Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america

Pulmonary cryptococcosis in immunocompetent children presenting with chest pain: Three case reports

BACKGROUND

Cryptococcus is a systemic opportunistic pathogenic fungus that can cause infections in both immunocompromised and immunocompetent hosts, with diverse clinical manifestations, ranging from asymptomatic pulmonary lesions to disseminated central nervous system infections. The incidence of pulmonary cryptococcosis (PC) has rapidly increased in recent years, with an increasing proportion of non-human immunodeficiency virus-infected and immunocompetent patients making its diagnosis challenging. If not properly recognized, PC can lead to systemic dissemination and high mortality rates. Early diagnosis and treatment can improve the prognosis. This study summarizes the clinical features of three immunocompetent children with PC who presented with chest pain to raise clinicians' awareness of the disease and reduce mortality.

CASE SUMMARY

Three male pediatric patients in good health were hospitalized because of chest pain without cough or fever. Chest computed tomography (CT) revealed pleural-based nodules and consolidation with cavitation. A lung biopsy was performed in one case, and Cryptococcus was cultured from the pathological tissues. Cryptococcus was detected in the alveolar lavage fluid, and serum Cryptococcus capsular(C. capsular) polysaccharide antigen was positive in one case, and the other case was positive for serum C. capsular polysaccharide. All patients received oral fluconazole treatment. Follow-up chest CT scans after six months showed significant resolution of the lesions.

CONCLUSION

PC can also occur in immunocompetent children. When encountering children with chest pain only in the clinic, one should be vigilant about PC, promptly complete the relevant examinations, and avoid misdiagnosis.

Elevating fungal care: bridging Brazil's healthcare practices to global standards

Brazil faces unique challenges in managing invasive fungal infections (IFIs) due to diverse ecosystems, a rural workforce, and prevalent health conditions. In Europe, IFIs are primarily associated with transplantation, intensive care, and chronic diseases. Inspired by initiatives in the Caribbean and Latin America in 2019, efforts to map global diagnostic and treatment resources expanded to Africa, Europe, and Asia/Pacific. This study conducts a comparative analysis, mainly drawing data from Brazil and Europe, to investigate IFI epidemiology and management. Data were collected through online surveys distributed to Brazilian and European institutions, with collaborations from scientific organizations. Surveys covered institutional profiles, IFI diagnoses, accessibility to diagnostic techniques, and antifungal drugs. A comparative survey involving 96 Brazilian and 388 European institutions revealed variations in the perception and practices related to fungal pathogens. Differences in ranking and prevalence were observed, along with variations in diagnostic procedures, fluorescence dye usage, culture practices, antifungal medication availability, and technological approaches. Europe exhibited higher utilization rates for molecular diagnostic approaches, including PCR tests, and therapeutic drug monitoring (TDM) was more widespread in Europe compared with Brazil, indicating substantial differences in understanding and managing fungal infections. Customized IFI management is crucial, considering regional differences and addressing technological gaps like underutilized PCR. The study advocates for increased international collaboration, targeted training, and enhanced resources to foster a unified global approach in preventing, diagnosing, and treating IFI.

IMPORTANCE

This work is significant as it highlights the unique challenges Brazil faces in managing invasive fungal infections (IFIs) due to its diverse ecosystems and public health landscape. By comparing Brazil's situation with Europe-where IFIs are mainly linked to transplantation and intensive care-this study identifies key disparities in diagnostic and treatment practices. The findings reveal substantial differences in the availability and use of molecular diagnostics, antifungal drugs, and therapeutic drug monitoring, with Europe demonstrating more advanced practices. By mapping these variations, the study underscores the importance of tailored approaches to IFI management that consider regional differences and technological gaps. Ultimately, it calls for enhanced international collaboration, targeted training, and resource allocation to improve IFI outcomes globally, particularly in regions with limited access to advanced diagnostic tools and treatments.

Emerging Treatments in Neonatal Fungal Infections: Progress and Prospects

Fungal infections in neonates are potentially life threatening. The differential diagnosis for neonatal rashes is extensive, with common culprits including both bacteria and fungi. Candida albicans is the predominant fungal pathogen, causing infections that range from superficial disease to severe systemic conditions, including sepsis and meningitis. Neonates, especially those who are preterm, are particularly susceptible because of developmentally immature immune systems and the use of invasive procedures and devices in neonatal intensive care units. Congenital cutaneous candidiasis, acquired in utero or during delivery, can lead to disseminated infection with high mortality rates. Early diagnosis and prompt antifungal treatment are crucial but challenging because of subtle clinical presentations, making accurate identification of the offending organism essential for selecting the appropriate treatment. Candida species account for the majority of neonatal fungal infections, with different species necessitating distinct treatments because of varying susceptibility profiles. Aspergillus, another significant pathogen, poses high mortality risks and can present either cutaneously or systemically. Malassezia, though less common, primarily affects preterm infants with catheter-related fungemia. Other fungal species, including Zygomycetes, Trichosporon, and Cryptococcus, rarely produce neonatal infections but are noteworthy for consideration. Treatment of fungal infection is critical despite the relative paucity of information regarding the clinical pharmacology of many antifungal drugs in neonates. We review the major antifungal agents (e.g., amphotericin B, the echinocandins, the azoles) and provide pharmacologic and dosing information. Finally, preventive strategies, including the use of stringent aseptic techniques and careful clinical monitoring, are essential to mitigate both the incidence and severity of these infections in neonates and infants in the first months of life.

The Hidden Fortress: A Comprehensive Review of Fungal Biofilms with Emphasis on Cryptococcus neoformans

Biofilms are structurally organized communities of microorganisms that adhere to a variety of surfaces. These communities produce protective matrices consisting of polymeric polysaccharides, proteins, nucleic acids, and/or lipids that promote shared resistance to various environmental threats, including chemical, antibiotic, and immune insults. While algal and bacterial biofilms are more apparent in the scientific zeitgeist, many fungal pathogens also form biofilms. These surprisingly common biofilms are morphologically distinct from the multicellular molds and mushrooms normally associated with fungi and are instead an assemblage of single-celled organisms. As a collection of yeast and filamentous cells cloaked in an extracellular matrix, fungal biofilms are an extreme threat to public health, especially in conjunction with surgical implants. The encapsulated yeast, Cryptococcus neoformans, is an opportunistic pathogen that causes both pulmonary and disseminated infections, particularly in immunocompromised individuals. However, there is an emerging trend of cryptococcosis among otherwise healthy individuals. C. neoformans forms biofilms in diverse environments, including within human hosts. Notably, biofilm association correlates with increased expression of multiple virulence factors and increased resistance to both host defenses and antifungal treatments. Thus, it is crucial to develop novel strategies to combat fungal biofilms. In this review, we discuss the development and treatment of fungal biofilms, with a particular focus on C. neoformans.

Fungal arthritis

Fungal arthritis is a rare infection with a global distribution that affects neonates, the elderly, and immunocompromised individuals, resulting in severe outcomes. It presents a challenge for healthcare professionals due to its rarity, lack of characteristic features, and difficulty isolating and identifying responsible organisms. Studies on their pathophysiology and treatment have been limited, and evidence-based treatment options are lacking. The pathogens infect through direct inoculation, extension from adjacent infective foci, or distant dissemination via the bloodstream. Typically, it manifests as either monoarthritis or oligoarthritis, with the knee joint being the most common target. Systemic disease is often absent, while pulmonary and cutaneous diseases are the most frequent extra-articular manifestations. Diagnosis frequently necessitates the direct visualisation of the organism in specimens and cultures of synovial fluid and membranes. A combination of medical (antifungal) and surgical treatments is often required.

