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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.
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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
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Castro Castro J, Díaz López MD. [Cryptococcal meningitis associated with hydrocephalus in an immunocompetent patient]. An Sist Sanit Navar 2024; 47:e1067. [PMID: 38451042 PMCID: PMC10933692 DOI: 10.23938/assn.1067] [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] [Received: 09/11/2023] [Revised: 12/05/2023] [Accepted: 02/06/2024] [Indexed: 03/08/2024]
Abstract
Cryptococcal meningitis is an infrequent infection with high morbidity and mortality. Its presentation in immunocompetent patients is rare. We present the case of a 67-year-old male who was admitted for subacute symptoms of gait disturbance and urinary incontinence. Neurological examination revealed inability to stand and memory impairment. Cranial imaging showed obstructive tetraventricular hydrocephalus with areas of gliosis in the cerebellar peduncles. Endoscopic treatment of hydrocephalus was performed and cerebrospinal fluid samples taken revealing the growth of Cryptococcus neoformans. The patient improved with the endoscopic treatment and after completing intravenous antifungal therapy with liposomal amphotericin B and fluconazole for ten weeks. Antifungals are used to treat cryptococcal meningitis in immunocompetent patients. On rare occasions, it presents with hydrocephalus, a situation that requires surgical treatment using cerebrospinal fluid diversions or endoscopic techniques.
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Mabovula NS, Enicker BC. A comparison of the surgical outcomes of ventriculoperitoneal versus lumbar peritoneal shunts in the management of intracranial hypertension secondary to cryptococcal meningitis in HIV infected adult patients. Clin Neurol Neurosurg 2024; 238:108184. [PMID: 38394855 DOI: 10.1016/j.clineuro.2024.108184] [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] [Received: 01/05/2024] [Revised: 02/16/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVE Cryptococcal meningitis (CM), an AIDS-defining illness, significantly impacts morbidity and mortality. This study aims to compare complications arising from ventriculoperitoneal shunt (VPS) and lumbar peritoneal shunt (LPS) procedures used to manage refractory intracranial hypertension (IH) secondary to CM in HIV-infected patients. METHODS Retrospective data were collected from January 2003 to January 2015 for HIV-infected adults diagnosed with refractory IH secondary to CM and subsequently shunted. Demographics, clinical characteristics, antiretroviral therapy, laboratory findings (including CD4 count and CSF results), CT brain scan results, shunt-related complications, and mortality were compared between VPS and LPS groups. RESULTS This study included 83 patients, with 60 (72%) undergoing VPS and 23 (28%) receiving LPS. Mean ages were comparable between VPS (32.5) and LPS (32.2) groups (p = 0.89). Median CD4+ counts were 76 cells/µl (IQR= 30-129) in VPS versus 54 cells/µl (IQR= 31-83) in LPS (p=0.45). VPS group showed a higher mean haemoglobin of 11.5 g/dl compared to 9.9 g/dl in the LPS group (p=0.001). CT brain scans showed hydrocephalus in 55 VPS and 13 LPS patients respectively. Shunt complications were observed in 17 (28%) VPS patients versus 10 (43.5%) LPS patients (p=0.5). Patients developing shunt sepsis in the VPS group exhibited a median CD4+ count of 117 cells/µl (IQR= 76-129) versus 48 cells/µl (IQR= 31- 66) in the LPS group (p=0.03). Early shunt malfunction occurred more frequently in the LPS group compared to VPS group (p=0.044). The mean hospital stay was 6.2 days for VPS versus 5.4 days for LPS patients (p=0.9). In-hospital mortality was 6%, occurring in three VPS and two LPS patients respectively. CONCLUSION Shunting procedures remain important surgical interventions for refractory IH secondary to HIV-related CM. However, cautious consideration is warranted for patients with CD4 counts below 200 cells/µL due to increased shunt complications. This study suggests a trend toward higher complication rates in patients undergoing LPS insertion.
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Affiliation(s)
- Ndyebo S Mabovula
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, KwaZulu Natal 4091, South Africa.
| | - Basil C Enicker
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, KwaZulu Natal 4091, South Africa.
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Cornejo-Venegas G, Carreras X, Salcedo AS, Soriano-Moreno DR, Salinas JL, Alave J. Cerebrospinal fluid shunting for the management of cryptococcal meningitis: a scoping review. Ther Adv Infect Dis 2024; 11:20499361241228666. [PMID: 38333229 PMCID: PMC10851763 DOI: 10.1177/20499361241228666] [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: 10/31/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
Objective This scoping review aimed to describe studies that evaluate the management of cryptococcal meningitis (CM) using cerebrospinal fluid (CSF) shunts, types of shunts used, and clinically relevant patient outcomes. Methods We searched in the following databases: PubMed, Web of Science/Core collection, Embase, the Cochrane Library, and clinicaltrials.gov on 1 April 2022. We included two-arm and one-arm cohort studies that evaluated clinically relevant patient outcomes. Case reports were used to describe the type of CSF shunts used and the rationale behind its selection. The selection and extraction processes were independently performed by two authors. Results This study included 20 cohort studies and 26 case reports. Only seven cohort studies compared two groups. Ventriculoperitoneal shunt was the most commonly used type of shunt (82.1%). The main indications for placing a shunt were persistently high opening pressure (57.1%) and persisting neurological symptoms or deterioration (54.3%). Cohort studies suggest that patients with shunt showed improvement in some outcomes such as neurological symptoms and hospital stay length. The most common shunt complications were post-operative fever (1-35.6%) and shunt obstruction (7-16%). Conclusion CSF shunts may improve some clinically relevant outcomes in patients with CM, but the evidence is very uncertain.
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Affiliation(s)
| | - Xosse Carreras
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Andrea S. Salcedo
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - David R. Soriano-Moreno
- Unidad de Investigación Clínica y Epidemiológica, Escuela de Medicina, Universidad Peruana Unión, Lima, Peru
| | - Jorge L. Salinas
- Division of Infectious Diseases & Geographic Medicine, Stanford University, CA, USA
| | - Jorge Alave
- Escuela de Medicina, Universidad Peruana Unión, Carretera Central Km 19.5 Ñaña, Chosica, Lima 15464, Peru
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Kagimu E, Engen N, Ssebambulidde K, Kasibante J, Kiiza TK, Mpoza E, Tugume L, Nuwagira E, Nsangi L, Williams DA, Hullsiek KH, Boulware DR, Meya DB, Rhein J, Abassi M, Musubire AK. Therapeutic Lumbar Punctures in Human Immunodeficiency Virus-Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management? Open Forum Infect Dis 2022; 9:ofac416. [PMID: 36092828 PMCID: PMC9454029 DOI: 10.1093/ofid/ofac416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs. Methods We prospectively enrolled human immunodeficiency virus (HIV)-seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within 7 days. Results Our analysis included 533 participants. Participants with baseline ICP >350 mm H2O were more likely to have Glasgow Coma Scale (GCS) score <15 (P < .001), seizures (P < .01), and higher quantitative cryptococcal cultures (P < .001), whereas participants with ICP <200 mm H2O were more likely to have baseline sterile CSF cultures (P < .001) and CSF white blood cell count ≥5 cells/µL (P = .02). Thirty-day mortality was higher in participants with baseline ICP >350 mm H2O and ICP <200 mm H2O as compared with baseline ICP 200-350 mm H2O (hazard ratio, 1.55 [95% confidence interval, 1.10-2.19]; P = .02). Among survivors at least 7 days, the 30-day relative mortality was 50% higher among participants who did not receive any additional therapeutic LPs compared to those with ≥1 additional follow-up LP (33% vs 22%; P = .04), irrespective of baseline ICP. Conclusions Management of increased ICP remains crucial in improving clinical outcomes in cryptococcal meningitis. Guidelines should consider an approach to therapeutic LPs that is not dictated by baseline ICP.
