1
|
Ohira K, Kawarada Y, Iwata R, Satake M. MRI changes in cryptococcal meningoencephalitis exacerbated by antifungal treatment due to post-infectious inflammatory syndrome: A case report. Radiol Case Rep 2024; 19:5579-5585. [PMID: 39296744 PMCID: PMC11406346 DOI: 10.1016/j.radcr.2024.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 08/05/2024] [Accepted: 08/07/2024] [Indexed: 09/21/2024] Open
Abstract
Cryptococcal meningitis is one of the most common fungal meningitis in adults and causes disabling morbidity and mortality worldwide. The occurrence of postinfectious inflammatory response syndrome during cryptococcal meningitis treatment presents a diagnostic challenge. This time course seems paradoxical because patients show worsening symptoms and imaging findings. However, laboratory data improve with antifungal treatments. Herein, we present a case of an older woman diagnosed with cryptococcal meningitis who later developed postinfectious inflammatory response syndrome. Despite the initial antifungal treatment and improvements in cerebrospinal fluid analysis results, the patient's neurological condition deteriorated; imaging findings worsened. Magnetic resonance imaging at the time of postinfectious inflammatory response syndrome showed more prominent meningeal enhancement and brain edema, consistent with postinfectious inflammatory response syndrome, combined with negative repeat cerebrospinal fluid cultures for cryptococcal species. This case highlights the importance of considering postinfectious inflammatory response syndrome when patients with cryptococcal meningitis show clinical worsening during treatment. Prompt corticosteroid therapy significantly improves patient outcomes. Radiologists and clinicians should be aware of postinfectious inflammatory response syndrome to provide appropriate therapeutic options and improve prognosis in patients with cryptococcal meningitis.
Collapse
Affiliation(s)
- Kenji Ohira
- Department of Radiology, Shin-Kuki General Hospital, , 418-1 Kamihayami, Kuki City, Saitama Prefecture 346-8530
| | - Yo Kawarada
- Department of Radiology, Shin-Kuki General Hospital, , 418-1 Kamihayami, Kuki City, Saitama Prefecture 346-8530
| | - Ryoko Iwata
- Department of Radiology, Shin-Kuki General Hospital, , 418-1 Kamihayami, Kuki City, Saitama Prefecture 346-8530
| | - Mitsuo Satake
- Department of Radiology, Shin-Kuki General Hospital, , 418-1 Kamihayami, Kuki City, Saitama Prefecture 346-8530
| |
Collapse
|
2
|
Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, Hagen F, Spec A, Oladele R, Govender NP, Chen SC, Mody CH, Groll AH, Chen YC, Lionakis MS, Alanio A, Castañeda E, Lizarazo J, Vidal JE, Takazono T, Hoenigl M, Alffenaar JW, Gangneux JP, Soman R, Zhu LP, Bonifaz A, Jarvis JN, Day JN, Klimko N, Salmanton-García J, Jouvion G, Meya DB, Lawrence D, Rahn S, Bongomin F, McMullan BJ, Sprute R, Nyazika TK, Beardsley J, Carlesse F, Heath CH, Ayanlowo OO, Mashedi OM, Queiroz-Telles Filho F, Hosseinipour MC, Patel AK, Temfack E, Singh N, Cornely OA, Boulware DR, Lortholary O, Pappas PG, Perfect JR. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. THE LANCET. INFECTIOUS DISEASES 2024; 24:e495-e512. [PMID: 38346436 DOI: 10.1016/s1473-3099(23)00731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/13/2023] [Indexed: 03/21/2024]
Abstract
Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.
Collapse
Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia; Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC, Australia; Centre for the AIDS Programme of Research in South Africa, Durban, South Africa.
| | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Tihana A Bicanic
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tania C Sorrell
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Adilia Warris
- Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Infectious Diseases, Great Ormond Street Hospital, London, UK
| | - Ferry Hagen
- Faculty of Science, Institute for Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, Netherlands; Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Rita Oladele
- College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nelesh P Govender
- Institute of Infection and Immunity, St George's University London, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sharon C Chen
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Christopher H Mody
- Department of Microbiology, Immunology and Infectious Diseases, Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Andreas H Groll
- Infectious Disease Research Program, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany; Center for Bone Marrow Transplantation, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany
| | - Yee-Chun Chen
- 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, Zhunan, Taiwan
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alexandre Alanio
- Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Groupe de recherche Mycologie Translationnelle, Département de Mycologie, Université Paris Cité, Paris, France; Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | | | - Jairo Lizarazo
- Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Faculty of Health, Univesidad de Pamplona, Cúcuta, Colombia
| | - José E Vidal
- Departmento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil; Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto de Medicina Tropical, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Takahiro Takazono
- Department of Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Martin Hoenigl
- Division of Infectious Diseases, Translational Medical Mycology Research Unit, European Confederation of Medical Mycology Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria; BioTechMed, Graz, Austria
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia; School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jean-Pierre Gangneux
- Institute for Health, Environment and Work Research-Irset, Inserm UMR_S 1085, University of Rennes, Rennes, France; Laboratory for Parasitology and Mycology, Centre National de Référence Mycoses Invasives et Antifongiques LA Asp-C, University Hospital of Rennes, Rennes, France
| | - Rajeev Soman
- Jupiter Hospital, Pune, India; Deenanath Mangeshkar Hospital, Pune, India; Hinduja Hospital, Mumbai, India
| | - Li-Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai China
| | - Alexandro Bonifaz
- Hospital General de México, Dermatology Service, Mycology section, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Jeremy N Day
- Department of Clinical Microbiology and Infection, Royal Devon and Exeter University Hospital NHS Trust, Exeter, UK
| | - Nikolai Klimko
- Department of Clinical Mycology, Allergy and Immunology, I Mechnikov North Western State Medical University, Staint Petersburg, Russia
| | - Jon Salmanton-García
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Grégory Jouvion
- Histology and Pathology Unit, Ecole nationale vétérinaire d'Alfort, Maisons-Alfort, France; Dynamyc Team, Université Paris Est Créteil and Ecole nationale vétérinaire d'Alfort, Créteil, France
| | - David B Meya
- Infectious Diseases Institute, School of Medicine, College of Heath Sciences, Makerere University, Kampala, Uganda
| | - David Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Sebastian Rahn
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Brendan J McMullan
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Rosanne Sprute
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Tinashe K Nyazika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Fabianne Carlesse
- Pediatric Department, Federal University of São Paulo, São Paulo, Brazil; Oncology Pediatric Institute-IOP-GRAACC, Federal Univeristy of São Paulo, São Paulo, Brazil
| | - Christopher H Heath
- Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Perth, WA, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia; UWA Medical School, Internal Medicine, The University of Western Australia, Perth, WA, Australia
| | - Olusola O Ayanlowo
- Dermatology Unit, Department of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Olga M Mashedi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mina C Hosseinipour
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA; UNC Project Malawi, Lilongwe, Malawi
| | - Atul K Patel
- Department of Infectious Diseases, Sterling Hospitals, Ahmedabad, India
| | - Elvis Temfack
- Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Nina Singh
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Oliver A Cornely
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany; Clinical Trials Centre Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Olivier Lortholary
- Université de Paris Cité, APHP, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Centre d'Infectiologie Necker-Pasteur, Institut Imagine, Paris, France; Institut Pasteur, CNRS, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, UMR 2000, Paris, France
| | - Peter G Pappas
- Mycoses Study Group Central Unit, Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA.
| |
Collapse
|
3
|
Rocha MF, Bain HDC, Stone N, Meya D, Darie L, Toma AK, Lunn MPT, Mehta AR, Coughlan C. Reframing the clinical phenotype and management of cryptococcal meningitis. Pract Neurol 2024:pn-2024-004133. [PMID: 38997136 DOI: 10.1136/pn-2024-004133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 07/14/2024]
Abstract
Cryptococcal meningitis is an important global health problem, resulting from infection with the yeast Cryptococcus, especially Cryptococcus neoformans and Cryptococcus gattii, which cause a spectrum of disease ranging from pulmonary and skin lesions to life-threatening central nervous system involvement. The diagnosis and management of cryptococcal meningitis have substantially changed in recent years. Cryptococcal meningitis often occurs in people living with advanced HIV infection, though in high-income countries with robust HIV detection and treatment programmes, it increasingly occurs in other groups, notably solid-organ transplant recipients, other immunosuppressed patients and even immunocompetent hosts. This review outlines the clinical presentation, management and prognosis of cryptococcal meningitis, including its salient differences in people living with HIV compared with HIV-negative patients. We discuss the importance of managing raised intracranial pressure and highlight the advantages of improved multidisciplinary team working involving neurologists, infectious disease specialists and neurosurgeons.
Collapse
Affiliation(s)
- Maria Francisca Rocha
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hamish D C Bain
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Neil Stone
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lucia Darie
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ahmed K Toma
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael P T Lunn
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arpan R Mehta
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- MRC Protein Phosphorylation & Ubiquitylation Unit, School of Life Sciences, University of Dundee, Dundee, UK
| | - Charles Coughlan
- National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
4
|
Ding M, Nielsen K. Inbred Mouse Models in Cryptococcus neoformans Research. J Fungi (Basel) 2024; 10:426. [PMID: 38921412 PMCID: PMC11204852 DOI: 10.3390/jof10060426] [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: 04/25/2024] [Revised: 06/01/2024] [Accepted: 06/14/2024] [Indexed: 06/27/2024] Open
Abstract
Animal models are frequently used as surrogates to understand human disease. In the fungal pathogen Cryptococcus species complex, several variations of a mouse model of disease were developed that recapitulate different aspects of human disease. These mouse models have been implemented using various inbred and outbred mouse backgrounds, many of which have genetic differences that can influence host response and disease outcome. In this review, we will discuss the most commonly used inbred mouse backgrounds in C. neoformans infection models.
Collapse
Affiliation(s)
| | - Kirsten Nielsen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455, USA
| |
Collapse
|
5
|
Vlasova-St. Louis I, Mohei H. Molecular Diagnostics of Cryptococcus spp. and Immunomics of Cryptococcosis-Associated Immune Reconstitution Inflammatory Syndrome. Diseases 2024; 12:101. [PMID: 38785756 PMCID: PMC11120354 DOI: 10.3390/diseases12050101] [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: 02/20/2024] [Revised: 05/05/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Cryptococcal infection poses a significant global public health challenge, particularly in regions near the equator. In this review, we offer a succinct exploration of the Cryptococcus spp. genome and various molecular typing methods to assess the burden and genetic diversity of cryptococcal pathogens in the environment and clinical isolates. We delve into a detailed discussion on the molecular pathogenesis and diagnosis of immune reconstitution inflammatory syndrome (IRIS) associated with cryptococcosis, with a specific emphasis on cryptococcal meningitis IRIS (CM-IRIS). Our examination includes the recent literature on CM-IRIS, covering host cellulomics, proteomics, transcriptomics, and genomics.
Collapse
Affiliation(s)
| | - Hesham Mohei
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| |
Collapse
|
6
|
Meya DB, Williamson PR. Cryptococcal Disease in Diverse Hosts. N Engl J Med 2024; 390:1597-1610. [PMID: 38692293 DOI: 10.1056/nejmra2311057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Affiliation(s)
- David B Meya
- From the Infectious Diseases Institute and the Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda (D.B.M.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.B.M.); and the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.R.W.)
| | - Peter R Williamson
- From the Infectious Diseases Institute and the Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda (D.B.M.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.B.M.); and the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.R.W.)
| |
Collapse
|
7
|
McHale TC, Boulware DR, Kasibante J, Ssebambulidde K, Skipper CP, Abassi M. Diagnosis and management of cryptococcal meningitis in HIV-infected adults. Clin Microbiol Rev 2023; 36:e0015622. [PMID: 38014977 PMCID: PMC10870732 DOI: 10.1128/cmr.00156-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Cryptococcal meningitis is a leading cause of morbidity and mortality globally, especially in people with advanced HIV disease. Cryptococcal meningitis is responsible for nearly 20% of all deaths related to advanced HIV disease, with the burden of disease predominantly experienced by people in resource-limited countries. Major advancements in diagnostics have introduced low-cost, easy-to-use antigen tests with remarkably high sensitivity and specificity. These tests have led to improved diagnostic accuracy and are essential for screening campaigns to reduce the burden of cryptococcosis. In the last 5 years, several high-quality, multisite clinical trials have led to innovations in therapeutics that have allowed for simplified regimens, which are better tolerated and result in less intensive monitoring and management of medication adverse effects. One trial found that a shorter, 7-day course of deoxycholate amphotericin B is as effective as the longer 14-day course and that flucytosine is an essential partner drug for reducing mortality in the acute phase of disease. Single-dose liposomal amphotericin B has also been found to be as effective as a 7-day course of deoxycholate amphotericin B. These findings have allowed for simpler and safer treatment regimens that also reduce the burden on the healthcare system. This review provides a detailed discussion of the latest evidence guiding the clinical management and special circumstances that make cryptococcal meningitis uniquely difficult to treat.
