Cryptococcal peritonitis: report of a case developing during continuous ambulatory peritoneal dialysis and review of the literature

Cryptococcal peritonitis in patients on the liver transplant waitlist: Reporting two cases with opposite outcomes

Cryptococcus neoformans is rarely associated with peritonitis in cirrhotic patients; nevertheless, it has a high mortality rate. Early diagnosis and prompt treatment may be the determining prognostic factors. This is a report of two patients awaiting a liver transplant who had opposite outcomes after the diagnosis of spontaneous cryptococcal peritonitis. In Patient 1, the fungal culture was positive in the blood and ascites. She had a poor evolution and died, which was likely caused by the delayed diagnosis and concomitant bacterial infections. In Patient 2, the fungus was found in the ascites, urine, and cerebrospinal fluid cultures. Antifungal treatment was effective. He underwent a liver transplant on the 83rd day of antifungal therapy and is still alive 1 year later. It is important to suspect fungal etiology when there is a lack of response to antibiotics in patients with decompensated cirrhosis and spontaneous peritonitis, and physicians must be aware of leukocyte count in the ascitic fluid, which is not so high in these cases. This report also emphasizes the need for the routine use of blood culture bottles for microbiological analysis of the ascitic fluid, as it was helpful to diagnose fungal peritonitis in both cases.

Cryptococcosis in HIV-negative Patients with Renal Dialysis: A Retrospective Analysis of Pooled Cases

Cryptococcosis is a lethal fungal infection mainly caused by Cryptococcus neoformans/C. gattii species. Currently, our understanding of cryptococcosis episodes in HIV-negative patients during renal dialysis remains scarce and fragmented. Here, we performed an analysis of pooled cases to systemically summarize the epidemiology and clinical characteristics of cryptococcosis among HIV-negative patients with renal dialysis. Using pooled data from our hospital and studies identified in four medical databases, 18 cases were identified and analyzed. The median duration time of renal dialysis for peritoneal renal dialysis and hemodialysis cases was 8 months and 36 months, respectively. Several non-neoformans/gattii species were identified among the renal dialysis recipients with cryptococcosis, particularly Cryptococcus laurentii and Cryptococcus albidus, which share similar clinical manifestations as those caused by C. neoformans and C. gattii. Our analyses suggest that physicians should consider the possibility of the occurrence of cryptococcosis among renal dialysis recipients even when cryptococcal antigen test result is negative. The timely removal of the catheter is crucial for peritoneal dialysis patients with cryptococcosis. In addition, there is a need for optimized antifungal treatment strategy in renal dialysis recipients with cryptococcal infections.

Successful treatment of Cryptococcus laurentii peritonitis in a patient on peritoneal dialysis

A 32-year-old man on peritoneal dialysis (PD) was hospitalized for seven days due to fever. A diagnosis of yeast-like fungal peritonitis was made by Gram staining. The patient was started on intravenous micafungin and oral fluconazole therapy following removal of the PD catheter. A fungal pathogen was isolated from the peritoneal fluid and identified as Cryptococcus species. Based on antifungal susceptibility testing, the treatment was changed to voriconazole and continued for 3 months. A genetic analysis identified the isolate as Cryptococcus laurentii (C. laurentii). This patient was diagnosed with C. laurentii PD-related peritonitis and was successfully treated with voriconazole and removal of the PD catheter.

Peritonitis caused by Blastomyces dermatitidis in a kidney transplant recipient: case report and literature review

Blastomyces dermatitidis is a dimorphic fungus endemic to the midwestern, south-central, and southeastern United States known to cause disseminated infection in immunocompromised individuals. We report a case of B. dermatitidis peritonitis in a renal allograft recipient with new-onset ascites and cytomegalovirus encephalitis. Peritoneal blastomycosis is a rare clinical entity and, to our knowledge, this patient represents the first known case of peritoneal blastomycosis in a solid organ transplant recipient. We review the clinical characteristics of B. dermatitidis peritonitis as well as the literature on fungal peritonitis with emphasis on dimorphic fungal pathogens. Clinical features suggestive of fungal peritonitis include new-onset ascites, abdominal pain, and fevers, especially with antecedent or concomitant pneumonia. A high index of clinical suspicion, along with the use of culture and non-culture diagnostics, is needed for early diagnosis and prompt initiation of therapy.

Intra-abdominal fungal infections

PURPOSE OF REVIEW

The clinical spectrum of intra-abdominal fungal infections has not been systematically analyzed in the literature.