Beyond Conventional Antifungals: Combating Resistance Through Novel Therapeutic Pathways

The rising burden of fungal infections presents a significant challenge to global healthcare, particularly with increasing antifungal resistance limiting treatment efficacy. Early detection and timely intervention remain critical, yet fungal pathogens employ diverse mechanisms to evade host immunity and develop resistance, undermining existing therapeutic options. Limited antifungal options and rising resistance necessitate novel treatment strategies. This review provides a comprehensive overview of conventional antifungal agents, their mechanisms of action, and emerging resistance pathways. Furthermore, it highlights recently approved and investigational antifungal compounds while evaluating innovative approaches such as nanotechnology, drug repurposing, and immunotherapy. Addressing antifungal resistance requires a multifaceted strategy that integrates novel therapeutics, enhanced diagnostic tools, and future research efforts to develop sustainable and effective treatment solutions.

Cryptococcosis

Cryptococcosis is an invasive fungal infection caused by yeasts of the genus Cryptococcus that causes a significant global burden of disease in both immunocompromised and immunocompetent individuals. Over the past several decades, diagnosis and management of cryptococcal disease have moved to focus on rapid, reliable, and cost-effective care delivery, with the advent of new antigen detection assays and novel antifungal treatment strategies.

Microbiological Diagnosis: A Key to Successfully Managing Cryptococcal Osteomyelitis Coexisting With Leprosy

Cryptococcus neoformans, an encapsulated yeast-like fungus, can induce a varied array of symptoms like meningitis, cryptococcomas of the brain, spinal cord granuloma, and disseminated disease, more so in people with impaired immune systems. Nonetheless, osseous lesions are rare. A 27-year-old male presented with a painful ulcer on his left lateral ankle. His medical history revealed leprosy for the last three years. The patient underwent an incisional biopsy and surgical debridement, and both the samples grew Cryptococcus neoformans on culture. Cryptococcal osteomyelitis involving the calcaneus and tibia was established. The patient was treated with liposomal amphotericin B followed by fluconazole. Cryptococcal osteomyelitis, though uncommon, should be included in the differential diagnosis of chronic osteolytic lesions for optimal patient care. This case highlighted that early diagnosis and confirmation through microbiological investigations are crucial for the successful management of these rare and potentially debilitating infections, even in immunocompetent individuals.

Genome restructuring and lineage diversification of Cryptococcus neoformans during chronic infection of human hosts

Classified as a critical public health threat by the World Health Organization, Cryptococcus neo-formans infections with significant morbidity and mortality. Reports of cryptococcosis persistence, relapse, and reinfection date back to the 1950s, yet the factors driving chronic infections remain poorly understood. A major challenge is the scarcity of serial patient specimens and detailed medical records to study the simultaneous evolution of the pathogen and host health status. This study provides the first genomic and phenotypic analysis of in-host evolution of C. neoformans during chronic infections lasting over a year in six immunocompromised patients. We find fungal genome evolution during persistent infection is characterized by large-scale genome restructuring and increasing genomic heterogeneity. Phenotypic changes show diversification in virulence traits and antifungal susceptibility. Genotypically and phenotypically distinct sub-lineages arise and co-persist within the same tissues, consistent with a model of diversifying selection and niche partitioning in the complex environment of human hosts.

Cerebrospinal Fluid Cytokines and Chemokines Involved in Cytotoxic Cell Function and Risk of Acute 14-Day Mortality in Persons with Advanced HIV and Cryptococcal Meningitis

BACKGROUND

The role of the immune response in acute mortality of cryptococcal meningitis remains unclear.

METHODS

Cerebrospinal fluid (CSF) from 337 Ugandans with first-episode cryptococcal meningitis was collected. CSF cytokines and chemokines were quantified and compared by 14-day survival, stratification by quartiles, and logistical regression to determine association with acute mortality.

RESULTS

Eighty-four (24.9%) participants died by day 14. Persons who survived to day 14 had higher levels of proinflammatory macrophage inflammatory protein (MIP)-3β and interferon (IFN)-β and cytotoxicity-associated granzyme B and inteferon gamma-induced protein (IP)-10 compared to those who died (P < .05 for each). Logistic regression analysis revealed that per 2-fold increase in proinflammatory interleukin (IL)-6, IL-1α, MIP-1β, MIP-3β, and IFN-β and cytotoxicity-associated IL-12, tumor necrosis factor-α, granzyme-B, and IP-10 CSF concentrations, the risk of acute 14-day mortality decreased. Similar biomarkers were implicated when stratified by quartiles and further identified that lower concentrations of anti-inflammatory IL-10 and IL-13 were associated with 14-day mortality (P < .05 for each).

CONCLUSIONS

Proinflammatory and cytotoxicity-associated cytokine and chemokine responses in the CSF decrease the risk of acute 14-day mortality. These data suggest that a cytotoxic immune environment in the CSF could potentially improve acute survival. Further research on cytotoxic cells is crucial to improve understanding of innate and adaptive immune responses in cryptococcal meningitis.

Identification of a protective antigen reveals the trade-off between iron acquisition and antigen exposure in a global fungal pathogen

Systemic infections caused by Cryptococcus claim over 161,000 lives annually, with global mortality rate close to 70% despite antifungal therapies. Currently, no vaccine is available. To develop an effective multivalent vaccine against this free-living opportunistic eukaryotic pathogen, it is critical to identify protective antigens. We previously discovered ZNF2oe strains elicit protective host immune responses and increase the abundance of antigens present in the capsule, which is required for its immunoprotection. Capsule is a defining feature of Cryptococcus species and composed of polysaccharides and mannoproteins. Here, we found increased levels of exposed mannoproteins in ZNF2oe cells. As mannoproteins are the primary components recognized by anticryptococcal cell-mediated immune responses and few have been characterized, we systemically screened all 49 predicted GPI-mannoproteins in Cryptococcus neoformans for enhanced host recognition. We identified those highly present in ZNF2oe cells and found Cig1 to be a protective antigen against cryptococcosis either as a recombinant protein vaccine or an mRNA vaccine. Cig1 is induced by iron limitation and is highly expressed by this fungus in infected mice and in patients with cryptococcal meningitis. Remarkably, iron restriction by the host induces cryptococcal cells to express iron-uptake proteins including Cig1, which act as cryptococcal antigens and in turn enhance host detection. Our results highlight an arms race between the pathogen and the host centered on iron competition, and the trade-off between cryptococcal iron acquisition and antigen exposure. These findings demonstrate the potential of leveraging this host-pathogen interaction for vaccine development.

Comparison of Early Fungicidal Activity and Mortality Between Daily Liposomal Amphotericin B and Daily Amphotericin B Deoxycholate for Cryptococcal Meningitis

BACKGROUND

Limited data exist on the antifungal activity of daily liposomal amphotericin B with flucytosine induction regimens for cryptococcal meningitis, which are recommended in high-income countries. Liposomal amphotericin B monotherapy at 3 mg/kg previously failed to meet noninferiority criteria compared to amphotericin B deoxycholate in its registrational clinical trial. We aimed to compare the quantitative antifungal activity and mortality between daily amphotericin B deoxycholate and daily liposomal amphotericin B among persons with human immunodeficiency virus (HIV)-related cryptococcal meningitis receiving adjunctive flucytosine 100 mg/kg/day.

METHODS

We analyzed data from 3 clinical studies involving participants with HIV-associated cryptococcal meningitis receiving either daily liposomal amphotericin B at 3 mg/kg/day with flucytosine (n = 94) or amphotericin B deoxycholate at 0.7-1.0 mg/kg/day with flucytosine (n = 404) as induction therapy. We compared participant baseline characteristics, cerebrospinal fluid (CSF) early fungicidal activity (EFA), and 10-week mortality.

RESULTS

We included 498 participants in this analysis, of whom 201 had available EFA data (n = 46 liposomal amphotericin B; n = 155 amphotericin B deoxycholate). Overall, there is no statistical evidence that the antifungal activity of liposomal amphotericin B (mean EFA, 0.495 [95% confidence interval {CI}, .355-.634] log10 colony-forming units [CFU]/mL/day) differ from amphotericin B deoxycholate (mean EFA, 0.402 [95% CI, .360-.445] log10 CFU/mL) (P = .13). Mortality at 10 weeks trended lower for liposomal amphotericin B (28.2%) versus amphotericin B deoxycholate (34.6%) but was not statistically different when adjusting for baseline characteristics (adjusted hazard ratio, 0.74 [95% CI, .44-1.25]; P = .26).