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Affiliation(s)
- Enock Kagimu
- Correspondence: Enock Kagimu, MD, Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda ()
| | - Nicole Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tadeo K Kiiza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda,Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Kathy Huppler Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R Boulware
- Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda,Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda,Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Seetahal-Maraj P, Giddings S, Ramcharan K, Ramnarine N. Obstructive Hydrocephalus Secondary to Cryptococcal Meningitis in an Immunocompetent Adult. Cureus 2021; 13:e18975. [PMID: 34820230 PMCID: PMC8606177 DOI: 10.7759/cureus.18975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 11/10/2022] Open
Abstract
Cryptococcal infections of the central nervous system (CNS) are common opportunistic infections in immunocompromised hosts. They can occur in immunocompetent hosts, and this has been documented in isolated case reports. Rapid neurological deterioration can be seen, particularly with hydrocephalus, and diagnosis can be difficult without a high index of suspicion. Treatment arms include prolonged antifungal therapy and cerebrospinal fluid (CSF) diversion procedures. We present a case of a middle-aged immunocompetent male, who presented with an acute confusional state and papilledema. An urgent computed tomography (CT) and magnetic resonance imaging (MRI) revealed obstructive hydrocephalus, and an external ventricular drain was placed. CSF samples were collected, and analysis revealed cryptococcal infection. He was treated with antifungal therapy but failed external ventricular drain challenging. A ventriculoperitoneal shunt was placed after negative CSF studies were obtained. While uncommon, cryptococcal meningitis in immunocompetent hosts can present with obstructive hydrocephalus. It can result in rapid neurological decline and death. Emergent CSF diversion and antifungal therapy are the primary treatment modalities. CSF diversion may be permanently required in some cases.
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Affiliation(s)
| | - Stanley Giddings
- Faculty of Clinical Medical Sciences, The University of the West Indies, Trinidad, TTO
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Abstract
Neuroinfectious diseases can affect immunocompetent and immunosuppressed individuals and cause a variety of emergencies including meningitis, encephalitis, and abscess. Neurologic infections are frequently complicated by secondary injuries that also present emergently such as cerebrovascular disease, acute obstructive hydrocephalus, and seizure. In most cases, timely recognition and early treatment of infection can improve the morbidity and mortality of infectious neurologic emergencies.
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Woo YH, Martinez LR. Cryptococcus neoformans-astrocyte interactions: effect on fungal blood brain barrier disruption, brain invasion, and meningitis progression. Crit Rev Microbiol 2021; 47:206-223. [PMID: 33476528 DOI: 10.1080/1040841x.2020.1869178] [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: 12/29/2022]
Abstract
Cryptococcus neoformans is an opportunistic, neurotropic, and encapsulated fungus that causes life-threatening cryptococcal meningitis (CM), especially in regions of the world where AIDS is endemic. The polysaccharide capsule of C. neoformans is the fungus major virulent factor, being copiously released during infection and causing immunosuppressive defects in the host. Although the capsular material is commonly associated with reactive astrocytes in fatal CM, little is known about the molecular and cellular interactions among astroglia and C. neoformans. As astrocytes also make up the neurovascular unit at the blood-brain barrier (BBB), which C. neoformans must transverse to colonize the central nervous system and cause CM; these cells may play a significant regulatory role in the prevention and progression of infection. For example, astrocytes are implicated in neurological disease including the regulation of cerebral intracranial pressure, immune function, and water homeostasis. Hence, in this review, we provide a general overview of astroglia biology and discuss the current knowledge on C. neoformans-astrocyte interactions including their involvement in the development of CM. This "gliocentric view" of cerebral cryptococcosis suggests that therapeutic interventions particularly targeting at preserving the neuroprotective function of astrocytes may be used in preventing and managing C. neoformans BBB transmigration, brain invasion, colonization, and meningitis.
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Affiliation(s)
- Yeon Hwa Woo
- Department of Metallurgical, Materials and Biomedical Engineering, College of Engineering, The University of Texas at El Paso, El Paso, TX, USA
| | - Luis R Martinez
- Department of Oral Biology, College of Dentistry, University of Florida, Gainesville, FL, USA
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Yang H, Yin F, Xiao T, Gan S, Pan Z, Peng J, Wu L. A correlation analysis between clinical manifestations, therapeutic strategies, and the prognosis of children with cryptococcal meningitis in China. Int J Infect Dis 2020; 95:241-245. [DOI: 10.1016/j.ijid.2020.03.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/14/2020] [Accepted: 03/25/2020] [Indexed: 02/08/2023] Open
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Loan JJM, Poon MTC, Tominey S, Mankahla N, Meintjes G, Fieggen AG. Ventriculoperitoneal shunt insertion in human immunodeficiency virus infected adults: a systematic review and meta-analysis. BMC Neurol 2020; 20:141. [PMID: 32303190 PMCID: PMC7164262 DOI: 10.1186/s12883-020-01713-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 03/31/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hydrocephalus is a common, life threatening complication of human immunodeficiency virus (HIV)-related central nervous system opportunistic infection which can be treated by insertion of a ventriculoperitoneal shunt (VPS). In HIV-infected patients there is concern that VPS might be associated with unacceptably high mortality. To identify prognostic indicators, we aimed to compare survival and clinical outcome following VPS placement between all studied causes of hydrocephalus in HIV infected patients. METHODS The following electronic databases were searched: The Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), EMBASE, CINAHL Plus, LILACS, Research Registry, the metaRegister of Controlled Trials, ClinicalTrials.gov, African Journals Online, and the OpenGrey database. We included observational studies of HIV-infected patients treated with VPS which reported of survival or clinical outcome. Data was extracted using standardised proformas. Risk of bias was assessed using validated domain-based tools. RESULTS Seven Hunderd twenty-three unique study records were screened. Nine observational studies were included. Three included a total of 75 patients with tuberculous meningitis (TBM) and six included a total of 49 patients with cryptococcal meningitis (CM). All of the CM and two of the TBM studies were of weak quality. One of the TBM studies was of moderate quality. One-month mortality ranged from 62.5-100% for CM and 33.3-61.9% for TBM. These pooled data were of low to very-low quality and was inadequate to support meta-analysis between aetiologies. Pooling of results from two studies with a total of 77 participants indicated that HIV-infected patients with TBM had higher risk of one-month mortality compared with HIV non-infected controls (odds ratio 3.03; 95% confidence-interval 1.13-8.12; p = 0.03). CONCLUSIONS The evidence base is currently inadequate to inform prognostication in VPS insertion in HIV-infected patients. A population-based prospective cohort study is required to address this, in the first instance.