RECENT FINDINGS

Even though intra-abdominal fungal infections have been recognized with increasing frequency in the recent years, most clinical experience is limited to case reports or uncontrolled case series. These infections are more common than clinically recognized disease. The clinical presentation varies broadly depending on the organism and host's immune status, but it is frequently severe, difficult to treat, and associated with significant morbimortality. Predisposing factors, clinical characteristics, and advances in the management are discussed.

SUMMARY

Intra-abdominal fungal infections are increasingly important in clinical practice. Early recognition and a combined treatment approach, usually consisting of surgical intervention and systemic antifungal therapy, are required for improved outcomes.

Rarity revisited: cryptococcal peritonitis

Cryptococcal peritonitis is a rare disease. Although the respiratory tract is considered to be the usual port of entry for the organism, the gastrointestinal tract can also serve as the potential site of entry. Here, we present a case of cryptococcal peritonitis that developed in an HIV-negative patient with underlying liver cirrhosis. We reviewed the literature and a total of 61 cases of cryptococcal peritonitis were identified. Liver cirrhosis, HIV/AIDS and end-stage renal disease on continuous ambulatory peritoneal dialysis were the major risk factors for developing crytococcal peritonitis.

How I treat cryptococcosis in organ transplant recipients

Cryptococcosis is a significant opportunistic mycoses in organ transplant recipients. Topical developments in the field in the past few years have highlighted important issues and at the same time raised new questions regarding the management of this yeast. These include, for example, management of pretransplant cryptococcosis during transplant candidacy and timing of transplant in these instances; potential for donor transmission of cryptococcosis in light of recent fatal transmissions; and prevention and treatment of Cryptococcus-associated immune reconstitution syndrome. Discussed herein are challenges posed by these issues and evidence-based data to optimize the management of posttransplant cryptococcosis.

Colitis as a manifestation of infliximab-associated disseminated cryptococcosis

The ability of tumor necrosis factor (TNF)-alpha inhibitors to impair pivotal pro-inflammatory host defenses may facilitate the development of disseminated cryptococcosis. Gastrointestinal (GI) tract disease is an unusual presentation of this yeast infection. We describe a unique case of disseminated cryptococcosis presenting as colitis that mimicked an exacerbation of Crohn's disease in a TNF-alpha inhibitor recipient. Review of existing literature shows that in immunocompromised patients, GI cryptococcosis invariably coexists with disseminated cryptococcosis, often lacks prominent GI symptomatology, and is primarily diagnosed postmortem. In cases with opportunistic infections, discontinuation of TNF-alpha inhibitors is a common practice, however rapid rebound of inflammatory responses may incur the risk of immune reconstitution syndrome.

Cryptococcosis of the upper genital tract

Upper genital tract infection by Cryptococcus neoformans has not previously been reported. We describe such a case, in order to alert clinicians to the existence of this rare infection. A 34-year-old woman with AIDS presented with chronic menorrhagia, fever, anemia, and thrombocytopenia. Despite blood transfusions and hormonal therapy, her vaginal bleeding could not be controlled and she became hemodynamically unstable. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed, at which time granulomatous peritonitis and prominent myometrial blood vessels were found. Histologic examination revealed cryptococcal infection of all upper genital organs. This case demonstrates that disseminated cryptococcosis may involve the upper genital tract in women, and may be associated with profuse vaginal bleeding.

Disseminated cryptococcosis complicated with bilateral pleural effusion and ascites during corticosteroid therapy for organizing pneumonia with myelodysplastic syndrome

An 83-year-old man with myelodysplastic syndrome was admitted to our hospital due to dyspnea and abnormal shadows on chest X-ray films during corticosteroid therapy for organizing pneumonia. He was diagnosed as having disseminated cryptococcosis with pulmonary lesions after detecting Cryptococcus neoformans. Both bilateral pleural effusion with or without ipsilateral pulmonary lesions and ascites ensued, and it was assumed that both direct involvement and serositis were associated with the fluid accumulation. Cryptococcal yeast was only detected in the right pleural effusion, and the titer of cryptococcal antigen was quite different between body cavities, even though it was positive in all sites.

Cryptococcal mesenteric lymphadenitis: an unusual cause of acute abdomen

Cryptococcal infection of intraabdominal organs or tissues is extremely rare. Herein we report a child with mesenteric cryptococcal lymphadenitis who presented with an acute abdomen misdiagnosed as acute appendicitis. Definitive diagnosis was established with 2nd look and lymph node biopsy. Clinicians should remember that cryptococcal infection of mesenteric lymph nodes may rarely mimic an acute abdomen and cause delay in diagnosis.