CONCLUSIONS

Daily liposomal amphotericin B induction demonstrated a similar rate of CSF fungal clearance and 10-week mortality as amphotericin B deoxycholate when combined with flucytosine for the treatment of HIV-associated cryptococcal meningitis.

Comparative evaluation of sensititre YeastOne and VITEK2 antifungal susceptibility tests with CLSI broth microdilution method of clinical Cryptococcus isolates in Taiwan

Commercial antifungal susceptibility tests were available for clinical yeast isolates. However, the updated Sensititre YeastOne (SYO) version YO10C excluded Cryptococcus species for susceptibility testing. Uncorrelation of antifungal susceptibility patterns by SYO and therapeutic outcomes had been recently reported. We compared the performance of current commercial susceptibility tests with the standard CLSI broth microdilution (BMD) method for clinical Cryptococcus isolates. Forty-seven clinical Cryptococcus isolates were included from 1 January 2012 to 30 June 2023, among which 44 isolates were Cryptococcus neoformans while 3 were Cryptococcus gattii. The performance of SYO version YO10C and VITEK2 YS09 was compared with the CLSI BMD method and correlated with MLST analysis and ERG11 mutation detection. Non-wild-type (non-WT) strains to amphotericin B (AMB) were observed in 11 isolates with the CLSI BMD method and 8 with SYO among 44 C. neoformans isolates, but only 1 isolate was classified as non-WT by both methods. Additionally, all C. neoformans isolates were susceptible to AMB with their MIC ≤1 µg/mL according to the clinical breakpoint defined by EUCAST. Non-WT to FLC were observed in 5 C. neoformans isolates with SYO, but they were classified as WT by CLSI BMD and VITEK2. The essential agreements between SYO and CLSI BMD were >90% to most antifungal agents except ITC in C. neoformans isolates (64%) and AMB in C. gattii group (67%). Between SYO and CLSI BMD, the major error (ME) rates were 11% (n = 5) to FLC, 5% (n = 2) to ITC, and 2% (n = 1) to 5FC in C. neoformans isolates, and the very major error to 5FC was found in one C. gattii isolate. ERG11 mutation with identical I199V was detected in 89% (n = 39) C. neoformans isolates, and 97% (n = 38) of them belonged to sequence type (ST) 5. The ERG11 mutation or cryptococcal ST was not associated with a decrease of antifungal susceptibilities. ME of FLC by SYO version YO10C compared to the CLSI BMD method reached up to 11% of C. neoformans isolates. The results of FLC MIC by SYO should be interpreted cautiously and correlated with therapeutic response, and further verification with the CLSI BMD method or VITEK2 is required.

IMPORTANCE

The study pointed out the major errors of fluconazole susceptibility results in clinical Cryptococcus neoformans isolates between the commercial Sensititre YeastOne Susceptibility Plate version YO10C and the standard CLSI broth microdilution method. The results should be interpreted carefully with clinical correlation, and a different method of antifungal susceptibility testing should be considered if a discrepancy of susceptibility results is suspected.

Ex Vivo Host Transcriptomics During Cryptococcus neoformans, Cryptococcus gattii, and Candida albicans Infection of Peripheral Blood Mononuclear Cells From South African Volunteers

Cryptococcus neoformans, Cryptococcus gattii, and Candida albicans are opportunistic fungal pathogens associated with infections in immunocompromised hosts. Cryptococcal meningitis (CM) is the leading fungal cause of human immunodeficiency virus-related deaths globally, with the majority occurring in Africa. The human immune response to C albicans infection has been studied extensively in large genomics studies whereas cryptococcal infections, despite their severity, are comparatively understudied. Here we investigated the transcriptional response of immune cells after in vitro stimulation with in vitro C neoformans, C gattii, and C albicans infection of peripheral blood mononuclear cells collected from healthy South African volunteers. We found a lower transcriptional response to cryptococcal stimuli compared to C albicans and unique expression signatures from all 3 fungal stimuli. This work provides a starting point for further studies comparing the transcriptional signature of CM in immunocompromised patients, with the goal of identifying biomarkers of disease severity and possible novel treatment targets.

Comparison of mNGS with conventional methods for diagnosis of cryptococcal meningitis: a retrospective study

The application of metagenomic next-generation sequencing (mNGS) in the diagnosis of cryptococcal meningitis is relatively under characterized. Here, we retrospectively evaluated data from cryptococcal meningitis patients who were tested using mNGS and/or routine testing, including fungal culture, India ink staining, and cryptococcal antigen (CrAg) testing. The performance of mNGS was then assessed. Initial cerebrospinal fluid (CSF) samples were collected from 65 patients with suspected central nervous system (CNS) infection and tested using conventional tests and/or mNGS. mNGS offers a culture-independent approach, facilitating a rapid and unbiased detection of a broad spectrum of pathogens. Patients with bacterial tuberculous or viral meningitis were used as mNGS-positive controls and one autoimmune encephalitis patient was used as an mNGS-negative control. In the 45 patients diagnosed with cryptococcal meningitis, the sensitivity, specificity, positive predictive value, negative predictive value, and concordance rate of mNGS were 92%, 100%, 100%, 90.9%, and 95.6%, respectively. Compared to conventional methods, the sensitivity of mNGS was slightly lower than CrAg tests (96.7%) but higher than India ink (79.5%) and culturing (63.4%). Of the two negative mNGS cases (2/25, 8.0%), one was positive by India ink staining, culture, and CrAg testing, while the other was positive only by CrAg testing. A combination of mNGS and conventional methods enhanced the detection rate to 100%. Our study demonstrates that both CrAg and mNGS offer excellent diagnostic accuracy for cryptococcal meningitis, and utilizing both tests can enhance clinical assessment and patient management.

Impact of an institutional antifungal stewardship program on antifungal usage and outcomes in patients with invasive fungal infections

Therapeutic and prophylactic use of antifungals is rising continuously. However, inadequate awareness of diagnostic and treatment guidelines and limited laboratory modalities lead to inappropriate use. This study assessed the impact of an institutional antifungal stewardship program on antifungal use practices and patient outcomes. In the pre-intervention phase, data was collected regarding antifungal therapy among patients with invasive fungal infections. Appropriateness of antifungal prescription was assessed. In the intervention phase, simple algorithms for diagnosis and management of fungal infections were prepared from international guidelines and incorporated into a booklet for distribution. Monthly training sessions were conducted. New serological and molecular tests and therapeutic drug monitoring were introduced. In the post-intervention phase, an antifungal stewardship team was constituted for clinical advisory on demand and ongoing training. Data regarding antifungal therapy was collected and compared with pre-intervention data. Untreated patients decreased from 25% to 18.9% post-intervention (P = .28). Appropriate antifungal use increased from 72.6% to 77.9% (P = .4) among patients with a single fungal infection, and from 57.1% to 88.5% (P = .04) for at least one infection among those with dual fungal infections. 49 incidents of inappropriate use in various categories were seen among 75 patients receiving antifungals pre-intervention, decreasing to 42 incidents among 94 patients post-intervention (P = .06), particularly evident among patients with dual infections (P = .002). Mortality increased from 51% to 75.86% post-intervention (P = .0001). Overall, the small improvement noticed in antifungal usage pattern can still be considered significant, given the limited study period.

Lateral flow assay as radiological prognosis factor of pulmonary cryptococcosis: a single center retrospective study in China

Background

Lateral flow assay (LFA) has demonstrated high sensitivity and specificity for diagnosing cryptococcosis. However, its role in predicting therapeutic efficacy for pulmonary cryptococcosis (PC) remains underexplored.

Methods

We conducted a retrospective analysis of HIV-negative patients with PC to describe the clinical profile and identify potential predictors of radiological prognosis.