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Affiliation(s)
- James J. M. Loan
- Centre for Clinical Brain Sciences and Centre for Discovery Brain Sciences, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
- Edinburgh Medical School, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
- Division of Neurosurgery, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925 South Africa
| | - Michael T. C. Poon
- Centre for Clinical Brain Sciences and Centre for Discovery Brain Sciences, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
- Edinburgh Medical School, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
| | - Steven Tominey
- Edinburgh Medical School, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
| | - Ncedile Mankahla
- Division of Neurosurgery, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925 South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - A. Graham Fieggen
- Division of Neurosurgery, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925 South Africa
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Efficacy of ventriculoperitoneal shunting in patients with cryptococcal meningitis with intracranial hypertension. Int J Infect Dis 2019; 88:102-109. [PMID: 31499210 DOI: 10.1016/j.ijid.2019.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/14/2019] [Accepted: 08/31/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal (VP) shunting in cryptococcal meningitis (CM) patients with high intracranial pressure (ICP) has been studied extensively. METHODS A total of 74 CM patients with ICP were identified, including 27 patients with or without ventriculomegaly receiving VP shunting. RESULTS Through retrospective analysis, there was an obvious decline in ICP as well as Cryptococcus count after VP shunting. Damage to the cranial nerves was improved after the surgery. For those patients receiving VP shunting, there was an obvious decline in ICP as well as Cryptococcus count, with less usage of mannitol. Hydrocephalus or ventriculomegaly was improved, and both the clearance time of Cryptococcus and the hospitalization time were shortened (p<0.05). The complications of VP shunting were not common. CONCLUSIONS For patients diagnosed with CM and with apparent ICP, VP shunting can be considered regardless of whether there is damage to the cranial nerves or hydrocephaly.
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Abstract
Purpose of review To perform an extensive review of recent literature and provide an update on the current epidemiology, clinical features and management of cryptococcal disease with a focus on the differences between patients depending on their immune status. Recent findings Emerging literature has highlighted the inflammatory pathophysiology and varied manifestations of cryptococcal infections in patients who are apparently healthy but paradoxically have a more critical clinical course compared to their immunosuppressed counterparts. Summary Non-HIV cryptococcal meningitis has greater mortality compared to that seen in HIV patients. Basic science experiments closely analyzing the underlying pathophysiological response to this infection have demonstrated the predominant role of T cell-mediated inflammatory injury in causing worse clinical outcomes. Further studies are needed to define the need for immunosuppressive agents in the treatment of this illness.
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Affiliation(s)
- Seher Anjum
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), 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 (NIH), Bethesda, MD, USA
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Hamdan N, Billon Grand R, Moreau J, Thines L. Cryptococcal meningitis in an immunocompetent patient with obstructive hydrocephalus: A case report. Neurochirurgie 2018; 64:324-326. [PMID: 30195720 DOI: 10.1016/j.neuchi.2018.05.178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 05/14/2018] [Accepted: 05/24/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cryptococcal infections of the central nervous system are very rare in immunocompetent patients. They usually present as meningitis or as fungal cysts with or without hydrocephalus. Rapid diagnosis and treatment is crucial to the prognosis. CASE REPORT We report the case of an immunocompetent 40-year-old male patient with no medical or surgical history and no recent travel, who was hospitalized in our neurosurgery department because of a rapidly worsening headache. The neurological examination revealed no focal deficit but worrying signs of increased intracranial pressure. Magnetic resonance imaging (MRI) with contrast showed thick and large-scale cortico-pial cerebellar enhancements, associated with severe obstructive hydrocephalus. This required emergency endoscopic ventriculocisternostomy during which we observed cottony tissues along the ventricular walls. Biopsied tissues and cerebrospinal fluid samples (CSF) were not contributive. A CT scan of the chest and abdomen and blood markers of common primary tumors were all negative. No evidence of HIV infection or any cause of immunosuppression was identified. Symptoms and a second MRI slightly improved with intravenous corticosteroid therapy. The hypothesis of a lymphoma or granulomatous disease was made initially for which direct surgical biopsies were scheduled. The diagnosis of cryptococcal meningitis was obtained later on by simultaneous plasma and CSF Cryptococcus antigen detection. Cryptococcus neoformans (formerly C. neoformans var. grubii [serotype A]) was then identified by PCR. Clinical improvement was obtained with antifungal therapy. CONCLUSION Cryptococcal meningitis is a well-known condition in immunocompromised patients, often causing hydrocephalus requiring neurosurgical management. The diagnosis is more difficult in patients with no history of HIV or organ transplant. Neurologists and neurosurgeons must consider this possibility in case of diffuse, thick leptomeningeal enhancement on MRI.
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Affiliation(s)
- N Hamdan
- Service de neurochirurgie, CHRU Jean-Minjoz, 25030, Besançon, France.
| | - R Billon Grand
- Service de neurochirurgie, CHRU Jean-Minjoz, 25030, Besançon, France
| | - J Moreau
- Service de maladies infectieuses et tropicales, CHRU Jean-Minjoz, 25030 Besançon, France
| | - L Thines
- Service de neurochirurgie, CHRU Jean-Minjoz, 25030, Besançon, France
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Risk factors and outcomes of cerebrospinal fluid overdrainage in HIV-negative patients with cryptococcal meningitis after the ventriculoperitoneal shunting procedure. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 51:545-551. [DOI: 10.1016/j.jmii.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 05/16/2017] [Accepted: 06/06/2017] [Indexed: 11/20/2022]
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Liu J, Chen ZL, Li M, Chen C, Yi H, Xu L, Tan F, Peng FH. Ventriculoperitoneal shunts in non-HIV cryptococcal meningitis. BMC Neurol 2018; 18:58. [PMID: 29716538 PMCID: PMC5930737 DOI: 10.1186/s12883-018-1053-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 04/17/2018] [Indexed: 11/11/2022] Open
Abstract
Background Persistent and uncontrollable intracranial hypertension (ICH) and difficulty in reducing Cryptococcus count are severe problems in cryptococcal meningitis (CM) patients. The therapeutic effects of ventriculoperitoneal shunts (VPS) in non-HIV CM patients are not fully known, and the procedure is somewhat unusual. Here, our study offers a review to investigate the role of VPS in non-HIV CM. Methods We retrospectively collected data on 23 non-HIV CM patients with and without ventriculomegaly from 2010 to 2016. Their demographic data, clinical manifestations, cerebrospinal fluid (CSF) features and outcomes were analysed. Results We found that non-HIV CM patients without ventriculomegaly were older, had earlier treatment times and had shorter symptom durations than CM patients with ventriculomegaly. In both groups, headache, vomiting, fever and loss of vision were the most common clinical features. CSF pressure and Cryptococcus count were significantly decreased after operation. VPS could provide sustained relief from ICH symptoms such as headache. 13% of patients had poor outcomes because of serious underlying disease, while 87% of patients had good outcomes. Conclusions The use of a VPS is helpful in decreasing ICH and fungal overload in non-HIV CM patients, and VPS should be performed before CM patients present with symptoms of severe neurological deficit.
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Affiliation(s)
- Jia Liu
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Zhuo-Lin Chen
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Min Li
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Chuan Chen
- Department of Neurosurgery, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Huan Yi
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Li Xu
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Feng Tan
- Department of Neurology, Foshan Chinese Medicine Hospital, Foshan, 528000, Guangdong, China
| | - Fu-Hua Peng
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, 510630, Guangdong, China.