Collapse
Affiliation(s)
- Thomas C. McHale
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Caleb P. Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
8
|
Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
Collapse
Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
9
|
van Halsema CL, Eades CP, Johnston VJ, Miller RF. British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical investigation and management of pyrexia of unknown origin 2023. HIV Med 2023; 24 Suppl 4:3-18. [PMID: 37956976 DOI: 10.1111/hiv.13558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 11/21/2023]
Affiliation(s)
- C L van Halsema
- Regional infectious diseases unit, Manchester University NHS Foundation Trust
| | - C P Eades
- Regional infectious diseases unit, Manchester University NHS Foundation Trust
- University of Manchester
| | - V J Johnston
- London School of Hygiene & Tropical Medicine
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust
| | - R F Miller
- London School of Hygiene & Tropical Medicine
- Institute for Global Health, University College London
- Central & North West London NHS Foundation Trust
| |
Collapse
|
10
|
Yeh TK, Lin KP, Chuang YC, Wang LA, Chen CJ, Lee DY, Huang YT, Liu PY. Clinical metagenomics-assisted diagnosis of relapsed HIV-associated cryptococcal meningitis. Int J STD AIDS 2023; 34:740-744. [PMID: 37147923 DOI: 10.1177/09564624231174179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
To date, the identification of crypotococcal relapse remains clinically challenging as it often has similar manifestation with paradoxical immune reconstitution inflammatory syndrome. This study reports on the use of metagenomics assisted next generation sequencing to aid in diagnosing recurrent cryptococcal meningitis in an person living with HIV experiencing recurring symptoms, despite negative culture results for Cryptococcus neoformans in the cerebrospinal fluid. Although fungal culture was negative, when reads from metagenomic and metatranscriptomic sequencing performed on the Day 308 cerebrospinal fluid sample were mapped onto the genome from the Day 4 isolate, 589 specific reads were identified. NCBI BLAST search also revealed Cryptococcus-specific 18S/25S/28S ribosomal RNA, indicating a relapse of the disease.
Collapse
Affiliation(s)
- Ting Kuang Yeh
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Genomic Center for Infectious Diseases, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuan Pei Lin
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu Chuan Chuang
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Li An Wang
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chih Jun Chen
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ding Yu Lee
- Department of Bioscience and Biotechnology, National Taiwan Ocean University, Keelung, Taiwan
| | - Yao Ting Huang
- Department of Computer Science and Information Engineering, National Chung Cheng University, Chiayi, Taiwan
| | - Po Yu Liu
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Genomic Center for Infectious Diseases, Taichung Veterans General Hospital, Taichung, Taiwan
- Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| |
Collapse
|
11
|
Leone F, Cotugno N, Casamento Tumeo C, Zangari P, Palomba P, Adorisio R, De Benedetti F, Bracaglia C, Papoff P, Ajassa C, Palma P, Bernardi S. Hyperinflammatory syndrome in a paediatric patient with a recent diagnosis of HIV/AIDS infection: hemophagocytic lymphohistiocytosis or immune reconstitution syndrome? BMC Infect Dis 2023; 23:477. [PMID: 37464267 DOI: 10.1186/s12879-023-08457-9] [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: 12/09/2022] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Haemophagocytic lymphohistiocytosis is a rare and life-threatening condition caused by uncontrolled immune activation leading to excessive inflammation and tissue destruction. It could either be due to a primary genetic defect or be triggered by secondary causes such as infections, autoimmune diseases, rheumatological diseases or post-transplant immunosuppression. We here report the case of a 4-year-old child with a recent AIDS diagnosis who developed a severe systemic inflammation. CASE REPORT We here report the case of a 4-year-old child with a recent AIDS diagnosis who was admitted to the ER with acute respiratory failure due to Pneumocystis jiroveci infection and Aspergillosis; the following microbiological assessment also showed a CMV, HSV, EBV and HHV-7 coinfection. On the 51st day after she'd started antiretroviral therapy, 39th after she'd followed a course of Bactrim and Caspofungin for PJI and Ambisome for pulmonary Aspergillosis, she started presenting fever, unresponsive to broad-spectrum antibiotic therapy. She also presented worsening of her clinical conditions, with evidence at the laboratory assessments of progressive raise in inflammatory indexes, coagulopathy, trilinear cytopenia and hyperferritinemia. To perform the differential diagnosis between IRIS and HLH, HLA-DR on T cells was studied, turning out negative for IRIS. Therefore, in the suspicion of HLH, a bone marrow aspirate and biopsy were performed with evidence of trilinear cytopenia, prevalence of T-cells and macrophages with signs of phagocytosis. She was started on high-dose steroids and Anakinra for a total of 29 days, resulting in prompt apyrexia and progressive improvement of her clinical conditions and laboratory results. CONCLUSION To the best of our knowledge there is poor literature available about the differential diagnosis of HLH and IRIS, therefore medical management in the concurrence of these two conditions needs to be further investigated, especially in a setting where immunological testing is not quickly available. The clinical differences between these pathologies are blurred and the bone marrow biopsy within marker for IRIS helped us to distinguish these two entities.
Collapse
Affiliation(s)
- Fabrizio Leone
- Policlinico Umberto I, Maternal Infantile and Urological Sciences Department, Sapienza University of Rome, Rome, Italy.
| | - Nicola Cotugno
- Clinical and Research Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics (DPUO), Bambino Gesù Children Hospital, IRCCS, Rome, Italy
- Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Chiara Casamento Tumeo
- Academic Department of Pediatrics (DPUO), Bambino Gesù Pediatric Hospital, IRCCS, Rome, Italy
| | - Paola Zangari
- Clinical and Research Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics (DPUO), Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Patrizia Palomba
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rachele Adorisio
- Heart Failure, Transplant and Mechanical Cardiocirculatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart Lung Transplantation, ERN GUARD HEART: Bambino Gesù Hospital and Research Institute, Rome, Italy
| | | | - Claudia Bracaglia
- Division of Rheumatology, Bambino Gesù Children's Hospital, IRCCS, Roma, Italy
| | - Paola Papoff
- Department of Pediatrics, Pediatric Intensive Care Unit, Umberto I Policlinico, Sapienza University of Rome, Rome, Italy
| | - Camilla Ajassa
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Paolo Palma
- Clinical and Research Unit of Clinical Immunology and Vaccinology, Academic Department of Pediatrics (DPUO), Bambino Gesù Children Hospital, IRCCS, Rome, Italy
- Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Stefania Bernardi
- Unit of Immune and Infectious Disease, University Department of Pediatrics, DPUO, Bambino Gesù Children's Hospital, Rome, Italy
| |
Collapse
|
12
|
Kawano T, Zhou J, Anwar S, Salah H, Dayal AH, Ishikawa Y, Boetel K, Takahashi T, Sharma K, Inoue M. T cell infiltration into the brain triggers pulmonary dysfunction in murine Cryptococcus-associated IRIS. Nat Commun 2023; 14:3831. [PMID: 37380639 DOI: 10.1038/s41467-023-39518-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 06/16/2023] [Indexed: 06/30/2023] Open
Abstract
Cryptococcus-associated immune reconstitution inflammatory syndrome (C-IRIS) is a condition frequently occurring in immunocompromised patients receiving antiretroviral therapy. C-IRIS patients exhibit many critical symptoms, including pulmonary distress, potentially complicating the progression and recovery from this condition. Here, utilizing our previously established mouse model of unmasking C-IRIS (CnH99 preinfection and adoptive transfer of CD4+ T cells), we demonstrated that pulmonary dysfunction associated with the C-IRIS condition in mice could be attributed to the infiltration of CD4+ T cells into the brain via the CCL8-CCR5 axis, which triggers the nucleus tractus solitarius (NTS) neuronal damage and neuronal disconnection via upregulated ephrin B3 and semaphorin 6B in CD4+ T cells. Our findings provide unique insight into the mechanism behind pulmonary dysfunction in C-IRIS and nominate potential therapeutic targets for treatment.
Collapse
Affiliation(s)
- Tasuku Kawano
- Department of Comparative Biosciences, The University of Illinois at Urbana-Champaign, 2001 South Lincoln Avenue, Urbana, IL, 61802, USA
- Division of Pathophysiology, Department of Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, 4-4-1 Komatsushima Aoba-Ku, Sendai, Miyagi, 981-8558, Japan
| | - Jinyan Zhou
- Department of Comparative Biosciences, The University of Illinois at Urbana-Champaign, 2001 South Lincoln Avenue, Urbana, IL, 61802, USA
- Neuroscience Program, The University of Illinois at Urbana-Champaign, 405 North Matthews Avenue, Urbana, IL, 61801, USA
| | - Shehata Anwar
- Department of Comparative Biosciences, The University of Illinois at Urbana-Champaign, 2001 South Lincoln Avenue, Urbana, IL, 61802, USA
- Department of Pathology, Faculty of Veterinary Medicine, Beni-Suef University (BSU), Beni-Suef, 62511, Egypt
| | - Haneen Salah
- Department of Comparative Biosciences, The University of Illinois at Urbana-Champaign, 2001 South Lincoln Avenue, Urbana, IL, 61802, USA
- School of Molecular and Cell Biology, The University of Illinois at Urbana-Champaign, 407 South Goodwin Avenue, Urbana, IL, 61801, USA
| | - Andrea H Dayal
- Department of Comparative Biosciences, The University of Illinois at Urbana-Champaign, 2001 South Lincoln Avenue, Urbana, IL, 61802, USA
- School of Molecular and Cell Biology, The University of Illinois at Urbana-Champaign, 407 South Goodwin Avenue, Urbana, IL, 61801, USA
| | - Yuzuki Ishikawa
- Department of Comparative Biosciences, The University of Illinois at Urbana-Champaign, 2001 South Lincoln Avenue, Urbana, IL, 61802, USA
- School of Molecular and Cell Biology, The University of Illinois at Urbana-Champaign, 407 South Goodwin Avenue, Urbana, IL, 61801, USA
| | - Katelyn Boetel
- Department of Comparative Biosciences, The University of Illinois at Urbana-Champaign, 2001 South Lincoln Avenue, Urbana, IL, 61802, USA
- School of Molecular and Cell Biology, The University of Illinois at Urbana-Champaign, 407 South Goodwin Avenue, Urbana, IL, 61801, USA
| | - Tomoko Takahashi
- Division of Pathophysiology, Department of Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, 4-4-1 Komatsushima Aoba-Ku, Sendai, Miyagi, 981-8558, Japan
| | - Kamal Sharma
- Department of Anatomy and Cell Biology, University of Illinois, Chicago, 808 S. Wood Street, Chicago, IL, 60612, USA
| | - Makoto Inoue
- Department of Comparative Biosciences, The University of Illinois at Urbana-Champaign, 2001 South Lincoln Avenue, Urbana, IL, 61802, USA.
- Neuroscience Program, The University of Illinois at Urbana-Champaign, 405 North Matthews Avenue, Urbana, IL, 61801, USA.