Results

All the 168 participants received antifungal therapy with a triazole agent. Of these, 84.5% experienced partial or complete absorption of pulmonary lesions. The results of the gamma test, chi-square trend test, and ordinal logistic regression all indicated that both baseline LFA and changes in LFA after treatment were significant predictors of imaging prognosis. The degree of radiological improvement was inversely associated with the baseline LFA positive grade(P for linear-by-linear association: 0.011, Spearman correlation coefficient = -0.17; γ= -0.368, P = 0.045). Patients with a decrease in LFA after therapy had significantly better radiological outcomes compared to those with equal or increased LFA(linear-by-linear association, P = 0.014, Spearman correlation coefficient = 0.188; γ = 0.371, P = 0.012). Additionally, favorable outcomes were more likely in patients with lesions confined to the right lung.

Conclusions

LFA shows potential of monitoring radiological outcomes in pulmonary cryptococcosis.

Reframing the clinical phenotype and management of cryptococcal meningitis

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.

Star-Shaped Glatiramer Acetate Mitigates Pulmonary Dysfunction and Brain Neurodegeneration in a Murine Model of Cryptococcus-Associated IRIS

Cryptococcal-associated immune reconstitution inflammatory syndrome (C-IRIS) is a clinical worsening or new presentation of cryptococcal disease following the initiation of antiretroviral therapy. C-IRIS is primarily driven by an influx of pathological CD4 + T cells, which triggers a hyperinflammatory response. The murine model of C-IRIS is a way to study the disease in mice and understand how the immune system triggers life-threatening outcomes in patients. We previously developed a murine C-IRIS model and demonstrated that C-IRIS is triggered by pathological CD4 + T cells, particularly Th1 cells, in the brain, which triggers neurodegeneration and pulmonary dysfunction. Using this unique mouse model, we tested the therapeutic effect of a star-shaped glatiramer acetate (sGA), which is a more effective isomeric form than linear GA. Here, we observed that sGA suppresses Th1 differentiation in the lung tissues, reducing CD4 + T cell and Th1 cell count. It also reduced microglia populations in the brain. Together, these changes improved respiratory dysfunction caused by C-IRIS, lowered mortality rate, and reduced brain neurodegeneration. These findings suggest that sGA could be an effective therapeutic strategy for managing C-IRIS.

Audit for antifungal treatment usage in adults with invasive fungal infection: A prospective observational study

OBJECTIVE

The antifungal audit aimed to evaluate antifungal usage in a tertiary care center. It focused on patient profiles, the appropriateness of antifungal use, associated adverse drug reactions, reasons for suboptimal usage, and the economic burden caused by prolonged non-optimal antifungal use.

METHODOLOGY

Conducted at All India Institute of Medical Sciences, New Delhi, India from January 2019 to December 2020, the study evaluated systemic antifungal use in 100 hospitalized adults with invasive fungal infections. Data collected included patient characteristics, evidence of disease, antifungal agents used, drug ADRs, appropriateness, and economic impact. Antifungal use was assessed using a predefined score (score <10 considered non-optimal), and ideal therapy duration was calculated based on treatment guidelines (IDSA & ECIL).

RESULTS

Optimal antifungal use was observed in 66.0 % of cases. Common reasons for non-optimal use included alternate drug selection (18 %), inappropriate dosage (12 %), lack of adjustment after microbiological results (14 %), and incorrect therapy duration (16 %). Targeted antifungal therapy was observed in 39 out of 100 patients, while pre-emptive antifungal therapy was used in 32 out of 100 patients. Voriconazole (35.1 %), caspofungin (23.1 %), and liposomal amphotericin B (20.1 %) were commonly prescribed. Liposomal amphotericin B had the highest adverse reaction rate (81.4 %). The total cost of antifungal therapy for 100 patients was ₹67,06,840 (approximately 80,350 $), with non-optimal prolonged therapy leading to an additional economic burden of ₹1,149,191 (approximately 13,841 $). Overall, 748 (39.7 %) day of therapy were non-optimal, contributing to 17.1 % of the total cost of antifungal therapy.

CONCLUSION

We observed non-optimal use of antifungal agents in 34 % of the study participants. The study results show that the antifungal audit enhances stewardship by pinpointing causes of non-optimal use, ensuring adherence to prescribing standards, optimizing clinical outcomes, and minimizing drug-related toxicities in tertiary care centres.

Efficacy of two novel antifungal lipopeptides, AF4 and AF5 of bacillomycin D family in murine models of invasive candidiasis, cryptococcosis, and aspergillosis

Invasive fungal diseases are an important public health concern due to an increase in the at-risk population and high mortality associated with these infections. Managing invasive fungal infections poses a significant challenge given the limited antifungal options and the emergence of resistance in key fungal pathogens. Through a comprehensive approach, we evaluated the in vitro antifungal activity and the in vivo efficacy of two novel lipopeptides, AF4 and AF5 in murine models of disseminated candidiasis, cryptococcosis, and aspergillosis. Flow cytometry analysis with propidium iodide showed a dose-dependent increase in the permeability and disruption of fungal cell membranes, underscoring the membrane perturbing effects of AF4 and AF5. These observations were further substantiated by SEM analyses that showed yeast cell and hyphal deformation and leakage of cellular contents. Our in vivo investigations utilizing two doses (5 and 10 mg/kg bodyweight) of each lipopeptide and its comparison with standard antifungal therapies showed lipopeptides significantly improved the odds of mice survival in invasive candidiasis and cryptococcosis models, with a reduction in organ fungal burden by 2 to 3-log10 order. Additionally, in the disseminated aspergillosis model, treatment with 10 mg/kg of AF4 significantly improved median survival from 4 to 10 days while achieving a notable 1-log10 order reduction in organ fungal burden. Overall, our study underscores the potent and broad-spectrum antifungal activity of lipopeptides in mouse infection models, hinting at their promising therapeutic potential in invasive fungal disease.

Pulmonary cryptococcosis associated with Cryptococcus neoformans in an immunocompetent child

We report a pediatric case of pulmonary cryptococcosis caused by Cryptococcus neoformans in an immunocompetent child. Although the patient presented with mild clinical symptoms, pulmonary imaging revealed severe abnormalities. The diagnosis was confirmed through fungal culture of bronchoalveolar lavage fluid and detection of serum cryptococcal antigen. An appropriate and adequately administered course of antifungal treatment led to a favorable prognosis.

Disseminated Cryptococcal Gattii infection in a patient with anti-granulocyte-macrophage colony-stimulating-factor autoantibody: a case report

BACKGROUND

Cryptococcosis is an opportunistic fungal infection in immunocompromised patients. The major species include Cryptococcus grubii, Cryptococcus neoformans, and rarely, Cryptococcus gattii. Here we present a disseminated Cryptococcus gattii infection in a patient with elevated granulocyte-macrophage colony-stimulating-factor autoantibody which was successfully treated with antifungal therapy.

CASE PRESENTATION

A 61-year-old healthy man presented with a 3-week history of blurred vision, low-grade fever, headache, and a one-year history of low back pain following a fall on his farm. Physical examination revealed lower back tenderness and diplopia. He was tested negative for hepatitis B, C, and human immunodeficiency virus. Chest X-ray revealed a focal opacity in the right retrocardiac paraspinal region and pleural effusion. Magnetic resonance imaging showed a mass located at the L1 prevertebral region and multiple rim-enhancing lesions in bilateral cerebral hemispheres. Thoracoscopy demonstrated cystic lesions at the right costopleural angle. Pathology and microbiology studies confirmed the diagnosis of disseminated Cryptococcus gatti infection. Autoantibodies to granulocyte-macrophage colony-stimulating factor were detected and were considered to cause disseminated cryptococcosis. The patient was started on amphotericin B followed by fluconazole treatment. One month later, the symptoms ameliorated and repeated image studies after 1 year of follow-up showed the resolution of lesions.

CONCLUSION

This report describes the first case of disseminated Cryptococcus gattii infection involving the musculoskeletal system, respiratory system, and central nervous system with granulocyte-macrophage colony-stimulating-factor autoantibody by evidence of histology and microbiology.