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Mehta GU, Panackal AA, Murayi R, Bennett JE, Williamson PR, Chittiboina P. Corticosteroids for shunted previously healthy patients with non-HIV cryptococcal meningoencephalitis. J Neurol Neurosurg Psychiatry 2018; 89:219-220. [PMID: 28550070 PMCID: PMC5702587 DOI: 10.1136/jnnp-2017-315830] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/29/2017] [Accepted: 05/03/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Gautam U Mehta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Anil A Panackal
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA.,Division of Infectious Diseases, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Roger Murayi
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - John E Bennett
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA.,Division of Infectious Diseases, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Peter R Williamson
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
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Pham C, Bennett I, Jithoo R. Cryptococcal meningitis causing obstructive hydrocephalus in a patient on fingolimod. BMJ Case Rep 2017; 2017:bcr-2017-220026. [PMID: 28687690 DOI: 10.1136/bcr-2017-220026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cryptococcosis is a recognised opportunistic infection in immunocompromised patients. The long-term adverse effect profile of fingolimod, an immunomodulating agent approved for use in multiple sclerosis in 2010, is only just emerging. We report the first case to our knowledge of a patient presenting with obstructive hydrocephalus secondary to cryptococcal meningitis in the setting of fingolimod therapy. Extensive posterior fossa leptomeningeal inflammation with associated cerebellar oedema resulted in effacement of the fourth ventricle and obstructive hydrocephalus requiring urgent ventriculostomy. Induction, consolidative and maintenance antifungal therapy was prescribed and subsequent conversion to a ventriculoperitoneal shunt was successful in relieving the patient's ventriculomegaly. Awareness of these rare, novel and life-threatening complications of fingolimod-associated immunocompromise is critical as the use of such drugs is expected to rise.
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Affiliation(s)
- Chengde Pham
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
| | - Iwan Bennett
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
| | - Rondhir Jithoo
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
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Repeated therapeutic lumbar punctures in cryptococcal meningitis – necessity and/or opportunity? Curr Opin Infect Dis 2016; 29:539-545. [DOI: 10.1097/qco.0000000000000315] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
Cryptococcosis is an invasive mycosis caused by pathogenic encapsulated yeasts in the genus Cryptococcus. Cryptococcus gained prominence as a pathogen capable of widespread disease outbreaks in vulnerable populations. We have gained insight into the pathobiology of Cryptococcus, including the yeast' s capacity to adapt to environmental pressures, exploit new geographic environments, and cause disease in both immunocompromised and apparently immunocompetent hosts. Inexpensive, point-of-care testing makes diagnosis more feasible than ever. The associated worldwide burden and mortality remains unacceptably high. Novel screening strategies and preemptive therapy offer promise at making a sustained and much needed impact on this sugar-coated opportunistic mycosis.
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Affiliation(s)
- Eileen K Maziarz
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, DUMC Box 102359, 315 Trent Drive, Durham, NC 27710, USA.
| | - John R Perfect
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, DUMC Box 102359, 315 Trent Drive, Durham, NC 27710, USA
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Diagnostic Challenges of Cryptococcus neoformans in an Immunocompetent Individual Masquerading as Chronic Hydrocephalus. Case Rep Neurol Med 2016; 2016:7381943. [PMID: 27525140 PMCID: PMC4971305 DOI: 10.1155/2016/7381943] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/24/2016] [Indexed: 12/03/2022] Open
Abstract
Cryptococcus neoformans can cause disseminated meningoencephalitis and evade immunosurveillance with expression of a major virulence factor, the polysaccharide capsule. Direct diagnostic assays often rely on the presence of the cryptococcal glucuronoxylomannan capsular antigen (CrAg) or visualization of the capsule. Strain specific phenotypic traits and environmental conditions influence differences in expression that can thereby compromise detection and timely diagnosis. Immunocompetent hosts may manifest clinical signs and symptoms indolently, often expanding the differential and delaying appropriate treatment and diagnosis. We describe a 63-year-old man who presented with a progressive four-year history of ambulatory dysfunction, headache, and communicating hydrocephalus. Serial lumbar punctures (LPs) revealed elevated protein (153–300 mg/dL), hypoglycorrhachia (19–47 mg/dL), lymphocytic pleocytosis (89–95% lymphocyte, WBC 67–303 mg/dL, and RBC 34–108 mg/dL), and normal opening pressure (13–16 cm H2O). Two different cerebrospinal fluid (CSF) CrAg assays were negative. A large volume CSF fungal culture grew unencapsulated C. neoformans. He was initiated on induction therapy with amphotericin B plus flucytosine and consolidation/maintenance therapy with flucytosine, but he died following discharge due to complications. Elevated levels of CSF Th1 cytokines and decreased IL6 may have affected the virulence and detection of the pathogen.
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Chen YF, Wang DN, Chen ZT, Zhao ZH, Lin Y, Wang HY, Wang N. Risk factors associated with acute/subacute cerebral infarction in HIV-negative patients with cryptococcal meningitis. J Neurol Sci 2016; 364:19-23. [DOI: 10.1016/j.jns.2016.02.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 02/24/2016] [Accepted: 02/24/2016] [Indexed: 02/08/2023]
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Henderson D, Sims-Williams HP, Wilhelm T, Sims-Williams H, Bhagani S, Thorne L. Neurosurgery and human immunodeficiency virus in the era of combination antiretroviral therapy: a review. J Neurosurg 2016; 126:897-907. [PMID: 27081898 DOI: 10.3171/2016.1.jns151194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Human immunodeficiency virus (HIV) is a global health problem. It renders the central nervous system susceptible to infectious and noninfectious diseases. HIV-positive individuals may present to neurosurgical services with brain lesions of unknown etiology. The differential diagnosis in these cases is broad, including opportunistic infections and malignancies, and investigation should be tailored accordingly. Opportunistic infections of the central nervous system can be complicated by hydrocephalus, and the management is pathogen dependent. Patients may also present to a neurosurgical service with conditions unrelated to their HIV status. This review outlines important conditions that cause brain lesions and hydrocephalus. It addresses the issues of diagnosis and intervention in HIV-positive patients in the era of combination antiretroviral therapy, while not ignoring the potential for opportunistic central nervous system infection in undiagnosed patients. The care of HIV-positive patients presenting to neurosurgical services requires a multidisciplinary approach, which is reflected in the authorship of this review, as well as in the guidance given.
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Affiliation(s)
| | | | | | | | | | - Lewis Thorne
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Abstract
OBJECT Patients with cryptococcal meningitis often develop symptomatic intracranial hypertension. The need for permanent CSF diversion in these cases remains unclear. METHODS Cases of cryptococcal meningitis over a 5-year period were reviewed from a single, large teaching hospital. Sources of identification included ICD-9 codes, operative logs, and microscopy laboratory records. RESULTS Fifty cases of cryptococcal meningitis were identified. Ninety-eight percent (49/50) of patients were HIV positive. Opening pressure on initial lumbar puncture diagnosing cryptococcal meningitis was elevated (> 25 cm H2O) in 33 cases and normal (≤ 25 cm H2O) in 17 cases. Thirty-eight patients ultimately developed elevated opening pressure over a follow-up period ranging from weeks to years. Serial lumbar punctures for relief of intracranial hypertension were performed in 29 cases. Thirteen of these patients ultimately had shunting procedures performed after failing to improve clinically. Two factors were significantly associated with the need for shunting: patients undergoing shunt placement were more likely to be women (5/13 vs 0/16; p = 0.01) and to have a pattern of increasing CSF cryptococcal antigen (10/13 vs 3/16 cases; p = 0.003). All patients re-presenting with mycological relapse either underwent or were offered shunt placement. CONCLUSIONS Neurosurgeons are often asked to consider CSF diversion in cases of cryptococcal meningitis complicated by intracranial hypertension. Most patients do well with serial lumbar punctures combined with antifungal therapy. When required, shunting generally provided sustained relief from intracranial hypertension symptoms. Ventriculoperitoneal shunts are the favored method of diversion. To the authors' knowledge, the present study is the largest series on diversionary shunts in primarily HIV-positive patients with this problem.