- Beckman Institute for Advanced Science and Technology, 405 North Matthews Avenue, Urbana, IL, 61801, USA.
| |
Collapse
|
13
|
Qi T, Chen F, Ma S, Zhang R, Liu L, Wang Z, Tang Y, Song W, Sun J, Yang J, Xu S, Zhao B, Shen Y, Chen J. Thalidomide for Recurrence of Symptoms following HIV-Associated Cryptococcal Meningitis. Infect Dis Ther 2023:10.1007/s40121-023-00817-x. [PMID: 37286922 DOI: 10.1007/s40121-023-00817-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023] Open
Abstract
INTRODUCTION Cryptococcal meningitis (CM) is a serious and fatal fungal infection that affects individuals infected with human immunodeficiency virus (HIV). Despite treatment, recurrence of symptoms is common and could lead to poor outcomes. Corticosteroids are not always useful in treating symptom recurrence following HIV/CM; thus, alternative therapy is needed. Thalidomide has been reported to be effective in treating symptom recurrence in several patients with HIV/CM. This retrospective study aimed to investigate the efficacy and safety of thalidomide in the treatment of symptom recurrence following HIV/CM. METHODS Patients who were treated with thalidomide for symptom recurrence following HIV/CM were retrospectively included. Clinical outcomes and adverse events were recorded and analyzed. RESULTS Sixteen patients admitted between July 2018 and September 2020 were included in the analysis. During a median follow-up period of 295 (166, 419) days, all patients achieved clinical improvement in a median of 7 (4, 20) days. Among them, nine (56%) achieved complete resolution of symptoms at a median of 187 (131, 253) days, including 40% (2/5) of immune reconstitution inflammatory syndrome (IRIS), 50% (3/6) of patients with elevated ICP only, and 80% (4/5) of patients with symptoms only. Seven (43%) patients experienced nine episodes of adverse events, but no severe adverse event attributable to thalidomide was observed. None of the patients withdrew from thalidomide due to adverse events. CONCLUSION Thalidomide appears to be effective and safe in treating different types of symptom recurrence in HIV/CM. This study provides preliminary evidence supporting future randomized clinical trials to further investigate the efficacy and safety of thalidomide in treating symptom recurrence in this population.
Collapse
Affiliation(s)
- Tangkai Qi
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Fang Chen
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
- Nanchang Ninth Hospital, Nanchang, 330002, Jiangxi, China
| | - Siyue Ma
- School of Nursing, Fudan University, Shanghai, China
| | - Renfang Zhang
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Li Liu
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Zhenyan Wang
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Yang Tang
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Wei Song
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Jianjun Sun
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Junyang Yang
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Shuibao Xu
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Bihe Zhao
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Yinzhong Shen
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China
| | - Jun Chen
- Department of Infection and Immunology, Shanghai Public Health Clinical Center, 2901 Caolang Road, Shanghai, 201508, China.
| |
Collapse
|
14
|
Hogan D, Bishburg E, Suryadevara M. Cerebellitis associated with cryptococcal-immune reconstitution inflammatory syndrome. IDCases 2023; 33:e01790. [PMID: 37273775 PMCID: PMC10236292 DOI: 10.1016/j.idcr.2023.e01790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 06/06/2023] Open
Abstract
Cerebellitis associated with cryptococcal immune reconstitution inflammatory syndrome (IRIS) has not been previously reported. We describe a unique case of IRIS associated cerebellitis in an AIDS patient with cryptococcosis.
Collapse
|
15
|
Lasry D, Cantarovich M, Sandal S. Sequelae of Cryptococcal-Immune Reconstitution Inflammatory Syndrome in a Kidney Transplant Recipient: A Case Report. Can J Kidney Health Dis 2023; 10:20543581231172399. [PMID: 37163140 PMCID: PMC10164251 DOI: 10.1177/20543581231172399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/14/2023] [Indexed: 05/11/2023] Open
Abstract
Rationale Cryptococcal-immune reconstitution inflammatory syndrome (C-IRIS) is a rare but recognized clinical entity in solid organ transplant recipients, though its clinical course and sequelae remain largely poorly described. Presenting Concerns of the Patient We present the case of a kidney transplant recipient who presented with headache and fever. A cerebrospinal fluid analysis was performed and found to be compatible with cryptococcal meningitis. After down titration of immunosuppression and antifungal initiation, the patient initially improved. Weeks later, they experienced a sudden deterioration in mental status, prompting admission to the intensive care unit (ICU). Diagnosis This deterioration was attributed to C-IRIS, which developed following rapid de-escalation of immunosuppression in response to the diagnosis of cryptococcal meningitis. Interventions The initial episode of C-IRIS responded well to high-dose steroids; however, maintenance immunosuppression was not increased. Outcomes Within 2 months, the patient presented again to the hospital with a pulmonary infiltrate and multifocal ischemic strokes. Novel Findings We argue this to be a case of relapsing multisystem C-IRIS, thus expanding the known spectrum of manifestations of C-IRIS in renal transplant recipients. We propose that following the diagnosis of C-IRIS, maintenance immunosuppression be escalated to avoid the risk of relapse and inflammatory-mediated organ dysfunction.
Collapse
Affiliation(s)
- David Lasry
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
- The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Multi-organ Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Shaifali Sandal
- Division of Nephrology, Department of Medicine, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
- The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Multi-organ Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, McGill University Health Centre, Montreal, QC, Canada
| |
Collapse
|
16
|
Samukawa S, Yoshimi R, Kojitani N, Uzawa Y, Takase-Minegishi K, Kirino Y, Soejima Y, Kato H, Nakajima H. Cryptococcal meningitis with atypical paradoxical inflammatory reactions after antifungal treatment in acquired immune deficiency syndrome: A case report. J Infect Chemother 2023; 29:347-352. [PMID: 36384196 DOI: 10.1016/j.jiac.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/24/2022] [Accepted: 11/07/2022] [Indexed: 11/14/2022]
Abstract
Cryptococcal meningitis (CM) is a life-threatening disease that primarily affects patients with human immunodeficiency virus (HIV). Antifungal therapy with antiretroviral treatment (ART) usually leads to the clinical remission of CM; however, in some cases, these treatments exacerbate intracranial inflammation because of paradoxical inflammatory reaction or immune reconstitution inflammatory syndrome (IRIS). Here we report two CM cases that presented atypical clinical courses attributed to paradoxical inflammatory reactions. The first case was a 43-year-old man with headache and vertigo diagnosed with CM and HIV. The patient's CM not only was refractory to the antifungal combination therapy of liposomal amphotericin B (L-AMB) and fluconazole (FLCZ) but suddenly worsened because of a paradoxical inflammatory reaction after 18 days of treatment. He passed away from brain herniation on day 23. The second case was a 43-year-old man diagnosed with CM and HIV. After receiving antifungal therapy and ART, the patient's status was stable for more than 3 years with undetectable HIV-RNA. He suddenly presented with brain inflammation and was diagnosed with IRIS due to CM (CM-IRIS). His brain lesions were migratory and refractory to various antifungal therapies such as L-AMB, FLCZ, flucytosine, and intrathecal amphotericin B. Although the cryptococcal antigen in the patient's cerebrospinal fluid gradually diminished after continuous antifungal therapies, his cognitive function declined, and right hemiparesis persisted. These two cases of CM presented atypical clinical courses, presumably because of paradoxical inflammatory reactions. It should be noted that the onset of CM-IRIS may not necessarily depend on the timing of ART initiation.
Collapse
Affiliation(s)
- Sei Samukawa
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan.
| | - Noriko Kojitani
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Yuji Uzawa
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Yutaro Soejima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Hideaki Kato
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| |
Collapse
|
17
|
Wan Z, Tao R, Hui J, Liu X, Peng X, Guo Y, Zhu X, Huang Y, Zhu B. Efficacy and safety of lenalidomide in HIV-associated cryptococcal meningitis patients with persistent intracranial inflammation: an open-label, single-arm, prospective interventional study. J Neuroinflammation 2023; 20:38. [PMID: 36793113 PMCID: PMC9933282 DOI: 10.1186/s12974-023-02717-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/01/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Patients with human immunodeficiency virus-associated cryptococcal meningitis (HIV-CM) have persistent intracranial inflammation despite negative cerebrospinal fluid (CSF) fungal cultures after optimal treatment for CM, which could be devastating for the central nervous system. However, a definitive treatment strategy for persistent intracranial inflammation despite optimal antifungal therapies is undefined. METHODS We identified 14 HIV-CM patients with persistent intracranial inflammation and conducted a 24-week, prospective, interventional study. All participants received lenalidomide (25 mg, p.o.) on days 1 to 21 of a 28-day cycle. Follow-up lasted for 24 weeks with visits at baseline and weeks 4, 8, 12, and 24. The primary endpoint was the change in clinical manifestations, routine CSF parameters, and MRI findings after lenalidomide treatment. An exploratory analysis was made on changes in cytokine levels in CSF. Safety and efficacy analyses were undertaken in patients who received at least one dose of lenalidomide. RESULTS Of 14 participants, 11 patients completed the 24 weeks of follow-up. Rapid clinical remission following lenalidomide therapy was observed. Clinical manifestations (fever, headache, altered mentation) were reversed fully by week-4 and remained stable during follow-up. A significant reduction in white blood cell (WBC) count in CSF was noted occurred at week-4 (P = 0.009). The median protein concentration in CSF decreased from 1.4 (0.7-3.2) g/L at baseline to 0.9 (0.6-1.4) at week-4 (P = 0.004). The median albumin concentration in CSF decreased from 79.2 (48.4-149.8) mg/L at baseline to 55.3 (38.3-89.0) mg/L at week-4 (P = 0.011). The WBC count, protein level, and albumin level in CSF remained stable and approached a normal range through week-24. There was no significant change in immunoglobulin-G, intracranial pressure (ICP), or chloride-ion concentration at each visit. Brain MRI demonstrated multiple lesions to be absorbed post-therapy. Levels of tumor necrosis factor-α granulocyte colony stimulating factor, interleukin (IL)-6, and IL-17A decreased significantly during 24-week follow-up. Two (14.3%) patients had mild skin rash, which resolved spontaneously. Lenalidomide-related serious adverse events were not observed. CONCLUSION Lenalidomide could improve persistent intracranial inflammation in HIV-CM patients significantly and was well tolerated without serious adverse events observed. And the additional randomized controlled study is required to further validate the finding.
Collapse
Affiliation(s)
- Zhikai Wan
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ran Tao
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiangjin Hui
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiang Liu
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaorong Peng
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yongzheng Guo
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xueling Zhu
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ying Huang
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Biao Zhu
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
| |
Collapse
|
18
|
Skipper CP, Hullsiek KH, Stadelman A, Williams DA, Ssebambulidde K, Okafor E, Tugume L, Nuwagira E, Akampurira A, Musubire AK, Abassi M, Muzoora C, Rhein J, Boulware DR, Meya DB. Sterile Cerebrospinal Fluid Culture at Cryptococcal Meningitis Diagnosis Is Associated with High Mortality. J Fungi (Basel) 2022; 9:46. [PMID: 36675867 PMCID: PMC9866844 DOI: 10.3390/jof9010046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Cryptococcus is the leading cause of AIDS-related meningitis in sub-Saharan Africa. The clinical implications of a sterile cerebrospinal fluid (CSF) culture among individuals diagnosed with cryptococcal meningitis using CSF cryptococcal antigen (CrAg) are unclear. We prospectively enrolled 765 HIV-positive Ugandans with first-episode cryptococcal meningitis from November 2010 to May 2017. All persons were treated with amphotericin-based induction therapy. We grouped participants by tertile of baseline CSF quantitative Cryptococcus culture burden and compared clinical characteristics, CSF immune profiles, and 18-week mortality. We found 55 (7%) CSF CrAg-positive participants with sterile CSF cultures. Compared to the non-sterile groups, participants with sterile CSF cultures had higher CD4 counts, lower CSF opening pressures, and were more frequently receiving ART. By 18 weeks, 47% [26/55] died in the sterile culture group versus 35% [83/235] in the low culture tertile, 46% [107/234] in the middle tertile, and 56% [135/241] in the high tertile (p < 0.001). The sterile group had higher levels of CSF interferon-gamma (IFN-γ), IFN-α, interleukin (IL)-6, IL-17, G-CSF, GM-CSF, and chemokine CXCL2 compared with non-sterile groups. Despite persons with sterile CSF cultures having higher CD4 counts, lower CSF opening pressures, and CSF cytokine profiles associated with better Cryptococcus control (e.g., IFN-γ predominant), mortality was similar to those with higher fungal burdens. This unexpected finding challenges the traditional paradigm that increasing CSF fungal burdens are associated with increased mortality but is consistent with a damage-response framework model.