Multiple Central Nervous System Cryptococcomas Masquerading as Lymphoma

Cryptococcal meningitis is a leading cause of morbidity and mortality in patients infected with human immunodeficiency virus. In over 90% of cases, it occurs at CD4 T lymphocyte (CD4) cell counts of less than 100 cells/mm3. Cryptococcomas are rare granulomatous lesions that can occur in disseminated central nervous system cryptococcal infection, primarily in immunocompetent hosts. Here we report a case of disseminated cryptococcal meningitis with numerous cryptococcomas mimicking metastases in a patient with HIV and a CD4 count of 115. The patient's serum and cerebrospinal fluid (CSF) cryptococcal antigen, CSF cryptococcal polymerase chain reaction, and serum and CSF cryptococcal cultures were all negative. Brain biopsy pathology confirmed the diagnosis. In this paper, we highlight the importance of early cerebral biopsy in the diagnosis and management of cryptococcoma.

A framework for exclusion of alternative diagnoses in sarcoidosis

Sarcoidosis is a multisystem granulomatous syndrome that arises from a persistent immune response to a triggering antigen(s). There is no "gold standard" test or algorithm for the diagnosis of sarcoidosis, making the diagnosis one of exclusion. The presentation of the disease varies substantially between individuals, in both the number of organs involved, and the manifestations seen in individual organs. These qualities dictate that health care providers diagnosing sarcoidosis must consider a wide range of possible alternative diagnoses, from across a range of presentations and medical specialties (infectious, inflammatory, cardiac, neurologic). Current guideline-based diagnosis of sarcoidosis recommends fulfillment of three criteria: 1) compatible clinical presentation and/or imaging 2) demonstration of granulomatous inflammation by biopsy (when possible) and, 3) exclusion of alternative causes, but do not provide guidance on standardized strategies for exclusion of alternative diagnoses. In this review, we provide a summary of the most common differential diagnoses for sarcoidosis involvement of lung, eye, skin, central nervous system, heart, liver, and kidney. We then propose a framework for testing to exclude alternative diagnoses based on pretest probability of sarcoidosis, defined as high (typical findings with sarcoidosis involvement confirmed in another organ), moderate (typical findings in a single organ), or low (atypical/findings suggesting of an alternative diagnosis). This work highlights the need for informed and careful exclusion of alternative diagnoses in sarcoidosis.

Cryptococcoma in an immunocompetent patient: Unveiling the mystery of a rare rim-enhancing brain lesion

A 59-year-old immunocompetent male who initially presented with symptoms of stroke was found to have an incidental rim-enhancing lesion on magnetic resonance imaging (MRI) of the brain. This discovery led to a lumbar puncture to analyze the cerebrospinal fluid, resulting in the diagnosis of cryptococcoma. The patient was subsequently managed with liposomal amphotericin B, followed by consolidation and maintenance therapy with fluconazole. The patient achieved a positive outcome, demonstrating the effectiveness of early diagnosis and targeted treatment. The rarity of cryptococcoma in immunocompetent individuals makes this case particularly unusual and noteworthy. It underscores the need for more extensive research to enable prompt diagnosis and effective management.

Amphotericin B for injection triggers degranulation of human LAD2 mast cells by MRGPRX2 and pseudo-allergic reactions in mice via MRGPRB2 activation

Amphotericin B, a polyene macrolide antifungal agent, still plays an important role in the management of serious systemic fungal infections. Amphotericin B deoxycholate (AmBd) has been used to treat invasive fungal infections for over 60 years and remains the primary clinical formulation currently available. Anaphylactoid reactions triggered by AmBd in the clinic have been documented. However, the molecular and cellular events contributing to these reactions have not been clearly elucidated to date. This study demonstrates that the human Mas-related G protein-coupled receptor X2 (MRGPRX2) is the receptor that mediates these anaphylactoid responses. Molecular docking and cellular thermal shift assay (CETSA) indicate that AmBd exhibits potential affinity with MRGPRX2. In vitro, exposure to AmBd results in significant release of LAD2 mast cell granules and induces intracellular Ca2+ mobilization as well as activation of PLC-γ/IP3R and PI3K/AKT signaling pathways. However, these phenomena are reduced in MRGPRX2-knockdown LAD2 cells. In vivo, AmBd triggers paw swelling and a rapid drop in core body temperature in wild-type (WT) mice. However, these reactions are almost absent in MRGPRB2 (the mouse homolog of MRGPRX2) knockout mice (MRGPRB2MUT, MUT). The above results suggest that AmBd activates PLC-γ/IP3R and PI3K/AKT signaling via MRGPRX2 (in human LAD2 mast cells) or MRGPRB2 (in mice), leading to the release of mast cell granules and subsequent triggering of pseudo-allergic reactions. Taken together, this study clarifies the role of MRGPRX2 in triggering pseudo-allergic reactions to AmBd and suggests that MRGPRX2 could be a potential therapeutic target for controlling these reactions.

Idiopathic eosinophilia complicated with cryptococcal meningitis: a case report

Idiopathic eosinophilia, characterized by unexplained peripheral blood eosinophilia after ruling out secondary causes, is an extremely rare condition. Cryptococcal meningitis is a life-threatening opportunistic infection that primarily affects immunocompromised individuals, such as those with advanced AIDS or leukemia. In this report, we present a unique case of idiopathic eosinophilia concurrent with cryptococcal meningitis, which, to the best of our knowledge, is the first such case described globally.

Case report: A diabetic patient with cryptococcal meningoencephalitis complicated by post-infectious inflammatory response syndrome

We report on a previously non-HIV-diagnosed, 47-year-old male diagnosed with diabetes mellitus (DM) and cryptococcal meningoencephalitis, who was referred to our institution for antifungal treatment. During the course of treatment, due to the development of refractory intracranial hypertension, Ommaya reservoirs were employed for cranial pressure reduction. The patient gradually recovered during subsequent antifungal therapy; however, symptoms worsened in the third month of treatment, leading to consideration of post-infectious inflammatory response syndrome (PIIRS) on examination. Once diagnosed, the symptoms improved significantly after approximately 130 days of treatment with additional corticosteroids.

Clinical imaging diagnosis of pulmonary cryptococcosis with different therapeutic responses

We aimed to differentiate and evaluate the clinical imaging features of pulmonary cryptococcosis with different therapeutic responses. The clinical imaging data of 70 patients with PC (complete response PC 37 cases and incomplete response PC 33 cases) were collected and compared to determine the independent risk factors for different therapeutic responses, and their diagnostic performances were verified by receiver operating characteristic curve analysis. Compared with complete response PC, incomplete response PC was more common with immunosuppression (10.8% vs. 45.5%, P = 0.001), intermediate progress (8.1% vs. 39.4%, P = 0.002), bilateral distribution (21.6% vs. 78.8%, P < 0.001), consolidation-interstitial pattern (10.8% vs. 42.4%, P = 0.003), pleural effusion (0 vs. 27.3%, P = 0.002) and mediastinal lymphadenopathy (0 vs. 24.2%, P = 0.005). Multivariate logistic regression showed that immunosuppression, intermediate progress, and bilateral distribution were independent risk factors, with low to moderate areas under curves (AUC, 0.656-0.786). Their combined performance was good with an AUC of 0.888. The diverse clinical imaging features can reflect the therapeutic response of PC. Immunosuppression, intermediate progress, and bilateral distribution were independent risk factors. Their combination can significantly improve diagnostic effects.

A rare case of cryptococcal meningitis with infarction of the splenium of the corpus callosum in an immunocompetent patient: A case report

Meningitis is a severe infection of the central nervous system. Cryptococcus neoformans is an uncommon fungal agent that can cause meningitis and often manifests unusual symptoms. While this infection is more prevalent in immunocompromised patients, it can also affect immunocompetent patients. A 33-year-old housewife living in the village visited our hospital emergency department complaining of a severe headache and mild fever for 7 days. We diagnosed an unusual occurrence of cryptococcal meningitis with infarction of the splenium of the corpus callosum in a patient who appeared to have a healthy immune system. This disease should be considered in immunocompetent individuals with persistent headache or other neurological findings, even in the absence of overt risk factors.