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Affiliation(s)
| | - Robert L Atmar
- Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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Abstract
Understanding of the taxonomy and phylogeny of Cryptococcus gattii has been advanced by modern molecular techniques. C. gattii probably diverged from Cryptococcus neoformans between 16 million and 160 million years ago, depending on the dating methods applied, and maintains diversity by recombining in nature. South America is the likely source of the virulent C. gattii VGII molecular types that have emerged in North America. C. gattii shares major virulence determinants with C. neoformans, although genomic and transcriptomic studies revealed that despite similar genomes, the VGIIa and VGIIb subtypes employ very different transcriptional circuits and manifest differences in virulence phenotypes. Preliminary evidence suggests that C. gattii VGII causes severe lung disease and death without dissemination, whereas C. neoformans disseminates readily to the central nervous system (CNS) and causes death from meningoencephalitis. Overall, currently available data indicate that the C. gattii VGI, VGII, and VGIII molecular types more commonly affect nonimmunocompromised hosts, in contrast to VGIV. New, rapid, cheap diagnostic tests and imaging modalities are assisting early diagnosis and enabling better outcomes of cerebral cryptococcosis. Complications of CNS infection include increased intracranial pressure, severe neurological sequelae, and development of immune reconstitution syndrome, although the mortality rate is low. C. gattii VGII isolates may exhibit higher fluconazole MICs than other genotypes. Optimal therapeutic regimens are yet to be determined; in most cases, initial therapy with amphotericin B and 5-flucytosine is recommended.
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Corti M, Priarone M, Negroni R, Gilardi L, Castrelo J, Arechayala AI, Messina F, Franze O. Ventriculoperitoneal shunts for treating increased intracranial pressure in cryptococcal meningitis with or without ventriculomegaly. Rev Soc Bras Med Trop 2015; 47:524-7. [PMID: 25229298 DOI: 10.1590/0037-8682-0176-2013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Cryptococcosis is an opportunistic mycosis, especially in patients that are human immunodeficiency virus (HIV)-positive, and frequently involves the central nervous system. METHODS We assessed the potential of ventriculoperitoneal shunting (VPS) in preventing mortality due to uncontrollable intracranial hypertension (ICH) in 15 patients with acquired immunodeficiency syndrome (AIDS)-related cryptococcal meningitis. RESULTS After 2 weeks of antifungal therapy consisting of amphotericin B deoxycholate with or without fluconazole, patients with persistent ICH underwent VPS, despite having persistent Cryptococcus neoformans infection. In 12 patients, the uncontrollable ICH was resolved by VPS. CONCLUSIONS Patients with cryptococcal meningoencephalitis who have ICH must be considered for VPS even with positive cerebrospinal fluid cultures.
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Affiliation(s)
- Marcelo Corti
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Maria Priarone
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Ricardo Negroni
- Mycology Unit, Francisco Javier Muñiz Hospital, Buenos Aires, Argentina
| | - Leonardo Gilardi
- Sociedad Iberoamericana de Información Cientifica, Buenos Aires, Argentina
| | - Jimena Castrelo
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Fernando Messina
- Mycology Unit, Francisco Javier Muñiz Hospital, Buenos Aires, Argentina
| | - Osvaldo Franze
- Neurosurgery Department, Francisco Javier Muñiz Hospital, Buenos Aires, Argentina
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Espino Barros Palau A, Morgan ML, Foroozan R, Lee AG. Neuro-ophthalmic presentations and treatment of Cryptococcal meningitis-related increased intracranial pressure. CANADIAN JOURNAL OF OPHTHALMOLOGY 2015; 49:473-7. [PMID: 25284106 DOI: 10.1016/j.jcjo.2014.06.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/25/2014] [Accepted: 07/15/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To illustrate three different ophthalmic presentations of cryptococcal meningitis (CM). INTRODUCTION CM is the most common manifestation of extra-pulmonary cryptococcosis. Intracranial hypertension occurs in up to 75% of patients with CM and is associated with increased mortality. CM can present to the ophthalmologist as vision loss, papilledema, abducens palsy, and/or other cranial neuropathies. PARTICIPANTS AND METHODS We report three cases, two C. neoformans and one C. gattii, highlighting the various CM presentations. The first was a woman immunosuppressed following kidney transplantation in whom idiopathic intracranial hypertension (IIH) was initially suspected. The second was a man immunocompromised by previously undiagnosed HIV/AIDS who presented with signs and symptoms of increased intracranial pressure. The third case is an immunocompetent man with bilateral disc edema and an incomplete macular star diagnosed with presumed neuroretinitis. Further evaluation revealed positive CSF cryptococcal antigen with culture positive for C. gattii. CONCLUSIONS Ophthalmologists should be aware that cryptococcosis can mimic more benign etiologies including IIH and neuroretinitis. Additionally, C. gattii, an emerging organism, can infect immunocompetent patients. In contrast to the typical treatment of increased ICP, serial lumbar punctures are recommended while acetazolamide and surgical CSF shunting may be harmful.
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Affiliation(s)
| | - Michael L Morgan
- Department of Ophthalmology, Houston Methodist Hospital, Houston, Tex
| | | | - Andrew G Lee
- Department of Ophthalmology, Houston Methodist Hospital, Houston, Tex; Baylor College of Medicine, Houston, Tex; Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medical College, Houston, Tex; UTMB Galveston, Galveston; UT M.D. Anderson Cancer Center, Houston, Tex; The University of Iowa Hospitals and Clinics, Iowa City, Iowa.
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Cryptococcosis. DIAGNOSIS AND TREATMENT OF FUNGAL INFECTIONS 2015. [PMCID: PMC7122569 DOI: 10.1007/978-3-319-13090-3_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cryptococcosis is an infectious disease caused by the encapsulated fungi Cryptococcus neoformans and Cryptococcus gattii. Once a relatively uncommon cause of human disease, cryptococcal infection can develop in apparently immunocompetent hosts and has emerged as an important opportunistic infection in humans over the past several decades as immunocompromised populations expand in the setting of HIV/AIDS, organ transplantation, malignancies, and treatment for other conditions. Clinical manifestations are myriad but pulmonary and central nervous system (CNS) infections are the most common. Improvements in diagnostic testing and standardized approaches to antifungal therapy, when available, have made considerable impact in the management of this infection. While the widespread use of highly active antiretroviral therapy (HAART) has improved the outcome of cryptococcosis in many HIV-infected patients, cryptococcosis remains an entity of considerable morbidity and mortality in many parts of the world, and restoration of host immunity can present management challenges that require individualized management. As immunocompromised populations continue to expand, it is likely that cryptococcosis will remain an important opportunistic fungal infection of humans requiring ongoing investigation.