Collapse
Affiliation(s)
- Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | | | - Anna Stadelman
- School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | | | - Elizabeth Okafor
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda
| | - Andrew Akampurira
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David B Meya
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| |
Collapse
|
19
|
Fiorio LM, Biasutti C, Rosa-Júnior M. Cryptococcus gattii infection complicated by immune reconstitution syndrome in a patient with common variable immunodeficiency. Rev Soc Bras Med Trop 2022; 55:S0037-86822022000100863. [PMID: 36542022 PMCID: PMC9757713 DOI: 10.1590/0037-8682-0443-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/19/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Luize Meloti Fiorio
- Universidade Federal do Espírito Santo, Centro de Ciências da Saúde, Vitória, ES, Brasil
| | - Claudia Biasutti
- Hospital Universitário Cassiano Antônio Moraes, Setor de Infectologia, Vitória, ES, Brasil
| | - Marcos Rosa-Júnior
- Hospital Universitário Cassiano Antônio Moraes, Setor de Neurorradiologia, Vitória, ES, Brasil
| |
Collapse
|
20
|
Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Clinical Studies to Animal Experiments. Microorganisms 2022; 10:microorganisms10122419. [PMID: 36557672 PMCID: PMC9780901 DOI: 10.3390/microorganisms10122419] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Cryptococcus neoformans is an encapsulated pathogenic fungus that initially infects the lung but can migrate to the central nervous system (CNS), resulting in meningoencephalitis. The organism causes the CNS infection primarily in immunocompromised individuals including HIV/AIDS patients, but also, rarely, in immunocompetent individuals. In HIV/AIDS patients, limited inflammation in the CNS, due to impaired cellular immunity, cannot efficiently clear a C. neoformans infection. Antiretroviral therapy (ART) can rapidly restore cellular immunity in HIV/AIDS patients. Paradoxically, ART induces an exaggerated inflammatory response, termed immune reconstitution inflammatory syndrome (IRIS), in some HIV/AIDS patients co-infected with C. neoformans. A similar excessive inflammation, referred to as post-infectious inflammatory response syndrome (PIIRS), is also frequently seen in previously healthy individuals suffering from cryptococcal meningoencephalitis. Cryptococcal IRIS and PIIRS are life-threatening complications that kill up to one-third of affected people. In this review, we summarize the inflammatory responses in the CNS during HIV-associated cryptococcal meningoencephalitis. We overview the current understanding of cryptococcal IRIS developed in HIV/AIDS patients and cryptococcal PIIRS occurring in HIV-uninfected individuals. We also describe currently available animal models that closely mimic aspects of cryptococcal IRIS observed in HIV/AIDS patients.
Collapse
|
21
|
Ssebambulidde K, Anjum SH, Hargarten JC, Chittiboina P, Shoham S, Seyedmousavi S, Marr KA, Hammoud DA, Billioux BJ, Williamson PR. Treatment recommendations for non-HIV associated cryptococcal meningoencephalitis including management of post-infectious inflammatory response syndrome. Front Neurol 2022; 13:994396. [PMID: 36530631 PMCID: PMC9751747 DOI: 10.3389/fneur.2022.994396] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/04/2022] [Indexed: 08/29/2023] Open
Abstract
Cryptococcal meningoencephalitis (CM) continues to cause major morbidity and mortality in a range of patients such as those immunosuppressed from HIV and with biologic immunosuppressants, including treatments of autoimmunity, malignancies, and conditioning regimens for transplantation. It is currently the most common cause of non-viral meningitis in the United States. Infections in previously healthy patients also develop with autoantibodies to granulocyte-macrophage colony stimulating factor or with monogenetic defects. In all populations, mortality and significant long-term morbidity occur in 30-50% despite therapy, and immune reconstitution and post-infectious inflammatory response syndromes complicate management. To help with these difficult cases, we present here a practical tutorial of the care of a range of patients with CM in the absence of HIV/AIDS.
Collapse
Affiliation(s)
- Kenneth Ssebambulidde
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Seher H. Anjum
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Jessica C. Hargarten
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Shmuel Shoham
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Kieren A. Marr
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Bridgette Jeanne Billioux
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Peter R. Williamson
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| |
Collapse
|
22
|
Tao R, Peng X, Liu X, Xu L, Su J, Lang G, Huang Y, Zhu B. Outcome of Lenalidomide Treatment for Cognitive Impairment Caused by Immune Reconstitution Inflammatory Syndrome in Patients with HIV-Related Cryptococcal Meningitis. J Inflamm Res 2022; 15:5327-5336. [PMID: 36131783 PMCID: PMC9484564 DOI: 10.2147/jir.s374333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Cognitive impairment associated with human immunodeficiency virus (HIV)-related cryptococcal meningitis (HCM) in the context of immune reconstitution inflammatory syndrome is difficult to address. This study was a follow-up of lenalidomide treatment outcomes in patients with HCM and cognitive impairment after complete cryptococcal clearance. Patients and Methods Seven HCM patients with neuroinflammation and cognitive impairment after complete cryptococcal clearance were enrolled in this prospective study. Neurocognitive assessment, clinical examination and cerebrospinal fluid (CSF) assays were performed before and after lenalidomide treatment. Results After lenalidomide treatment, the Montreal Cognitive Assessment [week (W) 0 (median [interquartile range]: 23.0 (13.0–24.0) vs W24: 26.0 (24.0–28.00), P=0.018] and International HIV Dementia Scale scores [W0: 9.0 (2.5–10.5) vs W24: 11.0 (10.00–12.0), P=0.028] improved significantly, mainly in the domain of memory function. There was no significant difference in the Center for Epidemiological Research Depression scores for anxiety and depression before and after treatment. Further stratified analyses revealed that the patients with cognitive improvement group had higher levels of CSF white blood cells [94.0 (44.0–180.0) vs 0 (0–1.5), P=0.032], CSF protein [4.9 (3.0–6.6) vs 0.6 (0.5–0.7), P=0.034], CSF albumin [318.5 (190.9–346.5) vs 33.5 (30.4–46.2), P=0.034], and CSF IgG [160.5 (73.8–256. 0) vs 4.7 (4.3–7.4), P=0.034] but a lower CSF glucose level [2.4 (2.0–2.7) vs 2.8 (2.8–3.9), P=0.032] than the patients with cognitive non-improvement group before treatment. CSF inflammatory cytokines of the growth-related oncogene, interleukin [IL]-10, granulocyte-colony stimulating factor, IL-6, IL-8, complement factor H, tumor necrosis factor-α, and α-2 macroglobulin were obviously decreased in patients with cognitive improvement group after lenalidomide treatment. Conclusion Lenalidomide potentially reduces cognitive impairment caused by immune reconstitution inflammatory syndrome in patients with HCM after cryptococcal clearance by inhibiting intracranial inflammation.
Collapse
Affiliation(s)
- Ran Tao
- Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiaorong Peng
- Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiang Liu
- Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Lijun Xu
- Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Junwei Su
- Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Guanjing Lang
- Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Ying Huang
- Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Biao Zhu
- Department of Infectious Diseases, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for the Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| |
Collapse
|
23
|
Zhao T, Xu X, Wu Y, Zhang W, Zeng Q, Lu Y, Yang T, Zhou G, Yu J, Lan K, Harypursat V, Chen Y. Comparison of amphotericin B deoxycholate in combination with either flucytosine or fluconazole, and voriconazole plus flucytosine for the treatment of HIV-associated cryptococcal meningitis: a prospective multicenter study in China. BMC Infect Dis 2022; 22:677. [PMID: 35941618 PMCID: PMC9358851 DOI: 10.1186/s12879-022-07665-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/02/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The most appropriate alternative to induction therapy for HIV-associated cryptococcal meningitis (CM) remains unclear when standard treatment is unavailable, inaccessible, intolerable, or ineffective. METHODS A prospective, multi-centre cohort study was conducted to analyze the data of 156 HIV-infected patients with CM who were treated with amphotericin B deoxycholate (AmB-D) + flucytosine (5FC), voriconazole (VCZ) + 5FC, or AmB-D + Fluconazole (Flu) as induction regimens. Clinical efficacy, cumulative mortality, and adverse effects were compared among the three treatment groups. RESULTS Fewer deaths occurred by week 4 and week 10 among patients receiving AmB-D + 5FC than among those receiving AmB-D + Flu [4 (5.1%) vs. 8 (16.0%) deaths by week 4; hazard ratio, 1.8; 95% confidence interval [CI], 1.0 to 3.3; p = 0.039; and 8 (10.3%) vs. 14 (28.0%) deaths by week 10; hazard ratio, 1.8; 95% CI, 1.1 to 2.7; p = 0.008, respectively]. AmB-D plus 5FC was found to result in significantly higher rates of cerebrospinal fluid (CSF) culture sterility (57.6% vs. 34% by week 2; 87.9% vs. 70% by week 10; p < 0.05 for both comparisons). However, the differences in CSF culture sterility and mortality between the VCZ + 5FC group and the AmB-D + 5FC group were not statistically significant. VCZ plus 5FC had a significantly advantageous effect on the incidence of new AIDS-defining illness and length of hospital stay, compared with AmB-D plus 5FC. Laboratory adverse events (grade 3 or 4), such as severe anemia, were less frequent with VCZ + 5FC use than with AmB-D combined with 5FC or Flu use. CONCLUSION Our results suggest that AmB-D combined with 5FC remains the more efficacious induction regimen compared to AmB-D plus Flu, and that VCZ + 5FC might be a potential alternative when the standard regimen is not readily available, accessible, tolerated, or effective. CLINICAL TRIALS Registration number, ChiCTR1900021195. Registered 1 February 2019, http://www.chictr.org.cn/showproj.aspx?proj=35362 .
Collapse
Affiliation(s)
- Ting Zhao
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Xiaolei Xu
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Yushan Wu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Wei Zhang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Qin Zeng
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Yanqiu Lu
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Tongtong Yang
- Division of Infectious Diseases, Public Health Clinical Center of Chengdu, Sichuan, China
| | - Guoqiang Zhou
- Division of Infectious Diseases, The First Hospital of Changsha, Hunan, China
| | - Jianhua Yu
- Division of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang, China
| | - Ke Lan
- Department of Infectious Disease, Longtan Hospital of Guangxi Zhuang Autonomous Region, Guangxi, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Yaokai Chen
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China.
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China.
| |
Collapse
|
24
|
Abstract
Cryptococcosis is a disease caused by the pathogenic fungi Cryptococcus neoformans and Cryptococcus gattii, both environmental fungi that cause severe pneumonia and may even lead to cryptococcal meningoencephalitis. Although C. neoformans affects more fragile individuals, such as immunocompromised hosts through opportunistic infections, C. gattii causes a serious indiscriminate primary infection in immunocompetent individuals. Typically seen in tropical and subtropical environments, C. gattii has increased its endemic area over recent years, largely due to climatic factors that favor contagion in warmer climates. It is important to point out that not only C. gattii, but the Cryptococcus species complex produces a polysaccharidic capsule with immunomodulatory properties, enabling the pathogenic species of Cryptococccus to subvert the host immune response during the establishment of cryptococcosis, facilitating its dissemination in the infected organism. C. gattii causes a more severe and difficult-to-treat infection, with few antifungals eliciting an effective response during chronic treatment. Much of the immunopathology of this cryptococcosis is still poorly understood, with most studies focusing on cryptococcosis caused by the species C. neoformans. C. gattii became more important in the epidemiological scenario with the outbreaks in the Pacific Northwest of the United States, which resulted in phylogenetic studies of the virulent variant responsible for the severe infection in the region. Since then, the study of cryptococcosis caused by C. gattii has helped researchers understand the immunopathological aspects of different variants of this pathogen.
Collapse
|
25
|
Liu J, Liu J, Qin BE, Yao S, Wang A, Yang L, Su Z, Xu X, Jiang Y, Peng F. Post-Infectious Inflammatory Response Syndrome in an HIV-Negative Immunocompetent Elderly Patient With Cryptococcal Meningitis: A Case Report and Literature Review. Front Immunol 2022; 13:823021. [PMID: 35281037 PMCID: PMC8904365 DOI: 10.3389/fimmu.2022.823021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/01/2022] [Indexed: 11/20/2022] Open
Abstract
We report a previously healthy 82-year-old male with cryptococcal meningitis (CM) who represented neurological deterioration due to post-infectious inflammatory response syndrome (PIIRS) occurring in 4 months after initial antifungal therapy. He was treated with corticosteroids for 2 months and recovered clinically. However, the clinical manifestation, cerebrospinal fluid (CSF), and brain magnetic resonance imaging (MRI) results got worse again on the next day after corticosteroid withdrawal. The analysis of inflammatory cytokines and culture on CSF, as well as brain MRI, still suggested a diagnosis of PIIRS. Therefore, corticosteroid therapy was used again and he subsequently obtained a complete resolution of symptoms.