Sclareolide as Antifungal Strategy Against Cryptococcus neoformans: Unveiling Its Mechanisms of Action

Cryptococcal infection commonly begins as an opportunistic infection in humans, however, this can escalate to a systemic or life-threatening form in immunocompromised individuals. Here, we aim to identify novel antifungal molecules from plants resources. Sclareolide, a phytochemical classified as a sesquiterpene lactone, was assessed against Cryptococcus neoformans H99. Sclareolide exhibited promising antifungal properties with a minimum inhibitory concentration (MIC) of 16 µg/mL. Additionally, the C. neoformans growth rate was significantly affected by sclareolide treatment in a concentration-dependent manner, as observed through a time killing assay, with a significant reduction at MIC × 8 compared to the control by 48 h. To elucidate the underlying mechanisms of sclareolide antifungal activity, fluorescence-based methods were employed. Propidium iodide (PI) accumulation assay indicated a reduction in C. neoformans membrane integrity, with values as low as 6.62 ± 0.18% after treatment. Moreover, sclareolide at MIC × 4 and MIC × 8 significantly increased the production of reactive oxygen species (ROS) and reduced the mitochondrial membrane potential (MMP), suggesting oxidative stress and mitochondrial dysfunction in C. neoformans. Sclareolide did not induce caspase-dependent apoptosis, suggesting a non-apoptotic mechanism. Further, a checkerboard experiment was performed to assess potential synergistic interaction with Amphotericin B, however, no synergism was observed. Moving on, sclareolide at 128 µg/mL did not exhibit toxicity in Galleria mellonella, further supporting its potential as a safe antifungal agent. These findings suggest that the antifungal activity of sclareolide against C. neoformans is mediated by oxidative stress. Further in vivo and pharmacokinetic studies are recommended to explore the potential of sclareolide as a prototype for the development of novel anti-cryptococcal therapies.

Cryptococcus neoformans infections: aspartyl protease potential to improve outcome in susceptible hosts

Though a confined or a broad population is exposed respectively to endemic or pandemic infections, in the same environment, some individuals resist the development of infections. The attributed reason is the inheritance of a set of immune system genes that can efficiently deal with the pathogens. In this study, we show how outbred mice differentially respond to Cryptococcus neoformans, a fungal pathogen, and the mechanism through which the surviving mice mount a protective immune defense. We identified that those mice developing antibodies specifically against Pep1p, an aspartic protease secreted by C. neoformans, had significantly improved survival. Vaccination (either prophylactic or therapeutic) with a recombinant Pep1p significantly increased the survival of the mice by decreasing the fungal load and stimulating a protective immune response. Passive immunization of C. neoformans-infected mice with monoclonal antibodies developed against Pep1p also improves the survival of the mice by increasing phagocytosis of C. neoformans and decreasing the multiplication of this fungus. Together, these data demonstrate the prophylactic and therapeutic potentials of the C. neoformans antigenic protein Pep1p or Pep1p-specific antibodies against this fungal infection. Also, this study suggests that the immunological interaction and thereby the responses developed against a pathogen guide the hosts to behave differentially against microbial pathogenicity.

IMPORTANCE

Vaccination and immunotherapies against fungal pathogens still remain a challenge. Here, we show using an in vivo model based on outbred mice that development of antibodies against Pep1p, an antigenic protein of the fungal pathogen Cryptococcus neoformans, confers resistance to this fungal infection. In support of this observation, prophylactic or therapeutic immunization of the mice with recombinant Pep1p could improve their survival when infected with a lethal dose of C. neoformans. Moreover, passive therapy with monoclonal anti-Pep1p antibodies also enhanced survival of the mice from C. neoformans infection. The associated antifungal mechanisms were mounting of a protective immune response and the development of fungal specific antibodies that decrease the fungal burden due to an increase in their phagocytosis and/or inhibit the fungal multiplication. Together, our study demonstrates (a) the mode of host-fungal interaction and the immune response developed thereby play a crucial role in developing resistance against C. neoformans; (b) Pep1p, an aspartic protease as well as an antigenic protein secreted by C. neoformans, can be exploited for vaccination (both prophylactic and therapeutic) or immunotherapy to improve the host defense during this fungal infection.

Dose Optimization of Fluconazole After Initial Treatment Failure in Pulmonary Cryptococcosis in an Obese Patient with Type 2 Diabetes and Cirrhosis: A Case Report

Background

Pulmonary cryptococcosis is a fungal infection of the lungs, particularly challenging to treat in patients with multiple comorbidities such as obesity, type 2 diabetes, and cirrhosis. Fluconazole is a first-line medication for the treatment of pulmonary cryptococcosis, but currently there is a lack of clinical medication experience in obese patients with multiple comorbidities, especially in dose adjustment after treatment failure.

Case Introduction

This case report describes the experience of fluconazole in the treatment of pulmonary cryptococcal infection in a 45-year-old Chinese male with obesity, type 2 diabetes, and cirrhosis. The patient had a history of antifungal therapy for two weeks before admission, but the cough and hemoptysis were not improved. The treatment failed. After admission, it was recommended to use a conventional dose of fluconazole as an antifungal regimen according to the guidelines. However, the treatment effect was still unsatisfactory, due to the patients' cough, hemoptysis, and fever symptoms were not relieved. During this period, it was newly found that the patient had cirrhosis and type 2 diabetes and had not previously controlled blood glucose. Considering the above situation, combined with the pharmacokinetic characteristics of fluconazole and the patient's weight reaching 113 kg, the team readjusted the fluconazole medication regimen, and ultimately, the pulmonary infection improved without significant adverse reactions.

Results

We found that it was more suitable for patients with obesity to calculate the dose of fluconazole by the lean weight. By estimation, the patient was finally given a loading dose of 800 mg fluconazole, and his condition improved significantly. After two weeks of medication, it was adjusted to a maintenance dose of 600 mg until the pulmonary infection in the patient disappeared.

Conclusion

This case suggests that fluconazole antifungal therapy for pulmonary cryptococcal infection should fully consider the risk of comorbidities in patients. If necessary, medication dosage can be adjusted according to weight, and it is recommended to use lean bodyweight for evaluation and optimization. In addition, close attention should be paid to liver and kidney function.

Inhibition of RhoA Prevents Cryptococcus neoformans Capsule Glucuronoxylomannan-Stimulated Brain Endothelial Barrier Disruption

Cryptococcus neoformans (Cn) is an opportunistic fungus that causes severe central nervous system (CNS) disease in immunocompromised individuals. Brain parenchyma invasion requires fungal traversal of the blood-brain barrier. In this study, we describe that Cn alters the brain endothelium by activating small GTPase RhoA, causing reorganization of the actin cytoskeleton and tight junction modulation to regulate endothelial barrier permeability. We confirm that the main fungal capsule polysaccharide glucuronoxylomannan is responsible for these alterations. We reveal a therapeutic benefit of RhoA inhibition by CCG-1423 in vivo. RhoA inhibition prolonged survival and reduced fungal burden in a murine model of disseminated cryptococcosis, supporting the therapeutic potential of targeting RhoA in the context of cryptococcal infection. We examine the complex virulence of Cn in establishing CNS disease, describing cellular components of the brain endothelium that may serve as molecular targets for future antifungal therapies to alleviate the burden of life-threatening cryptococcal CNS infection.

