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Okeagu C, Anjum SH, Vitale S, Wang J, Singh D, Rosen LB, Magone MT, Fitzgibbon E, Williamson PR. Ocular Findings of Cryptococcal Meningitis in Previously Healthy Adults. J Neuroophthalmol 2023; 43:214-219. [PMID: 36255081 PMCID: PMC10110765 DOI: 10.1097/wno.0000000000001713] [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: 11/26/2022]
Abstract
BACKGROUND Patients with cryptococcal meningitis (CM) often have ocular manifestations; although data are describing these findings in nonimmunosuppressed, previously healthy individuals are scarce. METHODS A retrospective chart review was performed for previously healthy patients with CM who underwent a complete ophthalmological examination within a 5-year period at the National Institutes of Health. Demographics, CSF parameters, findings on initial ophthalmological examination, and MRI abnormalities were analyzed. RESULTS Forty-four patients within a median of 12 weeks after CM diagnosis were included in our study; 27 patients (61%) reported abnormal vision on presentation. Seventy-one percent of patients were not shunted at the time of their initial eye examination. The most common ocular abnormalities were visual field defects in 21 (66%), decreased visual acuity in 14 (38%), and papilledema in 8 (26%) patients. Intraocular pressure was within normal range in all patients. Cranial nerve defects were identified in 5 patients and optic neuropathy in 2 patients. Patients who had hydrocephalus or did not receive a ventriculoperitoneal shunt were not noted to have worse ocular abnormalities. CONCLUSIONS The most common ocular findings in our cohort of nontransplant, non-HIV cryptococcal meningitis patients were visual field defects, decreased visual acuity, and papilledema. Our results emphasize the need for a comprehensive eye examination in patients with CM who may not always report a change in vision on presentation.
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Affiliation(s)
- Chinwenwa Okeagu
- Consult Services Section, National Eye Institute (NEI), National Institutes of Health, Bethesda, MD, USA
| | - Seher H. Anjum
- Laboratory of Clinical Immunology and Microbiology(LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health, Bethesda, MD, USA
| | - Susan Vitale
- Consult Services Section, National Eye Institute (NEI), National Institutes of Health, Bethesda, MD, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Deven Singh
- Rutgers University, New Brunswick, N.J., USA
| | - Lindsey B. Rosen
- Laboratory of Clinical Immunology and Microbiology(LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health, Bethesda, MD, USA
| | - M. Teresa Magone
- Consult Services Section, National Eye Institute (NEI), National Institutes of Health, Bethesda, MD, USA
| | - Edmond Fitzgibbon
- Consult Services Section, National Eye Institute (NEI), National Institutes of Health, Bethesda, MD, USA
| | - Peter R. Williamson
- Laboratory of Clinical Immunology and Microbiology(LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health, Bethesda, MD, USA
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Peters RPH, Kestelyn PG, Zierhut M, Kempen JH. The Changing Global Epidemic of HIV and Ocular Disease. Ocul Immunol Inflamm 2020; 28:1007-1014. [PMID: 32396027 DOI: 10.1080/09273948.2020.1751214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose: Overview of the evolving epidemiology of human immunodeficiency virus (HIV)-related ocular disease over time. Method: Narrative review. Results: HIV enhances susceptibility to opportunistic eye infections, has direct pathogenic effects, and places patients at risk of immune recovery inflammatory syndromes in previously infected eyes after starting highly-active antiretroviral therapy (HAART). Widespread availability of HAART has resulted in a decrease of infectious ocular conditions such as cytomegalovirus retinitis, toxoplasmic retinitis, squamous cell carcinoma of the conjunctiva, and microvascular retinopathy. However, large coexisting burdens of tuberculosis, herpesvirus infection and syphilis (among others) continue to contribute to the burden of ocular disease, especially in low-resource settings. Growing risks of cataract, retinopathy and retinal nerve fiber thinning can affect patients with chronic HIV on HAART; thought due to chronic inflammation and immune activation. Conclusion: The changing epidemic of ocular disease in HIV-infected patients warrants close monitoring and identification of interventions that can help reduce the imminent burden of disease.