Collapse
Affiliation(s)
- Junyu Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bang-E Qin
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shiqi Yao
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Anni Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lu Yang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhihui Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaofeng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
26
|
Tao R, Peng X, Liu X, Su J, Lang G, Huang Y, Zhang Y, Zhu B. Lenalidomide Improves Cognitive Function and Reduces Immune Reconstitution Inflammatory Syndrome in HIV-1-Related Cryptococcal Meningitis. J Inflamm Res 2022; 15:2891-2899. [PMID: 35586751 PMCID: PMC9109900 DOI: 10.2147/jir.s353463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/27/2022] [Indexed: 11/26/2022] Open
Abstract
Cryptococcal meningitis (CM) is a common opportunistic infection in patients with acquired immune deficiency syndrome. Although there is a standardized treatment for CM, some patients still have CM-associated immune reconstitution inflammatory syndrome (IRIS) after anti-cryptococcal and antiretroviral therapy, which manifests as cognitive impairment. We report two cases of CM-associated IRIS in human immunodeficiency virus (HIV) patients that were treated with lenalidomide. The treatment yielded a rapid clinical remission and improved cognitive function in both patients; their Montreal Cognitive Assessment (MoCA) and International HIV Dementia Scale (IHDS) scores improved. Furthermore, we evaluated changes in 32 cytokines in the cerebrospinal fluid of two patients and found that both MoCA and IHDS were significantly negatively correlated with inflammation-related factors (growth-related oncogene, interleukin [IL]-10, IL-2, IL-8, macrophage inflammatory protein-1β, tumor necrosis factor [TNF]-α) and significantly positively correlated with dementia-related factors (αβ42 and total tau). Our study reveals the potential of lenalidomide in treating cognitive impairment caused by immune-mediated inflammation in patients with HIV-CM. Moreover, we speculate that lenalidomide improves cognitive function by regulating intracranial inflammation via multiple pathways, not only by TNF-α blocking.
Collapse
Affiliation(s)
- Ran Tao
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Xiaorong Peng
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Xiang Liu
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Junwei Su
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Guanjing Lang
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Ying Huang
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Yafei Zhang
- PET Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Biao Zhu
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
- Correspondence: Biao Zhu, Tel +0086-571-87236417, Fax +0086-571-87236416, Email
| |
Collapse
|
27
|
Han X, Liu H, Wang Y, Wang P, Wang X, Yi Y, Li X. A nomogram for predicting paradoxical immune reconstitution inflammatory syndrome associated with cryptococcal meningitis among HIV-infected individuals in China. AIDS Res Ther 2022; 19:20. [PMID: 35473805 PMCID: PMC9044738 DOI: 10.1186/s12981-022-00444-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/11/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) associated immune reconstitution inflammatory syndrome (CM-IRIS) is the second most common complication in HIV-infected individuals with cryptococcal meningitis, with a reported mortality rate ranging from 8 to 30%. Given the devastating consequences of CM-IRIS related intracranial neuroinflammation and its challenging in diagnosis, we conducted a study to explore the risk factors and the occurrence of paradoxical CM-IRIS in HIV-infected patients, which is of great value for prevention and clinical management. METHODS We conducted a retrospective cohort study to identify the indicators associated with paradoxical CM-IRIS among 86 HIV-infected patients with CM using univariate and multivariate cox analysis. A nomogram was constructed using selected variables to evaluate the occurrence of paradoxical CM-IRIS at 6 months and 12 months after ART initiation. The discrimination and calibration of the nomogram were assessed by concordance index (C-index) and calibration plots. Decision curves analysis (DCA) were used to evaluate clinical effectiveness of the nomogram. Subsequently, to help clinicians recognize patients at high risk faster, patients were divided into high-risk and low-risk groups according to the best cutoff point identified by X-tile. RESULTS Of 86 AIDS patients with CM, 22.1% experienced paradoxical CM-IRIS at a median of 32 days after antiretroviral therapy (ART) initiation. The occurrence of paradoxical CM-IRIS was associated with age, ART initiation within 4 weeks of antifungal treatment, a four-fold increase in CD4 T cell counts, C-reactive protein levels, and hemoglobin levels independently. These five variables were further used to construct a predictive nomogram. The C-index (0.876) showed the favorable discriminative ability of the nomogram. The calibration plot revealed a high consistency between the predicted and actual observations. DCA showed that the nomogram was clinically useful. Risk stratification based on the total score of the nomogram showed well-differentiated in the high-risk and low-risk groups. Clinicians should pay attention to patients with total points high than 273. CONCLUSIONS We identified the predictive factors of paradoxical CM-IRIS and constructed a nomogram to evaluate the occurrence of paradoxical CM-IRIS in 6 months and 12 months. The nomogram represents satisfactory performance and might be applied clinically to the screening and management of high-risk patients.
Collapse
Affiliation(s)
- Xiaoxu Han
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Hui Liu
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Yuqi Wang
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Peng Wang
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Xin Wang
- Department of Integrated Traditional Chinese and Western Medicine, Peking University Ditan Teaching Hospital, Beijing, 100015, People's Republic of China
| | - Yunyun Yi
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China
| | - Xin Li
- Department of Integrated Traditional Chinese and Western Medicine, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, People's Republic of China.
- Department of Integrated Traditional Chinese and Western Medicine, Peking University Ditan Teaching Hospital, Beijing, 100015, People's Republic of China.
| |
Collapse
|
28
|
Tucker M, Sheikh AM, Villanueva MS. Rapidly enlarging pulmonary mass due to immune reconstitution inflammatory syndrome (IRIS) in an immunocompetent host with pulmonary Cryptococcus neoformans. BMJ Case Rep 2022; 15:e247495. [PMID: 35351746 PMCID: PMC8966528 DOI: 10.1136/bcr-2021-247495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/04/2022] Open
Abstract
An immunocompetent man presented with Cryptococcus neoformans disease manifesting as a large pulmonary mass (cryptococcoma). Despite an initial induction course of 4 weeks of liposomal amphotericin B (LAmB), followed by 8 weeks of fluconazole, the cryptococcoma enlarged in size. Ten days into a second course of induction therapy with LAmB and flucytosine, the cryptococcoma markedly increased in size with encroachment on critical vascular structures. Due to concern for immune reconstitution inflammatory syndrome (IRIS), prednisone was added with significant decrease in the size of the mass. To our knowledge, this is the first reported case of pulmonary cryptococcal-IRIS in an immunocompetent host.
Collapse
Affiliation(s)
- Mollie Tucker
- Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Abdul Majeed Sheikh
- Infectious Diseases, Charlotte Hungerford Hospital, Torrington, Connecticut, USA
| | | |
Collapse
|
29
|
Makhoul J, Uppal S, Siegel M. Double Trouble: Concomitant Unmasking and Paradoxical Immune Reconstitution Inflammatory Syndrome in a Patient with Newly Diagnosed HIV. IDCases 2022; 28:e01482. [PMID: 35392599 PMCID: PMC8980619 DOI: 10.1016/j.idcr.2022.e01482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/02/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a complication encountered in patients with HIV due to immune function recovery following the initiation of antiretroviral therapy. IRIS can be divided into two forms: paradoxical (recurrence of clinical signs of a previously treated opportunistic infection) and unmasking (uncovering of a previously undiagnosed and asymptomatic infection). We present the rare case of a 48-year-old man diagnosed with AIDS after presenting with cryptococcal meningitis who, shortly after initiation of ART, developed both unmasking IRIS due to Mycobacterium avium complex (MAC), and subsequently paradoxical IRIS to his prior cryptococcal meningitis infection. To our knowledge, cases in the medical literature describing “double IRIS” remain scarce.
Collapse
|
30
|
Poizot-Martin I, Brégigeon S, Palich R, Marcelin AG, Valantin MA, Solas C, Veyri M, Spano JP, Makinson A. Immune Reconstitution Inflammatory Syndrome Associated Kaposi Sarcoma. Cancers (Basel) 2022; 14:986. [PMID: 35205734 PMCID: PMC8869819 DOI: 10.3390/cancers14040986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 02/01/2023] Open
Abstract
People living with HIV (PLWH) with advanced immunosuppression who initiate antiretroviral therapy (ART) are susceptible to the occurrence of an immune reconstitution inflammatory syndrome (IRIS). Although ART is responsible for AIDS- associated Kaposi sarcoma (KS) improvement and resolution, new onset (unmasking KS-IRIS) or sudden progression of preexisting KS (paradoxical KS-IRIS) can occur after a time delay of between a few days and 6 months after the initiation or resumption of ART, even in patients with a low degree of immunocompromise. KS-IRIS incidence varies from 2.4% to 39%, depending on study design, populations, and geographic regions. Risk factors for developing KS-IRIS include advanced KS tumor stage (T1), pre-treatment HIV viral load >5 log10 copies/mL, detectable pre-treatment plasma-KSHV, and initiation of ART alone without concurrent chemotherapy. Both paradoxical and unmasking KS-IRIS have been associated with significant morbidity and mortality, and thrombocytopenia (<100,000 platelets/mm3 at 12 weeks) has been associated with death. KS-IRIS is not to be considered as ART failure, and an ART regimen must be pursued. Systemic chemotherapy for KS in conjunction with ART is recommended and, in contrast with management of IRIS for other opportunistic infections, glucocorticoids are contra-indicated. Despite our preliminary results, the place of targeted therapies in the prevention or treatment of KS-IRIS needs further assessment.
Collapse
Affiliation(s)
- Isabelle Poizot-Martin
- Assistance Publique-Hôpitaux de Marseille (APHM), Inserm, Institut de Recherche pour le Développement (IRD), SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, APHM Sainte-Marguerite, Service D’immuno-Hématologie Clinique, Aix-Marseille Université, 13009 Marseille, France
| | - Sylvie Brégigeon
- Assistance Publique-Hôpitaux de Marseille (APHM) Sainte-Marguerite, Service D’immuno-Hématologie Clinique, Aix-Marseille Université, 13009 Marseille, France;
| | - Romain Palich
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne University, 75013 Paris, France; (R.P.); (M.-A.V.)
| | - Anne-Geneviève Marcelin
- INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (iPLESP), AP-HP, Hôpital Pitié Salpêtrière, Service de Virologie, Sorbonne Université, 75013 Paris, France;
| | - Marc-Antoine Valantin
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne University, 75013 Paris, France; (R.P.); (M.-A.V.)
| | - Caroline Solas
- Assistance Publique-Hôpitaux de Marseille (APHM), Hôpital La Timone, Laboratoire de Pharmacocinétique et Toxicologie, INSERM 1207, IRD 190, Unité des Virus Emergents, Aix-Marseille Université, 13005 Marseille, France;
| | - Marianne Veyri
- Department of Medical Oncology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Institut Universitaire de Cancérologie (IUC), CLIP2 Galilée, Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne Université, 75013 Paris, France; (M.V.); (J.-P.S.)
| | - Jean-Philippe Spano
- Department of Medical Oncology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Institut Universitaire de Cancérologie (IUC), CLIP2 Galilée, Pierre Louis Epidemiology and Public Health Institute (iPLESP), INSERM U1136, Sorbonne Université, 75013 Paris, France; (M.V.); (J.-P.S.)
| | - Alain Makinson
- Centre Hospitalier Universitaire de Montpellier, Département des Maladies Infectieuses et Tropicales, INSERM U1175/IRD UMI 233, 34000 Montpellier, France;
| |
Collapse
|
31
|
Mohamed SH, Nyazika TK, Ssebambulidde K, Lionakis MS, Meya DB, Drummond RA. Fungal CNS Infections in Africa: The Neuroimmunology of Cryptococcal Meningitis. Front Immunol 2022; 13:804674. [PMID: 35432326 PMCID: PMC9010970 DOI: 10.3389/fimmu.2022.804674] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/03/2022] [Indexed: 01/13/2023] Open
Abstract
Cryptococcal meningitis (CM) is the leading cause of central nervous system (CNS) fungal infections in humans, with the majority of cases reported from the African continent. This is partly due to the high burden of HIV infection in the region and reduced access to standard-of-care including optimal sterilising antifungal drug treatments. As such, CM is responsible for 10-15% of all HIV-related mortality, with a large proportion being preventable. Immunity to the causative agent of CM, Cryptococcus neoformans, is only partially understood. IFNγ producing CD4+ T-cells are required for the activation of myeloid cells, especially macrophages, to enable fungal killing and clearance. However, macrophages may also act as a reservoir of the fungal yeast cells, shielding them from host immune detection thus promoting latent infection or persistent chronic inflammation. In this chapter, we review the epidemiology and pathogenesis of CNS fungal infections in Africa, with a major focus on CM, and the antifungal immune pathways operating to protect against C. neoformans infection. We also highlight the areas of research and policy that require prioritisation to help reduce the burden of CNS fungal diseases in Africa.