Cryptococcosis

Cryptococcus neoformans has risen to a worldwide highly recognizable major opportunistic pathogen with deadly consequences. It has become a model fungus to study a variety of paradigms in the host-fungus relationships. Genomic studies are advancing knowledge on its evolution and dissecting its virulence composite. Studies designed to understand host immunology to this fungus are leading to development of active and passive prevention and therapeutic strategies. This article collates and analyzes both new and old knowledge about the pathogen to help frame the meaning of human cryptococcosis as it starts to evolve in the new millennium.

Case report. Cutaneous cryptococcosis in a patient with systemic erythematous lupus

The first case of a cutaneous cryptococcosis associated with systemic erythematous lupus (SLE) diagnosed in our Mycology Reference Centre is presented: a 24-year-old female patient diagnosed with SLE, nephrotic syndrome, arterial hypertension, renal insufficiency due to glomerulonephritis type IV and cellulitis in the right thigh and gluteus. Cryptococcus neoformans was isolated by cutaneous biopsy and haemoculture. Cryptococcal antigen was detected in serum by the latex agglutination test. As the patient did not respond to fluconazol intravenous treatment, amphotericin B administration was performed. She died of acute renal insufficiency.

Fatal Hormonema dematioides peritonitis in a patient on continuous ambulatory peritoneal dialysis: criteria for organism identification and review of other known fungal etiologic agents

We report a fatal case a fungal peritonitis caused by the yeast-like dematiaceous mould Hormonema dematioides in a 45-year-old woman. The woman had a 13-year history of insulin-dependent diabetes mellitus and had been on continuous ambulatory peritoneal dialysis for chronic renal failure. H. dematioides was repeatedly isolated from the dialysate culture specimens collected on days 3, 9, 16, and 20 of her hospital stay. Preliminary culture reports on day 7 of the growth of a yeast-like fungus, a probable Candida species, prompted the administration of fluconazole (FLU). Intraperitoneal and intravenous FLU failed to eliminate the mould, and the patient expired on day 21 of her hospital stay. We use this case to present what appears to be the first report of fungal peritonitis due to H. dematioides, to provide laboratorians with criteria for differentiating this organism from the similar mould Aureobasidium pullulans and from various yeast genera, and to provide a review of known fungal taxa inciting peritonitis.

Cryptococcosis associated with HIV negative Indian patients and HIV positive Indian blood donors

Cryptococcosis, particularly cryptococcal meningitis (CM), has become an increasing problem globally in the AIDS era. In the present investigation we have made an effort for the first time to study Indian cases (100) both HIV-positive (23 cases, male, mostly Indian professional blood donors, PBDs') confirmed by an ELISA test and Western Blot but asymptomatic for CM and HIV-negative (77:49 male and 28 female) asymptomatic or symptomatic. These subjects were patients from the Lucknow hospitals admitted during the period between February, 1991 to February, 1994, for suspected cryptococcosis or CM. Of those cases, 10% were positive for cryptococcosis or CM. Meningoencephalitis was the dominant clinical manifestation in four (HIV-negative) cases of CM. CT scanning of the head of those cases revealed a noncommunicating hydrocephalus due to aqueductal stenosis (in 2 cases) and a communicating hydrocephalus with granuloma (by MRI) in another case. The latex agglutination test (LAT) of the sera was positive for Cryptococcus antigen in 6 (26%) of the (HIV-positive) patients and 4 (5%), of the HIV-negative cases. In the cases of CM, there was a lower antigen titre in CSF than in the pronase-treated sera. The LAT was found to be useful in diagnosis of cryptococcosis, especially in asymptomatic cases. The CSF of CM-positive cases revealed low levels of glucose, reduced cell count and high proteins. Among the HIV-negative cases, the onset of meningitis in 4 cases was preceded by the presence of encapsulated budding yeast cells in CSF India ink smear, or cryptococci in a direct urine smear in one case. The CSF culture of 3 cases was positive for mucoid Cryptococcus neoformans, showing brown colour effect (BCE) on Staib agar (syn. Guizotia abyssinica creatinine agar, bird seed agar). The isolated yeast strains were identified as C. neoformans var. neoformans by physiological tests. The pathogenicity test of strains revealed virulence to BALB/c mice evidenced by a high mortality of mice and significantly (p < 0.05) high CN burden (> 4-5 mean log(10) cfu), in the brain followed by other visceral organs (lung, liver, spleen, kidney and heart). The in-vitro susceptibility (MIC mu gmL(-1)) of strains.