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Affiliation(s)
- Remco P H Peters
- Foundation for Professional Development, Research Unit , East London, South Africa.,Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria , Pretoria, South Africa.,Department of Medical Microbiology, Maastricht University Medical Centre, CAPRHI School of Public Health & Primary Care , Maastricht, The Netherlands
| | | | - Manfred Zierhut
- Department of Ophthalmology, University of Tuebingen , Tübingen, Germany
| | - John H Kempen
- Department of Ophthalmology, Massachusetts Eye and Ear , Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School , Boston, Massachusetts, USA.,MCM Eye Unit, MyungSung Christian Medical Center and MyungSung Medical School , Addis Ababa, Ethiopia
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Aggarwal N, Barclay W, Shinohara ML. Understanding mechanisms underlying the pathology of immune reconstitution inflammatory syndrome (IRIS) by using animal models. CURRENT CLINICAL MICROBIOLOGY REPORTS 2018; 5:201-209. [PMID: 30555775 DOI: 10.1007/s40588-018-0099-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of Review Despite the increasing number of clinical reports on immune reconstitution inflammatory syndrome (IRIS), mechanistic understanding of IRIS is still largely limited. The main focus of this review is to summarize animal studies, which were performed to better understand the cellular and molecular mechanisms underlying the pathology of IRIS. Recent Findings Three IRIS animal models have been reported. They are Mycobacterial IRIS (M-IRIS), cryptococcal IRIS (C-IRIS) and Pneumocystis-IRIS. M-IRIS animal model suggested that, rather than lymphopenia itself, the failure to clear the pathogen by T cells results in excessive priming of the innate immune system. If this happens before T cell reconstitution, hosts likely suffer IRIS upon T cell reconstitution. Interestingly, T cells specific to self-antigens, not only pathogen-specific, could drive IRIS as well. Summary The mechanism to develop IRIS is quite complicated, including multiple layers of host immune responses; the innate immune system that detects pathogens and prime host immunity, and the adaptive immune system that is reconstituted but hyper-activated particularly through CD4+ T cells. Animal models of IRIS, although there are still small numbers of studies available, have already provided significant insights on the mechanistic understanding of IRIS.
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Affiliation(s)
- Nupur Aggarwal
- Duke University School of Medicine, Department of Immunology, Durham, NC, USA
| | - William Barclay
- Duke University School of Medicine, Department of Immunology, Durham, NC, USA
| | - Mari L Shinohara
- Duke University School of Medicine, Department of Immunology, Durham, NC, USA
- Duke University School of Medicine, Department of Molecular Genetics and Microbiology, Durham, NC, USA
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Weiss Z, Mehta N, Aung SN, Migliori M, Farmakiotis D. Rapid Reversal of Complete Binocular Blindness With High-Dose Corticosteroids and Lumbar Drain in a Solid Organ Transplant Recipient With Cryptococcal Meningitis and Immune Reconstitution Syndrome: First Case Study and Literature Review. Open Forum Infect Dis 2018; 5:ofy007. [PMID: 29423423 PMCID: PMC5798033 DOI: 10.1093/ofid/ofy007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 01/05/2018] [Indexed: 11/18/2022] Open
Abstract
Blindness is a rare, devastating, usually permanent complication of cryptococcal meningitis (CM). We present the first case of complete vision loss in a solid organ transplant recipient with CM treated with placement of a lumbar drain who had a dramatic visual recovery that started after 3 doses of high-dose steroids.
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Affiliation(s)
- Zoe Weiss
- Department of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nihaal Mehta
- Warren AlpertMedical School of Brown University, Providence, Rhode Island
| | - Su Nandar Aung
- Division of Infectious Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael Migliori
- Division of Ophthalmology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dimitrios Farmakiotis
- Division of Infectious Disease, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Isl
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Abstract
PURPOSE OF REVIEW The epidemiology and pathogenesis of, and risk factors for, cryptococcal immune reconstitution inflammatory syndrome (CM-IRIS) are reviewed with an emphasis on how new insights inform a rational management approach and prevention strategies. RECENT FINDINGS Risk factors for paradoxical CM-IRIS are a low inflammatory response and CD4 cell count at baseline, rapid immune restoration from this low baseline, and a high organism or antigen load at baseline and at antiretroviral therapy (ART) initiation. Detailed immune mechanisms are still unclear. Rapidly fungicidal induction therapy, allowing prompt initiation of ART (from around 3 weeks in resource-limited settings in the context of amphotericin B induction) at a time when organism and antigen loads are low, may reduce overall mortality without exacerbating paradoxical CM-IRIS, compared with initiation of ART at later time points. Recent cohorts suggest early recognition and management can reduce the mortality associated with paradoxical CM-IRIS. Unmasking CM-IRIS is preventable through screening for cryptococcal antigen prior to ART and preemptive antifungal treatment for those testing positive, although prospective studies are needed. SUMMARY Optimal antifungal induction and judicious ART timing, together with early recognition and management of developing cases, with thorough exclusion of alternative diagnoses, should help reduce paradoxical CM-IRIS-related mortality. Unmasking CM-IRIS cases should be preventable.