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A case of recurrent cryptococcal meningoencephalitis in an immunocompetent female. Case Rep Infect Dis 2014; 2014:407348. [PMID: 25276446 PMCID: PMC4171049 DOI: 10.1155/2014/407348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 06/10/2014] [Accepted: 06/28/2014] [Indexed: 12/04/2022] Open
Abstract
Cryptococcus neoformans is commonly associated with meningoencephalitis in immunocompromised patients and occasionally in apparently healthy individuals. Duration and regimen of antifungal treatment vary depending on the nature of the host and extent of disease and CNS shunts are placed in persistently elevated intracranial pressures. Recurrence of infection after initial treatment is not uncommon in HIV positive patients, Kaya et al. (2012) and Illnait-zaragozí et al. (2010). We describe a 39-year-old immunocompetent female that presented with neurologic deficits and increased intracranial pressure (ICP) due to cryptococcal meningoencephalitis that had a complicated course with drug induced hepatitis and persistently increased ICP that ultimately required shunt placement and presented again with relapse of cryptococcal meningoencephalitis after completion of antifungal treatment. Our case shows that recurrent cryptococcal meningitis can be seen in immunocompetent patients due to prolonged placement of CNS shunt and suggests that shunts should be removed after resolution of meningitis.
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McMullan BJ, Sorrell TC, Chen SCA. Cryptococcus gattii infections: contemporary aspects of epidemiology, clinical manifestations and management of infection. Future Microbiol 2013; 8:1613-31. [DOI: 10.2217/fmb.13.123] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cryptococcus gattii is an important primary and opportunistic pathogen, predominantly causing meningoencephalitis and pulmonary disease with substantial mortality. Initially considered geographically restricted to immune-competent, highly exposed individuals in the tropics, an apparent epidemic in North America has led to new perspectives on its ecology, epidemiology and clinical associations, which are distinct from its sibling species Cryptococcus neoformans. The role of C. gattii molecular genotypes/subtypes in different settings is under investigation. Diagnostic and treatment strategies are similar to those for C. neoformans in immunocompetent hosts, although data indicate that more prolonged induction, as well as total duration of therapy, is required. Exclusion of CNS involvement is mandatory. Brain cryptococcomas are characteristic of C. gattii infection, and raised intracranial pressure is common, for which surgery is often required. Immune reconstitution syndrome may occur. Ongoing C. gattii research and greater awareness and availability of specific diagnostic tests are required to improve patient outcomes.
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Affiliation(s)
- Brendan Joseph McMullan
- Department of Immunology & Infectious Diseases, Sydney Children‘s Hospital, Randwick, New South Wales, Australia
- School of Women‘s & Children‘s Health, University of New South Wales, Kensington, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Tania Christine Sorrell
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney Emerging Infections Biosecurity Institute, University of Sydney, New South Wales, Australia
| | - Sharon Chih-Ann Chen
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
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Pyrgos V, Seitz AE, Steiner CA, Prevots DR, Williamson PR. Epidemiology of cryptococcal meningitis in the US: 1997-2009. PLoS One 2013; 8:e56269. [PMID: 23457543 PMCID: PMC3574138 DOI: 10.1371/journal.pone.0056269] [Citation(s) in RCA: 222] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 01/07/2013] [Indexed: 01/17/2023] Open
Abstract
Cryptococcal meningitis (CM) causes significant morbidity and mortality globally; however, recent national trends have not been described. Incidence and trends for CM-associated hospitalizations in 18 states were estimated using the Agency for Healthcare and Research Quality (AHRQ) State Inpatient Databases (SID) datasets for 1997 through 2009. We identified 30,840 hospitalizations coded for CM, of which 21.6% were among HIV-uninfected patients. CM in-hospital mortality was significant (12.4% for women and 10.8% for men) with a total of 3,440 deaths over the study period. Co-morbidities of CM coded at increased frequency in HIV-uninfected CM hospitalized populations included hydrocephalus and acute/chronic renal failure as well as possible predispositions including transplantation, combined T and B cell defects, Cushing’s syndrome, liver disease and hypogammaglobulinemia. Median hospitalization costs were significant for CM and higher for HIV-uninfected patients (16,803.01 vs. 15,708.07; p<0.0001). Cryptococcal meningitis remains a disease with significant morbidity and mortality in the U.S. and the relative burden among persons without HIV infection is increasing.
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Affiliation(s)
- Vasilios Pyrgos
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Amy E. Seitz
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Claudia A. Steiner
- Center for Delivery, Organization and Markets, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, Rockville, Maryland, United States of America
| | - D. Rebecca Prevots
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Peter R. Williamson
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
- Section of Infectious Diseases, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois, United States of America
- * E-mail:
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New Insights in the Prevention, Diagnosis, and Treatment of Cryptococcal Meningitis. Curr HIV/AIDS Rep 2012; 9:267-77. [DOI: 10.1007/s11904-012-0127-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Said Criado I, Gómez G de la Pedrosa E, de Felipe Mimbrera A, Pintado García V. [Acute hydrocephalus as a presentation form of disseminated aspergillosis]. Enferm Infecc Microbiol Clin 2012; 30:348-50. [PMID: 22503114 DOI: 10.1016/j.eimc.2012.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 02/16/2012] [Accepted: 02/18/2012] [Indexed: 11/28/2022]
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Limper AH, Knox KS, Sarosi GA, Ampel NM, Bennett JE, Catanzaro A, Davies SF, Dismukes WE, Hage CA, Marr KA, Mody CH, Perfect JR, Stevens DA. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med 2011; 183:96-128. [PMID: 21193785 DOI: 10.1164/rccm.2008-740st] [Citation(s) in RCA: 359] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
With increasing numbers of immune-compromised patients with malignancy, hematologic disease, and HIV, as well as those receiving immunosupressive drug regimens for the management of organ transplantation or autoimmune inflammatory conditions, the incidence of fungal infections has dramatically increased over recent years. Definitive diagnosis of pulmonary fungal infections has also been substantially assisted by the development of newer diagnostic methods and techniques, including the use of antigen detection, polymerase chain reaction, serologies, computed tomography and positron emission tomography scans, bronchoscopy, mediastinoscopy, and video-assisted thorascopic biopsy. At the same time, the introduction of new treatment modalities has significantly broadened options available to physicians who treat these conditions. While traditionally antifungal therapy was limited to the use of amphotericin B, flucytosine, and a handful of clinically available azole agents, current pharmacologic treatment options include potent new azole compounds with extended antifungal activity, lipid forms of amphotericin B, and newer antifungal drugs, including the echinocandins. In view of the changing treatment of pulmonary fungal infections, the American Thoracic Society convened a working group of experts in fungal infections to develop a concise clinical statement of current therapeutic options for those fungal infections of particular relevance to pulmonary and critical care practice. This document focuses on three primary areas of concern: the endemic mycoses, including histoplasmosis, sporotrichosis, blastomycosis, and coccidioidomycosis; fungal infections of special concern for immune-compromised and critically ill patients, including cryptococcosis, aspergillosis, candidiasis, and Pneumocystis pneumonia; and rare and emerging fungal infections.