Cryptococcal invasion: a comprehensive case of adrenal and systemic infection amid immunosuppression

We report a case of disseminated cryptococcosis, an uncommon fungal infection predominantly affecting the lungs and central nervous system, with the rare involvement of adrenal cryptococcosis, compounded by meningitis and pneumonia. The patient, previously diagnosed with primary myelofibrosis and undergoing oral Ruxolitinib treatment, exhibited immunosuppression. Imaging via chest and abdominal CT scans revealed inflammation in the right lung's middle lobe, splenomegaly, a splenic lesion, and a left adrenal mass, initially prompting considerations of pheochromocytoma. However, unilateral adrenalectomy and subsequent pathological examination disclosed extensive infiltration by inflammatory and multinucleate giant cells, with Periodic acid-Schiff (PAS) staining confirming the diagnosis. The identification of adrenal cryptococcosis was further supported by positive adrenal pus culture and significantly elevated capsular antigens in both serum and cerebrospinal fluid, at titers of 1:2560. Following a month of oral antifungal treatment, marked reductions in capsular antigen levels were noted, to 1:640 and 1:160 in serum and cerebrospinal fluid, respectively. The patient was discharged on a regimen of oral amphotericin B, flucytosine, and fluconazole, with regular outpatient follow-ups showing no signs of recurrence or dissemination.

Disseminated cryptococcosis in a child with liver transplantation: a case report

BACKGROUND

Cryptococcus neoformans causes cryptococcosis, primarily affecting immunocompromised individuals, including solid-organ transplant recipients, and, less frequently, immunocompetent people.

CASE

A 15-year-old male with congenital hepatic fibrosis, portal hypertension, and cirrhosis underwent orthotopic liver transplantation. He received perioperative antimicrobial and antifungal prophylaxis and continued immunosuppressive treatment. Thirty months post-transplant, he presented with fever, hypertension, and sacroiliac joint pain. Peripheral blood cultures showed C. neoformans, confirmed by pan-fungal polymerase chain reaction assay and latex agglutination tests. Despite initial treatment with intravenous (IV) fluconazole, his condition worsened, necessitating intubation for acute hypoxic respiratory failure. Magnetic resonance imaging and computed tomography scans indicated disseminated cryptococcosis with lymphadenitis, possible meningitis, and pneumonia. Treatment was escalated to IV liposomal amphotericin B and 5-flucytosine, while reducing immunosuppressive treatment. Despite negative fungal cultures on the tenth day, the patient deteriorated, developing pancreatitis, pneumonia, and massive gastrointestinal bleeding, leading to death on the 35th day of hospitalization.

CONCLUSION

This case shows the severity and complexity of managing disseminated cryptococcosis in pediatric liver transplant recipients. Aggressive therapy and early identification are essential for improving outcomes in these high-risk patients.

Late Relapse of Previous Pulmonary Cryptococcosis With Symptoms Resembling Cerebral Infarction: A Case Report

Cryptococcosis, an infection caused by Cryptococcus neoformans and Cryptococcus gattii, predominantly targets the central nervous system (CNS) in patients with AIDS but is not limited to this group. The disease can also occur in individuals with various immunosuppressive conditions, frequently involving the brain or lungs. Cryptococcal meningitis (CM) is the most common form of fungal meningoencephalitis, leading to intracerebral infections, cerebral infarction, or hydrocephalus. The clinical presentation of CM is nonspecific, and imaging features can vary significantly. This case report presents a patient with cerebral infarction, who was HIV-negative but had been on long-term cortisone therapy. Notably, the patient had a history of pulmonary cryptococcosis 15 years prior to cerebral involvement. When initially at our clinic, histology and culture results from brain biopsies were negative and the earlier pulmonary cryptococcosis history was unknown. Subsequently, cryptococcal antigen was detected in both serum and cerebrospinal fluid (CSF), and C. neoformans was cultivated from CSF. This case highlights the critical importance of maintaining a high index of suspicion for CM, particularly in patients with a history of previous cryptococcal infections, and it also demonstrates the possibility of false-negative brain biopsy results due to secondary vascular events associated with CM.

Cryptococcus neoformans Periprosthetic Joint Infection in the Setting of Revision Shoulder Arthroplasty: A Case Report

An 83-year-old male, status one year post-primary right reverse shoulder arthroplasty, presented with clinical and radiographic signs of shoulder instability. The patient subsequently underwent revision reverse shoulder arthroplasty with postoperative cultures growing Cryptococcus neoformans in all five tissue samples. He was placed on temporary fluconazole since he demanded to leave the hospital during a holiday weekend with plans to get readmitted later. IV amphotericin B was used as induction treatment for two weeks followed by PO voriconazole, which was taken by the patient until eight months postoperatively. He was followed up in the orthopedic clinic status post revision procedure at one and two months and was found to be progressing well. The patient presented to the emergency department eight months after the revision procedure for an unrelated concern that was inconsequential. There were no signs of infection as vital signs and laboratory markers were normal. At 18 months postoperatively, he presented to an outside facility with a left distal femur periprosthetic fracture around a total knee implant, for which open reduction and internal fixation (ORIF) was performed. During this hospital stay, an orthopedic team, known to the authors, evaluated the patient. The right shoulder was stable and without pain, with vitals signs and laboratory markers showing no signs of infection. The patient reported that he continued to be employed as a maintenance worker at a motel. He was discharged soon and is living with current revision shoulder arthroplasty implants.

Cerebrospinal Fluid Lactate Levels as a Prognostic Indicator in Patients With Cryptococcal Meningitis Who Are HIV Negative: A Retrospective Cohort Study

Background

Cryptococcal meningitis (CM) is a severe central nervous system infection. In patients with HIV infections and coexisting CM, elevated baseline cerebrospinal fluid (CSF) lactate levels can predict increased mortality. However, the CSF lactate level's significance in patients with CM who are HIV negative remains unclear, necessitating further investigation to elucidate the potential distinctions and enhance patient management. This study investigated the significance of CSF lactate levels in patients with CM who were HIV negative.

Methods

This retrospective study utilized data from the clinical databases of patients who underwent lumbar punctures at a medical center in Kaohsiung City, southern Taiwan. Demographic data, CSF lactate levels, routine CSF analyses, and hematologic and neurologic findings were evaluated. The optimal CSF lactate threshold value was determined by the Youden index.

Results

This retrospective study included 70 patients with CM, among whom 44 (63%) and 26 (37%) tested negative and positive for HIV, respectively. The group without HIV exhibited higher CSF lactate levels, with an optimal CSF lactate cutoff point of 7.935 mmol/L for predicting 90-day mortality, resulting in significant predictive accuracies (area under the curve, 0.755; sensitivity, 57.1%; specificity, 100%); this value was an independent mortality predictor in patients who were HIV negative. In patients with CM who were HIV negative, CSF lactate levels ≥7.935 mmol/L correlated with higher mortality rates but without statistical significance. All patients with CM who were HIV negative and had CSF lactate levels ≥7.935 mmol/L died within 3 months of admission.

Conclusions

Patients with CM who were HIV negative had elevated CSF lactate levels that correlated with adverse outcomes, enabling early identification of high-risk individuals.

Disseminated Cryptococcus infection presenting as lytic skeletal lesions suggesting bony metastatic disease

A 76-year-old male diagnosed with sarcoidosis presented with atraumatic left anterior knee pain. Initial imaging of the left lower extremity revealed an eccentrically-based lytic lesion in the mid-distal femur with cortical erosion and an additional lytic lesion in the proximal tibia. Magnetic resonance imaging (MRI) demonstrated an aggressive lesion in the proximal tibia with surrounding marrow edema, cortical breach, and erosion into the distal patellar tendon. Given concern for metastatic bone lesions, a18-fluorodeoxyglucose positron emission tomography/computed tomography scan (FDG PET/CT) was performed which demonstrated concordant hypermetabolic lytic lesions at the left mid-distal femur and the left proximal tibia, as well as hypermetabolic diffuse lymphadenopathy. The patient was presumed to have metastatic lung cancer based on the presence of lung nodules. Due to concern for impending pathologic fracture, the patient underwent open biopsy with a plan for prophylactic fixation of both lesions. Intra-operatively, however, both lesions were found to contain pus, from which cultures ultimately grew Cryptococcus neoformans. This is a case of disseminated skeletal cryptococcosis masquerading as metastatic cancer in a patient without classic risk factors for disseminated cryptococcosis (defined as extrapulmonary evidence of infection). Classically, disseminated cryptococcosis is thought to occur in severely immunocompromised patients, such as those with human immunodeficiency virus (HIV) or organ transplant recipients. This case highlights the need to maintain a high index of suspicion in patients with underlying immunocompromising conditions, including less common conditions such as sarcoid, who present with bony lesions. This case report then discusses the diagnostic evaluation and treatment of disseminated skeletal cryptococcosis.

