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Sun LM, Chen TY, Chen WJ, Hsieh MJ, Liu JW, Huang CC, Wang CJ. Cryptococcus infection in a patient with nasopharyngeal carcinoma: imaging findings mimicking pulmonary metastases. Br J Radiol 2002; 75:275-8. [PMID: 11932223 DOI: 10.1259/bjr.75.891.750275] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
An asymptomatic pulmonary mass was found in a 42-year-old unmarried male with controlled nasopharyngeal carcinoma (NPC) during routine follow-up chest radiography 8 months following completion of radiotherapy. Chest CT demonstrated a 3x2 cm(2) left lower lobe (LLL) mass, with further small nodules in the same lobe. A presumptive diagnosis of lung metastases was made, and the patient underwent surgical resection with left lower lobectomy and mediastinal lymph node dissection. Pathologic examination of the masses in the LLL revealed granulomatous inflammation with cryptococcus infection. The dissected lymph nodes revealed anthracosis. The patient received 6 months of antifungal treatment with fluconazole. His NPC showed no evidence of local recurrence or distant metastases. Recognition that pulmonary cryptococcus infection can mimic metastases is important in reaching the correct diagnosis and therefore determining the correct treatment.
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Affiliation(s)
- L-M Sun
- Department of Radiation Oncology, Chang Gung University and Chang Gung Memorial Hospital Kaohsiung Center, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien 833, Taiwan
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