Collapse
Affiliation(s)
- Sally H Mohamed
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Tinashe K Nyazika
- Department of Clinical Science, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Kenneth Ssebambulidde
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - David B Meya
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Rebecca A Drummond
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Institute of Microbiology & Infection, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
32
|
Zhao T, Xu XL, Lu YQ, Liu M, Yuan J, Nie JM, Yu JH, Liu SQ, Yang TT, Zhou GQ, Liu J, Qin YM, Chen H, Harypursat V, Chen YK. The Effect of Early vs. Deferred Antiretroviral Therapy Initiation in HIV-Infected Patients With Cryptococcal Meningitis: A Multicenter Prospective Randomized Controlled Analysis in China. Front Med (Lausanne) 2021; 8:779181. [PMID: 34869498 PMCID: PMC8639871 DOI: 10.3389/fmed.2021.779181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The optimal timing for initiation of antiretroviral therapy (ART) in HIV-positive patients with cryptococcal meningitis (CM) has not, as yet, been compellingly elucidated, as research data concerning mortality risk and the occurrence of immune reconstitution inflammatory syndrome (IRIS) in this population remains inconsistent and controversial. Method: The present multicenter randomized clinical trial was conducted in China in patients who presented with confirmed HIV/CM, and who were ART-naïve. Subjects were randomized and stratified into either an early-ART group (ART initiated 2-5 weeks after initiation of antifungal therapy), or a deferred-ART group (ART initiated 5 weeks after initiation of antifungal therapy). Intention-to-treat, and per-protocol analyses of data for these groups were conducted for this study. Result: The probability of survival was found to not be statistically different between patients who started ART between 2-5 weeks of CM therapy initiation (14/47, 29.8%) vs. those initiating ART until 5 weeks after CM therapy initiation (10/55, 18.2%) (p = 0.144). However, initiating ART within 4 weeks after the diagnosis and antifungal treatment of CM resulted in a higher mortality compared with deferring ART initiation until 6 weeks (p = 0.042). The incidence of IRIS did not differ significantly between the early-ART group and the deferred-ART group (6.4 and 7.3%, respectively; p = 0.872). The percentage of patients with severe (grade 3 or 4) adverse events was high in both treatment arms (55.3% in the early-ART group and 41.8% in the deferred-ART group; p=0.183), and there were significantly more grade 4 adverse events in the early-ART group (20 vs. 13; p = 0.042). Conclusion: Although ART initiation from 2 to 5 weeks after initiation of antifungal therapy was not significantly associated with high cumulative mortality or IRIS event rates in HIV/CM patients compared with ART initiation 5 weeks after initiation of antifungal therapy, we found that initiating ART within 4 weeks after CM antifungal treatment resulted in a higher mortality compared with deferring ART initiation until 6 weeks. In addition, we observed that there were significantly more grade 4 adverse events in the early-ART group. Our results support the deferred initiation of ART in HIV-associated CM. Clinical Trials Registration: www.ClinicalTrials.gov, identifier: ChiCTR1900021195.
Collapse
Affiliation(s)
- Ting Zhao
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Xiao-Lei Xu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yan-Qiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Min Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jing Yuan
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jing-Min Nie
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jian-Hua Yu
- Division of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang, China
| | - Shui-Qing Liu
- Division of Infectious Diseases, Guiyang Public Health Clinical Center, Guizhou, China
| | - Tong-Tong Yang
- Division of Infectious Diseases, Public Health Clinical Center of Chengdu, Sichuan, China
| | - Guo-Qiang Zhou
- Division of Infectious Diseases, The First Hospital of Changsha, Hunan, China
| | - Jun Liu
- Division of Infectious Diseases, Kunming Third People's Hospital, Yunnan, China
| | - Ying-Mei Qin
- Division of Infectious Diseases, The Fourth's Hospital of Nanning, Guangxi, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yao-Kai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| |
Collapse
|
33
|
Arakawa N, Eguchi K, Nakamura Y, Tsukahara Y, Koushima Y, Matsushima H. Immune Reconstitution Inflammatory Syndrome-like Condition Associated with Pneumocystis jirovecii Pneumonia During Folinic Acid Treatment in a Rheumatoid Arthritis Patient. Intern Med 2021; 60:3143-3147. [PMID: 33840694 PMCID: PMC8545637 DOI: 10.2169/internalmedicine.6577-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A 94-year-old woman with rheumatoid arthritis who had been treated with low-dose methotrexate was referred to our hospital because of a 3-day history of a fever and pancytopenia. With a diagnosis of febrile neutropenia of unknown origin, empirical antibiotic treatment and folinic acid therapy were initiated. Despite a recovery from pancytopenia, the high fever remained, and dyspnea developed. She was clinically diagnosed with Pneumocystis jirovecii pneumonia (PCP) and successfully treated with trimethoprim/sulfamethoxazole and adjunctive corticosteroid therapy. Folinic acid treatment effectively brought about rapid immune recovery but might have led to a clinical manifestation of PCP resembling immune reconstruction inflammatory syndrome.
Collapse
Affiliation(s)
- Naoki Arakawa
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Kazuo Eguchi
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Yuki Nakamura
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Yuta Tsukahara
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Japan
| | - Youhei Koushima
- Hepatobiliary Pancreatic Department, Saitama Red Cross Hospital, Japan
| | | |
Collapse
|
34
|
Xu J, Ganguly A, Zhao J, Ivey M, Lopez R, Osterholzer JJ, Cho CS, Olszewski MA. CCR2 Signaling Promotes Brain Infiltration of Inflammatory Monocytes and Contributes to Neuropathology during Cryptococcal Meningoencephalitis. mBio 2021; 12:e0107621. [PMID: 34311579 PMCID: PMC8406332 DOI: 10.1128/mbio.01076-21] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/25/2021] [Indexed: 12/21/2022] Open
Abstract
Cryptococcal meningoencephalitis (CM) is a leading cause of central nervous system (CNS) infection-related mortality worldwide, with surviving patients often developing neurological deficiencies. While CNS inflammation has been implicated in the pathogenesis of CM, little is known about the relative contribution of the specific inflammatory/immune pathways to CNS pathology versus fungal clearance. Increased cerebrospinal fluid level of C-C chemokine receptor 2 (CCR2) ligand CCL2 is associated with disease deterioration in patients with CM. Using a murine model, we investigated the role of the CCR2 pathway in the development of CNS inflammation and pathology during CM. We found that CCR2-deficient mice exhibited improved 28-day survival and alleviated neurological disease scores despite a brain fungal burden higher than that of the WT mice. Reduced CM pathology in CCR2-deficient mice was accompanied by markedly decreased neuronal cell death around cryptococcal microcysts and restored expression of genes involved in neurotransmission, connectivity, and neuronal cell structure in the brains. Results show that CCR2 axis is the major pathway recruiting CD45hiCD11b+Ly6C+ inflammatory monocyte to the brain and indirectly modulates the accumulation of CD4+ T cells and CD8+ T cells. In particular, CCR2 axis promotes recruitment of interferon gamma (IFN-γ)-producing CD4+ T cells and classical activation of myeloid cells. In this context, CCR2 deletion limits the immune network dysregulation we see in CM and attenuates neuropathology. Thus, the CCR2 axis is a potential target for interventions aimed to limit inflammatory CNS pathology in CM patients. IMPORTANCE Cryptococcal meningoencephalitis (CM) causes nearly 200,000 deaths worldwide each year, and survivors frequently develop long-lasting neurological sequelae. The high rate of mortality and neurologic sequelae in CM patients indicate that antifungal therapies alone are often insufficient to control disease progression. Here, we reveal that CM disease progression in mice is accompanied by inflammatory monocytes infiltration at the periphery of the infected foci that overlap locally perturbed neuronal function and death. Importantly, we identified that CCR2 signaling is a critical pathway driving neuroinflammation, especially inflammatory monocyte recruitment, as well as CNS pathology and mortality in CM mice. Our results imply that targeting the CCR2 pathway may be beneficial as a therapy complementary to antifungal drug treatment, helping to reduce CNS damage and mortality in CM patients.
Collapse
Affiliation(s)
- Jintao Xu
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Anutosh Ganguly
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica Zhao
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Michel Ivey
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
| | - Rafael Lopez
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
| | - John J. Osterholzer
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Clifford S. Cho
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michal A. Olszewski
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| |
Collapse
|
35
|
Zhou LH, Zhao HZ, Wang X, Wang RY, Jiang YK, Huang LP, Yip CW, Cheng JH, Que CX, Zhu LP. Immune reconstitution inflammatory syndrome in non-HIV cryptococcal meningitis: Cross-talk between pathogen and host. Mycoses 2021; 64:1402-1411. [PMID: 34390048 PMCID: PMC9290805 DOI: 10.1111/myc.13361] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cryptococcal meningitis (CM)-associated immune reconstitution inflammatory syndrome (IRIS) is associated with high mortality, the epidemiology and pathophysiology of which is poorly understood, especially in non-HIV populations. OBJECTIVES We aim to explore the incidence, clinical risk factors, immunological profiles and potential influence of leukotriene A4 hydroxylase (LTA4H) on non-HIV CM IRIS populations. METHODS In this observational cohort study, 101 previously untreated non-HIV CM patients were included. We obtained data for clinical variables, 27 cerebrospinal fluid (CSF) cytokines levels and LTA4H genotype frequencies. Changes of CSF cytokines levels before and at IRIS occurrence were compared. RESULTS Immune reconstitution inflammatory syndrome was identified in 11 immunocompetent males, generating an incidence of 10.9% in non-HIV CM patients. Patients with higher CrAg titres (> 1:160) were more likely to develop IRIS, and titre of 1:1280 is the optimum level to predict IRIS occurrence. Baseline CSF cytokines were significantly higher in IRIS group, which indicated a severe host immune inflammation response. Four LTA4H SNPs (rs17525488, rs6538697, rs17525495 and rs1978331) exhibited significant genetic susceptibility to IRIS in overall non-HIV CM, while five cytokines were found to be associated with rs1978331, and baseline monocyte chemotactic protein 1 (MCP-1) became the only cytokine correlated with both IRIS and LTA4H SNPs. CONCLUSIONS Our study suggested that non-HIV CM patients with high fungal burden and severe immune inflammation response were more likely to developed IRIS. LTA4H polymorphisms may affect the pathogenesis of IRIS by regulating the level of baseline CSF MCP-1.
Collapse
Affiliation(s)
- Ling-Hong Zhou
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Hua-Zhen Zhao
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuan Wang
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Rui-Ying Wang
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Ying-Kui Jiang
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Ping Huang
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Ching-Wan Yip
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-Hui Cheng
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Chun-Xing Que
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Ping Zhu
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
36
|
Fisher KM, Montrief T, Ramzy M, Koyfman A, Long B. Cryptococcal meningitis: a review for emergency clinicians. Intern Emerg Med 2021; 16:1031-1042. [PMID: 33420904 DOI: 10.1007/s11739-020-02619-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 12/23/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization. OBJECTIVE This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM. DISCUSSION This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS). CONCLUSIONS CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.