Clinical Characteristics and Risk Factors for Cryptococcal Meningitis in Diverse Patient Populations in New York City

Background

Cryptococcal meningitis (CM) is responsible for 15%-20% of human immunodeficiency virus (HIV)-associated mortalities. CM prevalence has also increased in other immunocompromised populations of transplant recipients, patients with cancer, and individuals on immunomodulatory medication.

Methods

This retrospective review included 51 definitive patients with CM hospitalized at a tertiary academic medical center in New York City between 2010 and 2023. We assessed clinical features and outcomes of CM, with additional analysis of factors related to antiretroviral therapy (ART) adherence in HIV-infected cases and immunomodulatory medication history of HIV-negative cases.

Results

The cohort had a mean (standard deviation) age of 47.1 ± 15.1 years, and was predominantly male (37, 72.5%). Of 32 patients with HIV, 3 (9.4%) were newly diagnosed with HIV at the time of CM hospitalization, 5 (15.6%) had recurrent CM, and 2 (6.3%) had a CM relapse. The majority (30, 93.8%) of patients with HIV were ART nonadherent. Of 19 HIV-negative patients, 8 (42.1%) were solid-organ transplant recipients, 5 (26.3%) had autoimmune conditions of sarcoidosis or systemic lupus erythematosus, and 3 (15.8%) had chronic lymphocytic leukemia. Six (11.8%) patients died during hospitalization, 4 of whom had HIV.

Conclusions

The burden of CM in people with HIV and immunocompromised patients continues even in settings with accessible standard antifungal treatment though interventions of increased ART adherence for those with HIV and antifungal prophylaxis may improve morbidity and mortality.

A case of immunocompetent intracranial cryptococcoma in which intraoperative rapid pathological diagnosis and polymerase chain reaction led to early treatment: What to know to avoid misdiagnosis as brain tumor

Background

Cryptococcal infections of the central nervous system are infrequent in immunocompetent hosts and usually present as meningitis. However, a fungal mass called a cryptococcoma may form, requiring caution in therapeutic intervention. Here, we report a rare case in which treatment of intraventricular cryptococcoma in an immunocompetent patient was facilitated by rapid pathological diagnosis.

Case Description

A 58-year-old previously healthy man was admitted to our hospital with fever, headache, and gradually worsening hearing loss over 1 month. Cerebrospinal fluid analysis showed moderately elevated levels of protein and lymphocytic cells and decreased glucose. In addition, β2-microglobulin was highly elevated. Magnetic resonance imaging showed homogeneously enhanced lesions in lateral ventricles of the left and right hemispheres and the subarachnoid space, and 18F-fluorodeoxyglucose positron emission tomography revealed abnormal uptake corresponding to the lesion. A surgical excision was performed to achieve a definitive diagnosis. Intraoperative rapid pathology, including immunohistochemistry (IHC), yielded negative results for malignant tumor, suggesting the possibility of inflammatory granuloma. Additional targeted pathological diagnosis was immediately performed. Paraffin-embedded histopathological examination showed fibrocaseous granuloma and numerous fungal spores. Cryptococcus neoformans within the granuloma were suggested by Fontana-Masson and Grocott staining and confirmed by polymerase chain reaction (PCR), leading to a diagnosis of cryptococcoma. Antifungal agents were started 3 days postoperatively. The patient has since been doing well, with no recurrence.

Conclusion

This pathology can be difficult to distinguish from a brain tumor, so early pathological diagnosis, including rapid pathology with IHC and PCR, may be crucial.

Genetic mutations in Cryptococcus neoformans pyrimidine salvage pathway enzymes contribute to reduced susceptibility against 5-fluorocytosine

Cryptococcal meningitis is a high-mortality infection. Adding 5-fluorocytosine (5-FC) to its treatment improves outcomes, but resistance to 5-FC presents a significant challenge. We conducted whole-genome sequencing on seven C. neoformans isolates with varying 5-FC susceptibility, along with proteomic and in silico analyses. Our findings indicate that mutations in genes of the pyrimidine salvage pathway are responsible for 5-FC resistance. Specifically, we identified an E64G missense mutation in the FUR1 gene, a large deletion in the FCY1 gene, and a point mutation in FCY1 leading to a truncated protein. The proteomic data indicated that these mutations resulted in the absence or reduction of crucial enzymes in resistant isolates. Genetic transformations confirmed the association between these mutations and 5-FC resistance. Resistance to 5-FC can develop during treatment and is closely tied to mutations in key metabolic enzymes. Understanding in vivo resistance development is crucial for combating resistance and enhancing patient outcomes.

Pan-omics-based characterization and prediction of highly multidrug-adapted strains from an outbreak fungal species complex

Strains from the Cryptococcus gattii species complex (CGSC) have caused the Pacific Northwest cryptococcosis outbreak, the largest cluster of life-threatening fungal infections in otherwise healthy human hosts known to date. In this study, we utilized a pan-phenome-based method to assess the fitness outcomes of CGSC strains under 31 stress conditions, providing a comprehensive overview of 2,821 phenotype-strain associations within this pathogenic clade. Phenotypic clustering analysis revealed a strong correlation between distinct types of stress phenotypes in a subset of CGSC strains, suggesting that shared determinants coordinate their adaptations to various stresses. Notably, a specific group of strains, including the outbreak isolates, exhibited a remarkable ability to adapt to all three of the most commonly used antifungal drugs for treating cryptococcosis (amphotericin B, 5-fluorocytosine, and fluconazole). By integrating pan-genomic and pan-transcriptomic analyses, we identified previously unrecognized genes that play crucial roles in conferring multidrug resistance in an outbreak strain with high multidrug adaptation. From these genes, we identified biomarkers that enable the accurate prediction of highly multidrug-adapted CGSC strains, achieving maximum accuracy and area under the curve (AUC) of 0.79 and 0.86, respectively, using machine learning algorithms. Overall, we developed a pan-omic approach to identify cryptococcal multidrug resistance determinants and predict highly multidrug-adapted CGSC strains that may pose significant clinical concern.

Deciphering prognostic indicators in non-HIV cryptococcal meningitis: Constructing and validating a predictive Nomogram model

Cryptococcal meningitis (CM) is a well-recognized fungal infection, with substantial mortality in individuals infected with the human immunodeficiency virus (HIV). However, the incidence, risk factors, and outcomes in non-HIV adults remain poorly understood. This study aims to investigate the characteristics and prognostic indicators of CM in non-HIV adult patients, integrating a novel predictive model to guide clinical decision-making. A retrospective cohort of 64 non-HIV adult CM patients, including 51 patients from previous studies and 13 from the First Hospital of Shanxi Medical University, was analyzed. We assessed demographic features, underlying diseases, intracranial pressure, cerebrospinal fluid characteristics, and brain imaging. Using the least absolute shrinkage and selection operator (LASSO) method, and multivariate logistic regression, we identified significant variables and constructed a Nomogram prediction model. The model's calibration, discrimination, and clinical value were evaluated using the Bootstrap method, calibration curve, C index, goodness-of-fit test, receiver operating characteristic (ROC) analysis, and decision curve analysis. Age, brain imaging showing parenchymal involvement, meningeal and ventricular involvement, and previous use of immunosuppressive agents were identified as significant variables. The Nomogram prediction model displayed satisfactory performance with an akaike information criterion (AIC) value of 72.326, C index of 0.723 (0.592-0.854), and area under the curve (AUC) of 0.723, goodness-of-fit test P = 0.995. This study summarizes the clinical and imaging features of adult non-HIV CM and introduces a tailored Nomogram prediction model to aid in patient management. The identification of predictive factors and the development of the nomogram enhance our understanding and capacity to treat this patient population. The insights derived have potential clinical implications, contributing to personalized care and improved patient outcomes.