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Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, Harrison TS, Larsen RA, Lortholary O, Nguyen MH, Pappas PG, Powderly WG, Singh N, Sobel JD, Sorrell TC. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis 2010; 50:291-322. [PMID: 20047480 PMCID: PMC5826644 DOI: 10.1086/649858] [Citation(s) in RCA: 1707] [Impact Index Per Article: 121.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. These guidelines for its management have been built on the previous Infectious Diseases Society of America guidelines from 2000 and include new sections. There is a discussion of the management of cryptococcal meningoencephalitis in 3 risk groups: (1) human immunodeficiency virus (HIV)-infected individuals, (2) organ transplant recipients, and (3) non-HIV-infected and nontransplant hosts. There are specific recommendations for other unique risk populations, such as children, pregnant women, persons in resource-limited environments, and those with Cryptococcus gattii infection. Recommendations for management also include other sites of infection, including strategies for pulmonary cryptococcosis. Emphasis has been placed on potential complications in management of cryptococcal infection, including increased intracranial pressure, immune reconstitution inflammatory syndrome (IRIS), drug resistance, and cryptococcomas. Three key management principles have been articulated: (1) induction therapy for meningoencephalitis using fungicidal regimens, such as a polyene and flucytosine, followed by suppressive regimens using fluconazole; (2) importance of early recognition and treatment of increased intracranial pressure and/or IRIS; and (3) the use of lipid formulations of amphotericin B regimens in patients with renal impairment. Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies. However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients.
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Affiliation(s)
- John R Perfect
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina 27710, USA.
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37
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Abstract
Cryptococcosis occurs in immunocompromised and, in special cases, immunocompetent individuals. There have been a number of important advances in the field, but, despite current treatment, patients continue to die of the infection. This article reviews cryptococcosis epidemiology, clinical features, and management. Current knowledge is incomplete, however, so this article also discusses some of the gaps in the present understanding of cryptococcosis. The hope is that current research striving to understand the mechanisms of host evasion of Cryptococcus will result in improved treatment regimens that decrease both the mortality and morbidity of cryptococcosis.
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Affiliation(s)
- Shaunna M Huston
- Department of Medical Science, University of Calgary, Alberta, Canada
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38
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Lanternier F, Lecuit M, Lortholary O, Roujeau T, Renier D, Bougnoux ME. Successful lumbarperitoneal derivation during refractory intracranial pressure due to cryptococcal meningitis, in an HIV-negative patient. Med Mal Infect 2008; 38:285-6. [DOI: 10.1016/j.medmal.2008.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 03/03/2008] [Indexed: 11/25/2022]
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39
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Crum-Cianflone N, Truett A, R Wallace M. Cryptococcal meningitis manifesting as a large abdominal cyst in a HIV-infected patient with a CD4 count greater than 400 cells/mm(3). AIDS Patient Care STDS 2008; 22:359-63. [PMID: 18373418 PMCID: PMC2707923 DOI: 10.1089/apc.2007.0085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cryptococcal meningitis usually occurs among HIV-positive patients with CD4 counts less than 100 cells/mm(3) and manifests as headaches, fevers, and mental status changes. We present an unusual case of cryptococcal meningitis in a 34-year-old HIV-positive man presenting as a large abdominal cyst at the ventriculoperitoneal shunt site despite receiving highly active antiretroviral therapy (HAART) for more than 5 years and having a CD4 count more than 400 cells/mm(3).
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Affiliation(s)
- Nancy Crum-Cianflone
- Infectious Disease Clinic, Naval Medical Center, San Diego, California 92134-1005, USA.
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40
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Charlier C, Dromer F, Lévêque C, Chartier L, Cordoliani YS, Fontanet A, Launay O, Lortholary O. Cryptococcal neuroradiological lesions correlate with severity during cryptococcal meningoencephalitis in HIV-positive patients in the HAART era. PLoS One 2008; 3:e1950. [PMID: 18414656 PMCID: PMC2293413 DOI: 10.1371/journal.pone.0001950] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Accepted: 02/13/2008] [Indexed: 11/18/2022] Open
Abstract
Cryptococcal meningoencephalitis has an overall global mortality rate of 20% in AIDS patients despite antifungals. There is a need for additional means of precise assessment of disease severity. We thus studied the radiological brain images available from 62 HIV-positive patients with cryptococcocal meningoencephalitis to analyse the brain lesions associated with cryptococcosis in relationship with disease severity, and the respective diagnostic contribution of magnetic resonance (MR) versus computed tomography (CT). In this retrospective multicenter analysis, two neuroradiologists blindly reviewed the brain imaging. Prospectively acquired clinical and mycological data were available at baseline and during follow-up. Baseline images were abnormal on 92% of the MR scans contrasting with 53% of the CT scans. MR/CT cryptococcosis-related lesions included mass(es) (21%/9%), dilated perivascular spaces (46%/5%) and pseudocysts (8%/4%). The presence compared to absence of cryptococcosis-related lesions was significantly associated with high serum (78% vs. 42%, p = 0.008) and CSF (81% vs. 50%, p = 0.024) antigen titers, independently of neurological abnormalities. MR detected significantly more cryptococcosis-related lesions than CT for 17 patients who had had both investigations (76% vs. 24%, p = 0.005). In conclusion, MR appears more effective than CT for the evaluation of AIDS-associated cerebral cryptococcosis. Furthermore, brain imaging is an effective tool to assess the initial disease severity in this setting. Given this, we suggest that investigation for cryptococcosis-related lesions is merited, even in the absence of neurological abnormality, if a high fungal burden is suspected on the basis of high serum and/or CSF antigen titers.
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Affiliation(s)
- Caroline Charlier
- Centre National de Référence Mycologie et Antifongiques, Unité de Mycologie Moléculaire, CNRS URA 3012, Institut Pasteur, Paris, France
- Faculté de Médecine Paris V René Descartes, Hôpital Necker-Enfants Malades, Service des Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker-Pasteur, Paris, France
| | - Françoise Dromer
- Centre National de Référence Mycologie et Antifongiques, Unité de Mycologie Moléculaire, CNRS URA 3012, Institut Pasteur, Paris, France
| | | | - Loïc Chartier
- Unité de Recherche et d'Expertise en Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France
| | | | - Arnaud Fontanet
- Unité de Recherche et d'Expertise en Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France
| | - Odile Launay
- Université Paris-Descartes, Faculté de Médecine, Hôpital Cochin, Pôle de Médecine Interne, CIC de Vaccinologie Cochin-Pasteur, Paris, France
| | - Olivier Lortholary
- Centre National de Référence Mycologie et Antifongiques, Unité de Mycologie Moléculaire, CNRS URA 3012, Institut Pasteur, Paris, France
- Faculté de Médecine Paris V René Descartes, Hôpital Necker-Enfants Malades, Service des Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker-Pasteur, Paris, France
- * E-mail:
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41
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Pukkila-Worley R, Mylonakis E. Epidemiology and management of cryptococcal meningitis: developments and challenges. Expert Opin Pharmacother 2008; 9:551-60. [PMID: 18312157 DOI: 10.1517/14656566.9.4.551] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The significance of cryptococcal infection as a cause of human disease has dramatically evolved in recent years. The objective of this study was to outline the worldwide significance of cryptococcosis and review developments in the management of cryptococcal meningitis. Cryptococcus neoformans var. grubii remains an important cause of disease, particularly in hosts with acquired immunosuppression. Cryptococcus gattii, on the other hand, infects hosts with seemingly normal immune systems and a recent dramatic outbreak in a new ecologic environment highlights the emerging clinical significance of this fungal pathogen. The introduction of new antifungal agents and the adoption of strategies for controlling elevated intracranial pressure in cryptococcal meningitis have added to our therapeutic options. However, the mortality from this infection remains unacceptably high and we are faced with the specific challenges in the management of this disease.