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New Insights into HIV/AIDS-Associated Cryptococcosis. ISRN AIDS 2013; 2013:471363. [PMID: 24052889 PMCID: PMC3767198 DOI: 10.1155/2013/471363] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/10/2013] [Indexed: 12/27/2022]
Abstract
Cryptococcal meningitis is a life-threatening opportunistic fungal infection in both HIV-infected and HIV-uninfected patients. According to the most recent taxonomy, the responsible fungus is classified into a complex that contains two species (Cryptococcus neoformans and C. gattii), with eight major molecular types. HIV infection is recognized worldwide as the main underlying disease responsible for the development of cryptococcal meningitis (accounting for 80-90% of cases). In several areas of sub-Saharan Africa with the highest HIV prevalence despite the recent expansion of antiretroviral (ARV) therapy programme, cryptococcal meningitis is the leading cause of community-acquired meningitis with a high mortality burden. Although cryptococcal meningitis should be considered a neglected disease, a large body of knowledge has been developed by several studies performed in recent years. This paper will focus especially on new clinical aspects such as immune reconstitution inflammatory syndrome, advances on management, and strategies for the prevention of clinical disease.
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Montoya C, Paulo JD, Velásquez LF. Criptococosis ocular y retinitis por citomegalovirus en paciente inmunosuprimido. INFECTIO 2012. [DOI: 10.1016/s0123-9392(12)70033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Cryptococcal immune reconstitution inflammatory syndrome in HIV-1-infected individuals: proposed clinical case definitions. THE LANCET. INFECTIOUS DISEASES 2010; 10:791-802. [PMID: 21029993 DOI: 10.1016/s1473-3099(10)70170-5] [Citation(s) in RCA: 226] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cryptococcal immune reconstitution inflammatory syndrome (IRIS) may present as a clinical worsening or new presentation of cryptococcal disease after initiation of antiretroviral therapy (ART), and is thought to be caused by recovery of cryptococcus-specific immune responses. We have reviewed reports of cryptococcal IRIS and have developed a consensus case definition specifically for paradoxical crytopcoccal IRIS in patients with HIV-1 and known cryptococcal disease before ART, and a separate definition for incident cryptococcosis developed during ART (termed ART-associated cryptococcosis), for which a proportion of cases are likely to be unmasking cryptococcal IRIS. These structured case definitions are intended to aid design of future clinical, epidemiological, and immunopathological studies of cryptococcal IRIS, to standardise diagnostic criteria, and to facilitate comparisons between studies. As for definitions of tuberculosis-associated IRIS, definitions for cryptococcal IRIS should be regarded as preliminary until further insights into the immunopathology of IRIS permit their refinement.
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Shulman J, de la Cruz EL, Latkany P, Milman T, Iacob C, Sanjana V. Cryptococcal Chorioretinitis with Immune Reconstitution Inflammatory Syndrome. Ocul Immunol Inflamm 2009; 17:314-5. [DOI: 10.3109/09273940903003505] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
PURPOSE OF REVIEW Cryptococcal meningitis most commonly occurs in advanced HIV. Although diminishing in the developed world with antiretroviral therapy (ART), it remains a major problem in resource-limited settings. ART rollout will improve long-term HIV survival if opportunistic infections are effectively treated. Considering cryptococcal meningitis in that context, this review addresses excess morbidity and mortality in developing countries, treatment in areas of limited drug availability and challenges posed by combined anticryptococcal and HIV therapy. RECENT FINDINGS From Early Fungicidal Activity (EFA) studies, amphotericin B-flucytosine is best induction therapy but often unavailable; high dose amphotericin B monotherapy may be feasible in some settings. Where fluconazole is the only option, higher doses are more fungicidal. Serum cryptococcal antigen testing may identify patients at highest disease risk and primary prophylaxis is effective; the clinical role of such interventions needs to be established. Timing of ART introduction remains controversial; early initiation risks Immune Reconstitution Disease (IRD) delays may increase mortality. SUMMARY Amphotericin B based treatment is appropriate where possible. More studies are needed to optimize fluconazole monotherapy doses. Other research priorities include management of raised intracranial pressure, appropriate ART initiation and IRD treatment. Studies should focus on developing countries where problems are greatest.
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Affiliation(s)
- Derek J Sloan
- School of Clinical Sciences, University Clinical Departments, University of Liverpool, Liverpool, UK.
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