Collapse
Affiliation(s)
- Kathryn Marie Fisher
- Department of Emergency Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Tim Montrief
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace St., Pittsburgh, PA, 15261, USA
| | - Mark Ramzy
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace St., Pittsburgh, PA, 15261, USA
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.
| |
Collapse
|
37
|
Vlasova-St Louis I, Musubire AK, Meya DB, Nabeta HW, Mohei H, Boulware DR, Bohjanen PR. Transcriptomic biomarker pathways associated with death in HIV-infected patients with cryptococcal meningitis. BMC Med Genomics 2021; 14:108. [PMID: 33863324 PMCID: PMC8052789 DOI: 10.1186/s12920-021-00914-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/19/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a major cause of death in HIV-infected patients in sub-Saharan Africa. Many CM patients experience cryptococcosis-associated immune reconstitution inflammatory syndrome (C-IRIS), which is often fatal. We sought to identify transcriptomic biomarker pathways in peripheral blood that are associated with or predict the development of death or fatal C-IRIS among patients with CM who were enrolled in the Cryptococcal Optimal ART Timing Trial. METHODS We assessed peripheral blood gene expression using next-generation RNA sequencing in 4 groups of patients with CM: (1) no C-IRIS or Death; (2) C-IRIS survivors; (3) fatal C-IRIS; (4) Death without C-IRIS. Gene expression was assessed at the time of ART initiation, at 1, 4, and 8 weeks on ART, and at the time of C-IRIS events. RESULTS We identified 12 inflammatory and stress response pathways, including interferon type 1 signaling, that were upregulated at the time of ART initiation in patients with future fatal C-IRIS, as compared with survivors. The upregulation of transcripts involved in innate immunity (inflammasome, Toll-like receptor signaling), was observed at the time of fatal or nonfatal C-IRIS events. At the time of fatal C-IRIS events, numerous transcripts within fMLP, Rho family GTPases, HMGB1, and other acute phase response signaling pathways were upregulated, which reflects the severity of inflammation and systemic oxidative stress. Patients who died without recognized C-IRIS also had increased expression of pathways associated with oxidative stress and tissue damage. CONCLUSIONS Our results showed that overactivated innate immunity, involving Toll-like receptor/inflammasome pathways, and inflammation-induced oxidative stress, are associated with fatal outcomes. The results of this study provide insight into the molecular drivers of death and fatal C-IRIS to inform future diagnostic test development or guide targeted treatments.
Collapse
Affiliation(s)
| | - Abdu K Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - David B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Henry W Nabeta
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Hesham Mohei
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Paul R Bohjanen
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
38
|
Miyoshi S, Oda N, Gion Y, Taki T, Mitani R, Takata I, Taniguchi A, Sato Y, Miyahara N. Exacerbation of pulmonary cryptococcosis associated with enhancement of Th2 response in the postpartum period. J Infect Chemother 2021; 27:1248-1250. [PMID: 33840597 DOI: 10.1016/j.jiac.2021.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
Cryptococcosis is an invasive mycosis that has become increasingly prevalent in immunocompromised patients. Pregnant women are also one of the risk populations for cryptococcosis. Reversal of Th2 to Th1 response following resolution of immunosuppression during the postpartum period can lead to overt clinical manifestations of a previously silent infection, resembling an immune reconstitution inflammatory syndrome. Here, we report a case of a 30-year-old woman who had an exacerbation of pulmonary cryptococcosis in the postpartum period mimicking an immune reconstitution inflammatory syndrome. In the present case, chest computed tomography showed multiple small nodules on the day of the delivery; however, pulmonary cryptococcosis, which was subclinical during pregnancy, rapidly worsened to mass-like consolidation at one month after the delivery. Pathohistological examination of the lung specimen showed lung parenchyma infiltration with histiocytes and numerous lymphocytes without granulomatous formations, and a small number of yeast-like organisms consistent with Cryptococcus without capillary involvement. Immunohistochemical staining showed predominance of CD3+ cells and CD4+ cells over CD8+ cells. In addition, GATA3+ cells dominated over T-bet + cells. These data suggested exacerbation of pulmonary cryptococcosis associated with enhancement of Th2 response in the postpartum period.
Collapse
Affiliation(s)
- Shota Miyoshi
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Naohiro Oda
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan.
| | - Yuka Gion
- Department of Medical Technology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Takahiro Taki
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Reo Mitani
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Ichiro Takata
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama, Japan
| | - Akihiko Taniguchi
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Okayama, Japan
| | - Yasuharu Sato
- Department of Medical Technology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Nobuaki Miyahara
- Department of Medical Technology, Okayama University Graduate School of Health Sciences, Okayama, Japan; Department of Allergy and Respiratory Medicine, Okayama University Hospital, Okayama, Japan
| |
Collapse
|
39
|
Hu M, Liu S, Lu D, Zhong Y, Yu D, Qiu W, Lu Z, Zhang B. Case Report: Central Nervous System Immune Reconstitution Inflammatory Syndrome Related to Bacterial Meningitis. Front Immunol 2021; 12:585316. [PMID: 33868222 PMCID: PMC8044765 DOI: 10.3389/fimmu.2021.585316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
Central nervous system immune reconstitution inflammatory syndrome (CNS-IRIS) describes clinical characteristics that may be observed in previously immunocompromised patients during rapid restoration of immunity function in the presence of a pathogen. There have been no reports about CNS-IRIS related to bacterial meningitis so far. Here, we report a 24-year-old pregnant female patient with bacterial meningitis. Her clinical and neuroradiological condition worsened after induced labor despite great effective anti-infective therapy. CNS-IRIS was considered. Corticosteroids were administered, and the patient gradually recovered. We present the first case of CNS-IRIS associated with bacterial meningitis.
Collapse
Affiliation(s)
- Mengyan Hu
- Department of Neurology, Center for Mental and Neurological Disorders and Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Sanxin Liu
- Department of Neurology, Center for Mental and Neurological Disorders and Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Danli Lu
- Department of Neurology, Center for Mental and Neurological Disorders and Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yi Zhong
- Department of Dermatology, Guangzhou Women And Children's Medical Center, Guangzhou, China
| | - Dafan Yu
- Department of Neurology, Center for Mental and Neurological Disorders and Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Qiu
- Department of Neurology, Center for Mental and Neurological Disorders and Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhengqi Lu
- Department of Neurology, Center for Mental and Neurological Disorders and Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bingjun Zhang
- Department of Neurology, Center for Mental and Neurological Disorders and Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
40
|
Pett SL, Spyer M, Haddow LJ, Nhema R, Benjamin LA, Najjuka G, Bilima S, Daud I, Musoro G, Kitabalwa J, Selemani G, Kandie S, Cornelius KM, Katemba C, Berkley JA, Hassan AS, Kityo C, Hakim J, Heyderman RS, Gibb DM, Walker AS. Benefits of enhanced infection prophylaxis at antiretroviral therapy initiation by cryptococcal antigen status. AIDS 2021; 35:585-594. [PMID: 33306556 PMCID: PMC7613319 DOI: 10.1097/qad.0000000000002781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess baseline prevalence of cryptococcal antigen (CrAg) positivity; and its contribution to reductions in all-cause mortality, deaths from cryptococcus and unknown causes, and new cryptococcal disease in the REALITY trial. DESIGN Retrospective CrAg testing of baseline and week-4 plasma samples in all 1805 African adults/children with CD4+ cell count less than 100 cells/μl starting antiretroviral therapy who were randomized to receive 12-week enhanced-prophylaxis (fluconazole 100 mg/day, azithromycin, isoniazid, cotrimoxazole) vs. standard-prophylaxis (cotrimoxazole). METHODS Proportional hazards models were used to estimate the relative impact of enhanced-prophylaxis vs. standard-cotrimoxazole on all, cryptococcal and unknown deaths, and new cryptococcal disease, through 24 weeks, by baseline CrAg positivity. RESULTS Excluding 24 (1.4%) participants with active/prior cryptococcal disease at enrolment (all treated for cryptococcal disease), 133/1781 (7.5%) participants were CrAg-positive. By 24 weeks, 105 standard-cotrimoxazole vs. 78 enhanced-prophylaxis participants died. Of nine standard-cotrimoxazole and three enhanced-prophylaxis cryptococcal deaths, seven and two, respectively, were CrAg-positive at baseline. Among deaths of unknown cause, only 1/46 standard-cotrimoxazole and 1/28 enhanced-prophylaxis were CrAg-positive at baseline. There was no evidence that relative reductions in new cryptococcal disease associated with enhanced-prophylaxis varied between baseline CrAg-positives [hazard-ratio = 0.36 (95% confidence interval 0.13-0.98), incidence 19.5 vs. 56.5/100 person-years] and CrAg-negatives [hazard-ratio = 0.33 (0.03-3.14), incidence 0.3 vs. 0.9/100 person-years; Pheterogeneity = 0.95]; nor for all deaths, cryptococcal deaths or unknown deaths (Pheterogeneity > 0.3). CONCLUSION Relative reductions in cryptococcal disease/death did not depend on CrAg status. Deaths of unknown cause were unlikely to be cryptococcus-related; plausibly azithromycin contributed to their reduction. Findings support including 100 mg fluconazole in an enhanced-prophylaxis package at antiretroviral therapy initiation where CrAg screening is unavailable/impractical.
Collapse
Affiliation(s)
- Sarah L. Pett
- Institute for Global Health
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
- Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, New South Wales, Australia
| | - Moira Spyer
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | | | - Ruth Nhema
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Laura A. Benjamin
- Institute of Neurology, UCL, London
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | | | - Sithembile Bilima
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Godfrey Musoro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - George Selemani
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | | | | | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Robert S. Heyderman
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Division of Infection and Immunity, UCL, London, UK
| | - Diana M. Gibb
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Ann S. Walker
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| |
Collapse
|
41
|
Yoon HA, Felsen U, Wang T, Pirofski LA. Cryptococcus neoformans infection in Human Immunodeficiency Virus (HIV)-infected and HIV-uninfected patients at an inner-city tertiary care hospital in the Bronx. Med Mycol 2021; 58:434-443. [PMID: 31342058 DOI: 10.1093/mmy/myz082] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/19/2019] [Accepted: 06/26/2019] [Indexed: 12/26/2022] Open
Abstract
Cryptococcus neoformans causes life-threatening meningoencephalitis. Human immunodeficiency virus (HIV) infection is the most significant predisposing condition, but persons with other immunodeficiency states as well as phenotypically normal persons develop cryptococcosis. We retrospectively reviewed medical records of all patients with a diagnosis of cryptococcosis between 2005 and 2017 at our inner-city medical center in the Bronx, an epicenter of AIDS in New York City, and analyzed demographic data, clinical manifestations, laboratory findings, treatment, and mortality for these patients. In sum, 63% of the cases over this 12-year period occurred in HIV-infected patients. And 61% of the HIV-infected patients were non-adherent with antiretroviral therapy, 10% were newly diagnosed with AIDS, and 4% had unmasking cryptococcus-associated immune reconstitution inflammatory syndrome. The majority were Hispanic or black in ethnicity/race. HIV-uninfected patients (47/126) were older (P < .0001), and the majority had an immunocompromising condition. They were less likely to have a headache (P = .0004) or fever (P = .03), had prolonged time to diagnosis (P = .04), higher cerebrospinal fluid (CSF) glucose levels (P = .001), less CSF culture positivity (P = .03), and a higher 30-day mortality (P = .03). Cases in HIV-uninfected patients were often unsuspected during their initial evaluation, leading to a delay in infectious diseases consultation, which was associated with mortality (P = .03). Our study indicates that HIV infection remains the most important predisposing factor for cryptococcosis despite availability of antiretroviral therapy and highlights potential missed opportunities for earlier diagnosis and differences in clinical and prognostic factors between HIV-infected and HIV-uninfected patients.
Collapse
Affiliation(s)
- Hyun Ah Yoon
- Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Uriel Felsen
- Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Tao Wang
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Liise-Anne Pirofski
- Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| |
Collapse
|
42
|
Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Blood and Cerebrospinal Fluid Biomarkers to Treatment Approaches. Life (Basel) 2021; 11:life11020095. [PMID: 33514007 PMCID: PMC7912256 DOI: 10.3390/life11020095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 12/31/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) presents as an exaggerated immune reaction that occurs during dysregulated immune restoration in immunocompromised patients in late-stage human immunodeficiency virus (HIV) infection who have commenced antiretroviral treatments (ART). Virtually any opportunistic pathogen can provoke this type of immune restoration disorder. In this review, we focus on recent developments in the identification of risk factors for Cryptococcal IRIS and on advancements in our understanding of C-IRIS immunopathogenesis. We overview new findings in blood and cerebrospinal fluid which can potentially be useful in the prediction and diagnosis of cryptococcal meningitis IRIS (CM-IRIS). We assess current therapeutic regimens and novel treatment approaches to combat CM-IRIS. We discuss the utility of biomarkers for clinical monitoring and adjusting treatment modalities in acquired immunodeficiency syndrome (AIDS) patients co-infected with Cryptococcus who have initiated ART.