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Affiliation(s)
- Read Pukkila-Worley
- Massachusetts General Hospital, Division of Infectious Diseases, 55 Fruit Street, Boston, MA 02114-2696, USA
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Vakis A, Koutentakis D, Karabetsos D, Ntouros D. Intracerebral CSF collection mimicking cerebral abscess in a patient suffering from cryptococcal meningitis. J Infect 2006; 51:e233-5. [PMID: 16291277 DOI: 10.1016/j.jinf.2005.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Accepted: 02/01/2005] [Indexed: 11/16/2022]
Abstract
We report a case of a large intracerebral CSF collection formed along the course of the catheter of an ommaya-type reservoir (Medtronic 12 mm), implanted in a patient suffered from cryptococcal meningitis in the frame of CLL. This collection was at first diagnosed as intracerebral abscess but emergency craniotomy proves clear CSF collection with no signs of infection. We describe the case and we discuss the issue of CSF pressure pathophysiology and changes in flow dynamics, to patients with cryptococcal meningitis.
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Affiliation(s)
- Antonis Vakis
- Department of Neurosurgery, University of Crete, Medical School, Heraklion University Hospital, Voutes, 71021 Heraklion - Crete, Greece
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44
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Deb S, Walterfang M, Varghese D, Eisen DP, Tomlinson B, Velakoulis D. Cryptococcal dementia in a patient with sarcoidosis. Med J Aust 2006; 184:86-7. [PMID: 16411876 DOI: 10.5694/j.1326-5377.2006.tb00126.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 10/19/2005] [Indexed: 11/17/2022]
Affiliation(s)
- Siddhartha Deb
- Melbourne Neuropsychiatry Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
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45
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Macsween KF, Bicanic T, Brouwer AE, Marsh H, Macallan DC, Harrison TS. Lumbar drainage for control of raised cerebrospinal fluid pressure in cryptococcal meningitis: case report and review. J Infect 2005; 51:e221-4. [PMID: 16291274 DOI: 10.1016/j.jinf.2005.02.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2005] [Indexed: 10/25/2022]
Abstract
Raised intracranial pressure in the absence of ventricular dilatation is common in cryptococcal meningitis and associated with increased mortality. We report the case of a patient with HIV-associated cryptococcal meningitis, who developed increasing CSF pressure and visual impairment on therapy despite serial lumbar punctures. Insertion of a temporary lumbar drain controlled the opening pressure and resulted in full visual recovery. The advantages and necessary precautions with this approach are reviewed, and alternative protocols for the use of lumbar drains discussed.
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Affiliation(s)
- Karen F Macsween
- Division of Infectious Diseases, Department of Cellular and Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.
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46
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Wang KW, Chang WN, Chang HW, Wang HC, Lu CH. Clinical relevance of hydrocephalus in bacterial meningitis in adults. ACTA ACUST UNITED AC 2005; 64:61-5; discussion 66. [PMID: 15993186 DOI: 10.1016/j.surneu.2004.10.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Accepted: 09/02/2004] [Indexed: 01/30/2023]
Abstract
BACKGROUND The predictive factors, clinical relevance, and outcomes of hydrocephalus complicating adult bacterial meningitis were studied. METHODS In this 16-year retrospective study, 136 adult patients were identified with culture-proven bacterial meningitis. A comparison was made between the clinical and cerebrospinal fluid data of patients with and without hydrocephalus on admission. RESULTS Twenty-eight patients had hydrocephalus secondary to bacterial meningitis, accounting for 21% (28/136) of the episodes. Of the 28 patients, the initial computed tomographic scans and/or magnetic resonance imaging studies revealed hydrocephalus in 27 patients, and delayed hydrocephalus developed despite commencement of antimicrobial therapy in the remaining patient. The interval from initial symptoms to external ventricular drainage was 3.9 +/- 4.6 days (range, 1-14 days). Among them, 7 patients underwent external ventricular drainage for hydrocephalus during the acute phase of bacterial meningitis. At follow-up of at least 6 months or more, 14 patients survived and 14 died, with an overall mortality rate of 50%. CONCLUSION In this study, disturbed consciousness and a higher mean age at the time of admission are risk factors for developing hydrocephalus during the acute phase of bacterial meningitis. Poor outcomes are also found in this specific group of patients, and these may be attributed to the infection itself, hydrocephalus, or both. Because of fulminated clinical courses and high fatality rates, surgical intervention may be suitable only for those who have progressive hydrocephalus and are neurologically stable. In spite the high fatality rate, adequate treatment of neurologic complications and aggressive antimicrobial therapy are essential in improving therapeutic outcomes.
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Affiliation(s)
- Kuo-Wei Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital-Kaohsiung, Kaohsiung Hsien, Taiwan
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47
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Pappas PG. Managing Cryptococcal Meningitis Is about Handling the Pressure. Clin Infect Dis 2005; 40:480-2. [PMID: 15668875 DOI: 10.1086/427222] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Accepted: 10/19/2004] [Indexed: 11/03/2022] Open
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48
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Shoham S, Cover C, Donegan N, Fulnecky E, Kumar P. Cryptococcus neoformans Meningitis at 2 Hospitals in Washington, D.C.: Adherence of Health Care Providers to Published Practice Guidelines for the Management of Cryptococcal Disease. Clin Infect Dis 2005; 40:477-9. [DOI: 10.1086/427213] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2004] [Accepted: 09/14/2004] [Indexed: 11/03/2022] Open
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49
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Larsen RA, Bauer M, Thomas AM, Graybill JR. Amphotericin B and fluconazole, a potent combination therapy for cryptococcal meningitis. Antimicrob Agents Chemother 2004; 48:985-91. [PMID: 14982793 PMCID: PMC353060 DOI: 10.1128/aac.48.3.985-991.2004] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We evaluated the antifungal activities of amphotericin B, fluconazole, and flucytosine, alone and in combination, in a murine model of cryptococcal meningitis. The objectives were to determine the greatest antifungal effects achievable with these drugs alone or in combination. Meningitis was established in male BALB/c mice weighing 23 to 25 g by intracerebral injection of Cryptococcus neoformans. Treatment was started on day 2. Amphotericin B was tested at 0.3 to 1.3 mg/kg of body weight/day by slow intravenous injection. Fluconazole at 10 to 40 mg/kg/day and flucytosine at 20 to 105 mg/kg/day were administered in the sole source of drinking water. The mice were killed at 16 days, and the numbers of fungal colonies in the brain were quantified. The association between the response and the dose combination was evaluated by local nonparametric response surface methods; 99% confidence intervals were used to evaluate the antifungal effects. Ninety-five percent of the mice treated with amphotericin B at 0.5 mg/kg survived to the end of the experiment, regardless of the fluconazole or flucytosine dose used. The greatest activity was seen with amphotericin B plus fluconazole with or without flucytosine. However, the addition of flucytosine did not increase the antifungal activity. Given the widespread availability of amphotericin B and fluconazole and the relative safety profile of fluconazole compared to that of flucytosine, the full potential of this two-drug combination deserves further evaluation.
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Affiliation(s)
- Robert A Larsen
- Department of Medicine (Infectious Diseases), University of Southern California, Los Angeles, California 90033, USA.
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