Collapse
|
43
|
Acute Fluctuant Neurological Symptoms in Stable Chronic Cryptococcus gattii Cryptococcomas: A Novel Disease Complication. Neurologist 2020; 26:24-26. [PMID: 33394909 DOI: 10.1097/nrl.0000000000000297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cryptococcus, a yeast-like fungus, is the most common cause of fungal meningitis worldwide. The Cryptococcus gattii variety is concentrated in Australia has a greater propensity to infect immunocompetent hosts, cause meningitis and form crytococcomas. This case presents a novel disease complication, that is, acute neurological symptoms without seizures, disease progression or reactivation. CASE PRESENTATION A 58-year-old immunocompetent male was brought to the emergency department with dysarthria and right arm paraesthesias. Computed tomography of the brain brain and magnetic resonance imaging revealed no stroke but found several previously identified crytococcomas that demonstrated no interval change. Blood tests and lumbar puncture found only a low cryptococcal antigen complex titer (CRAG) (1:10) and a negative cell culture. He had remained compliant on his maintenance fluconazole therapy and had no immunocompromise or seizure activity. He was initially treated as a relapse of cryptococcal disease and restarted on induction therapy but after the cell culture returned negative and the symptoms resolved over the following days he was reverted back to maintenance therapy. DISCUSSION AND CONCLUSIONS Central nervous system cryptococcomas are difficult to treat, chronic infections, that in our patient had lasted over 10 years despite treatment compliance. A true cryptococcal meningitis relapse is indicated by positive cell cultures in previously sterile fluid but cryptococcoma progression is measured by serial magnetic resonance imaging or computed tomography scans. In the case of progression or relapse induction and consolidation therapy should be restarted. Our patient demonstrated neither relapse nor progression but presented with a novel disease complication of acute fluctuating neurology in chronic stable cryptococcomas.
Collapse
|
44
|
Song W, Shen YZ, Wang ZY, Qi TK, Liu L, Zhang RF, Wang JR, Tang Y, Chen J, Sun JJ, Lu HZ. Clinical features and treatment outcomes of human immunodeficiency virus-associated cryptococcal meningitis: a 2-year retrospective analysis. Chin Med J (Engl) 2020; 133:2787-2795. [PMID: 33273326 PMCID: PMC7717751 DOI: 10.1097/cm9.0000000000001191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is one of the most common opportunistic infections caused by Cryptococcus neoformans in human immunodeficiency virus (HIV)-infected patients, and is complicated with significant morbidity and mortality. This study retrospectively analyzed the clinical features, characteristics, treatment, and outcomes of first-diagnosed HIV-associated CM after 2-years of follow-up. METHODS Data from all patients (n = 101) of HIV-associated CM hospitalized in Shanghai Public Health Clinical Center from September 2013 to December 2016 were collected and analyzed using logistic regression to identify clinical and microbiological factors associated with mortality. RESULTS Of the 101 patients, 86/99 (86.9%) of patients had CD4 count <50 cells/mm, 57/101 (56.4%) were diagnosed at ≥14 days from the onset to diagnosis, 42/99 (42.4%) had normal cerebrospinal fluid (CSF) cell counts and biochemical examination, 30/101 (29.7%) had concomitant Pneumocystis (carinii) jiroveci pneumonia (PCP) on admission and 37/92 (40.2%) were complicated with cryptococcal pneumonia, 50/74 (67.6%) had abnormalities shown on intracranial imaging, amongst whom 24/50 (48.0%) had more than one lesion. The median time to negative CSF Indian ink staining was 8.50 months (interquartile range, 3.25-12.00 months). Patients who initiated antiretroviral therapy (ART) before admission had a shorter time to negative CSF Indian ink compared with ART-naïve patients (7 vs. 12 months, χ = 15.53, P < 0.001). All-cause mortality at 2 weeks, 8 weeks, and 2 years was 10.1% (10/99), 18.9% (18/95), and 20.7% (19/92), respectively. Coinfection with PCP on admission (adjusted odds ratio [AOR], 3.933; 95% confidence interval [CI], 1.166-13.269, P = 0.027) and altered mental status (AOR, 9.574; 95% CI, 2.548-35.974, P = 0.001) were associated with higher mortality at 8 weeks. CONCLUSION This study described the clinical features and outcomes of first diagnosed HIV-associated CM with 2-year follow-up data. Altered mental status and coinfection with PCP predicted mortality in HIV-associated CM.
Collapse
Affiliation(s)
- Wei Song
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Quincho-Lopez A, Montenegro-Idrogo J, Verona-Rubio RO. Colonic cryptococcosis as a rare presentation in HIV infection: a case report and review of the literature. Int J STD AIDS 2020; 31:1414-1419. [PMID: 33106111 DOI: 10.1177/0956462420951090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Colonic cryptococcal infection is unusual in people living with HIV (PLWH) and even more so without concomitant neurological compromise. Published case reports describe diarrhea and other intestinal manifestations that are often confused with systemic tuberculosis infection. We describe an Peruvian woman living with HIV on antiretroviral therapy who presented hypotensive with a 6-month history of fever and epigastric pain, in addition to episodes of sporadic diarrhea. Due to the suspicion of systemic tuberculosis, antituberculosis treatment was started. Days later, without clinical improvement, colonoscopy revealed ulcers in the transverse colon. Histopathological examination of biopsied tissue was compatible with Cryptococcus spp. She received antifungal therapy with amphotericin B and fluconazole. Despite the treatment, the patient died six days later from multiple organ failure.
Collapse
Affiliation(s)
| | - Juan Montenegro-Idrogo
- Facultad de Ciencias de la Salud, Universidad Científica del Sur, Lima, Peru.,Infectious Diseases and Tropical Medicine Service, Hospital Nacional Dos de Mayo, Lima, Peru
| | | |
Collapse
|
46
|
Firacative C. Invasive fungal disease in humans: are we aware of the real impact? Mem Inst Oswaldo Cruz 2020; 115:e200430. [PMID: 33053052 PMCID: PMC7546207 DOI: 10.1590/0074-02760200430] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/24/2020] [Indexed: 01/08/2023] Open
Abstract
Despite the medical advances and interventions to improve the quality of life of those in intensive care, people with cancer or severely immunocompromised or other susceptible hosts, invasive fungal diseases (IFD) remain severe and underappreciated causes of illness and death worldwide. Therefore, IFD continue to be a public health threat and a major hindrance to the success of otherwise life-saving treatments and procedures. Globally, hundreds of thousands of people are affected every year with Candida albicans, Aspergillus fumigatus, Cryptococcus neoformans, Pneumocystis jirovecii, endemic dimorphic fungi and Mucormycetes, the most common fungal species causing invasive diseases in humans. These infections result in morbidity and mortality rates that are unacceptable and represent a considerable socioeconomic burden. Raising the general awareness of the significance and impact of IFD in human health, in both the hospital and the community, is hence critical to understand the scale of the problem and to raise interest to help fighting these devastating diseases.
Collapse
Affiliation(s)
- Carolina Firacative
- Universidad del Rosario, School of Medicine and Health Sciences, Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, Bogota, Colombia
| |
Collapse
|
47
|
Khaw YM, Aggarwal N, Barclay WE, Kang E, Inoue M, Shinohara ML. Th1-Dependent Cryptococcus-Associated Immune Reconstitution Inflammatory Syndrome Model With Brain Damage. Front Immunol 2020; 11:529219. [PMID: 33133067 PMCID: PMC7550401 DOI: 10.3389/fimmu.2020.529219] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 09/04/2020] [Indexed: 01/02/2023] Open
Abstract
Cryptococcus-associated immune reconstitution inflammatory syndrome (C-IRIS) is identified upon immune reconstitution in immunocompromised patients, who have previously contracted an infection of Cryptococcus neoformans (Cn). C-IRIS can be lethal but how the immune system triggers life-threatening outcomes in patients is still poorly understood. Here, we establish a mouse model for C-IRIS with Cn serotype A strain H99, which is highly virulent and the most intensively studied. C-IRIS in mice is induced by the adoptive transfer of CD4+ T cells in immunocompromised Rag1-deficient mice infected with a low inoculum of Cn. The mice with C-IRIS exhibit symptoms which mimic clinical presentations of C-IRIS. This C-IRIS model is Th1-dependent and shows host mortality. This model is characterized with minimal lung injury, but infiltration of Th1 cells in the brain. C-IRIS mice also exhibited brain swelling with resemblance to edema and upregulation of aquaporin-4, a critical protein that regulates water flux in the brain in a Th1-dependent fashion. Our C-IRIS model may be used to advance our understanding of the paradoxical inflammatory phenomenon of C-IRIS in the context of neuroinflammation.
Collapse
Affiliation(s)
- Yee Ming Khaw
- Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, IL, United States
- Neuroscience Program, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Nupur Aggarwal
- Department of Immunology, Duke University School of Medicine, Durham, NC, United States
| | - William E. Barclay
- Department of Immunology, Duke University School of Medicine, Durham, NC, United States
| | - Eunjoo Kang
- Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, IL, United States
- Neuroscience Program, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Makoto Inoue
- Department of Comparative Biosciences, University of Illinois at Urbana-Champaign, Urbana, IL, United States
- Neuroscience Program, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Mari L. Shinohara
- Department of Immunology, Duke University School of Medicine, Durham, NC, United States
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, United States
| |
Collapse
|
48
|
Nel J, Dlamini S, Meintjes G, Burton R, Black JM, Davies NECG, Hefer E, Maartens G, Mangena PM, Mathe MT, Moosa MY, Mulaudzi MB, Moorhouse M, Nash J, Nkonyane TC, Preiser W, Rassool MS, Stead D, van der Plas H, van Vuuren C, Venter WDF, Woods JF. Southern African HIV Clinicians Society guidelines for antiretroviral therapy in adults: 2020 update. South Afr J HIV Med 2020; 21:1115. [PMID: 33101723 PMCID: PMC7564911 DOI: 10.4102/sajhivmed.v21i1.1115] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jeremy Nel
- Helen Joseph Hospital, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Sipho Dlamini
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Rosie Burton
- Southern African Medical Unit, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - John M Black
- Department of Medicine, Division of Infectious Diseases, Livingstone Tertiary Hospital, Port Elizabeth, South Africa
| | | | - Eric Hefer
- Private Practice Medical Adviser, Johannesburg, South Africa
| | - Gary Maartens
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Phetho M Mangena
- Department of Internal Medicine, School of Medicine, Pietersburg Hospital, Polokwane, South Africa.,Department of Medicine, School of Medicine, University of Limpopo, Turfloop, South Africa
| | | | - Mahomed-Yunus Moosa
- Department of Infectious Diseases, Division of Internal Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Michelle Moorhouse
- Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Nash
- Specialist Family Physician, Amathole District Clinical Specialist Team, East London, South Africa
| | - Thandeka C Nkonyane
- Department of Infectious Diseases, Faculty of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Department of Medicine, Dr George Mokhari Hospital, Pretoria, South Africa
| | - Wolfgang Preiser
- Department of Medical Virology, National Health Laboratory Service, Tygerberg, South Africa.,Department of Pathology, Faculty of Medicine and Health, Stellenbosch University, Cape Town, South Africa
| | - Mohammed S Rassool
- Clinical HIV Research Unit, Wits Health Consortium, Johannesburg, South Africa
| | - David Stead
- Department of Medicine, Faculty of Infectious Diseases, Frere and Cecilia Makiwane Hospitals, East London, South Africa.,Department of Medicine, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
| | - Helen van der Plas
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Cloete van Vuuren
- Department of Internal Medicine, Military Hospital, Bloemfontein, South Africa.,Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joana F Woods
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
49
|
Cryptococcal Immune Reconstitution Inflammatory Syndrome: An Unusual Presentation on the Tongue. ACTAS DERMO-SIFILIOGRAFICAS 2020. [DOI: 10.1016/j.adengl.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
50
|
Ballén J, Quiroga C, Palma F. Síndrome inflamatorio de reconstitución inmune criptocócico: presentación inusual en la lengua. ACTAS DERMO-SIFILIOGRAFICAS 2020; 111:617-619. [DOI: 10.1016/j.ad.2019.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/12/2019] [Accepted: 02/12/2019] [Indexed: 10/24/2022] Open
|