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Miller C, Daugherty R, McCulloch M, Stephens I, Williamson PR. Immune Reconstitution Inflammatory Syndrome Complicating Cryptococcal Meningitis in a Pediatric Heart Transplant Patient. Pediatr Infect Dis J 2022; 41:145-147. [PMID: 34609105 DOI: 10.1097/inf.0000000000003335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Immune reconstitution inflammatory syndrome can be a complication of cryptococcal meningitis after immune reconstitution from antiretroviral therapy in HIV or reduced immune suppression in transplant recipients. In this case report, the authors discuss the diagnosis and management of cryptococcal-associated immune reconstitution inflammatory syndrome in a 10-year-old pediatric heart transplant recipient.
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Affiliation(s)
- Chelsea Miller
- From the Department of Infectious Disease and Department of Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Reza Daugherty
- From the Department of Infectious Disease and Department of Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Michael McCulloch
- From the Department of Infectious Disease and Department of Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Ina Stephens
- From the Department of Infectious Disease and Department of Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
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2
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Stott KE, Loyse A, Jarvis JN, Alufandika M, Harrison TS, Mwandumba HC, Day JN, Lalloo DG, Bicanic T, Perfect JR, Hope W. Cryptococcal meningoencephalitis: time for action. THE LANCET. INFECTIOUS DISEASES 2021; 21:e259-e271. [PMID: 33872594 DOI: 10.1016/s1473-3099(20)30771-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Cryptococcal meningoencephalitis was first described over a century ago. This fungal infection is preventable and treatable yet continues to be associated with excessive morbidity and mortality. The largest burden of disease resides in people living with HIV in low-income and middle-income countries. In this group, mortality with the best antifungal induction regimen (7 days of amphotericin B deoxycholate [1·0 mg/kg per day] and flucytosine [100·0 mg/kg per day]) in a clinical trial setting was 24% at 10 weeks. The world is now at an inflection point in terms of recognition, research, and action to address the burden of morbidity and mortality from cryptococcal meningoencephalitis. However, the scope of interventional programmes needs to increase, with particular attention to implementation science that is specific to individual countries. This Review summarises causes of excessive mortality, interventions with proven survival benefit, and gaps in knowledge and practice that contribute to the ongoing high death toll from cryptococcal meningoencephalitis. TRANSLATIONS: For the Vietnamese and Chichewa translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Katharine Elizabeth Stott
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Angela Loyse
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - Joe N Jarvis
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK
| | | | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK
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Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections associated with HIV remain significant contributors to morbidity and mortality, particularly among people living with HIV (PLWH) in resource-limited settings worldwide. In this review, we discuss several recent important scientific discoveries in the prevention, diagnosis, and management around two of the major causes of CNS opportunistic infections-tuberculous meningitis (TBM) and cryptococcal meningitis including immune reconstitution syndrome (IRIS) associated with cryptococcal meningitis. We also discuss the CNS as a possible viral reservoir, highlighting Cerebrospinal fluid viral escape. RECENT FINDINGS CNS infections in HIV-positive people in sub-Saharan Africa contribute to 15-25% of AIDS-related deaths. Morbidity and mortality in those is associated with delays in HIV diagnosis, lack of availability for antimicrobial treatment, and risk of CNS IRIS. The CNS may serve as a reservoir for replication, though it is unclear whether this can impact peripheral immunosuppression. SUMMARY Significant diagnostic and treatment advances for TBM and cryptococcal meningitis have yet to impact overall morbidity and mortality according to recent data. Lack of early diagnosis and treatment initiation, and also maintenance on combined antiretroviral treatment are the main drivers of the ongoing burden of CNS opportunistic infections. The CNS as a viral reservoir has major potential implications for HIV eradication strategies, and also control of CNS opportunistic infections.
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4
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Melzani A, de Reynal de Saint Michel R, Ntab B, Djossou F, Epelboin L, Nacher M, Blanchet D, Demar M, Couppie P, Adenis A. Incidence and Trends in Immune Reconstitution Inflammatory Syndrome Associated With Histoplasma capsulatum Among People Living With Human Immunodeficiency Virus: A 20-Year Case Series and Literature Review. Clin Infect Dis 2021; 70:643-652. [PMID: 30921453 DOI: 10.1093/cid/ciz247] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/21/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Histoplasmosis is among the main acquired immunodeficiency syndrome (AIDS)-defining conditions in endemic areas. Although histoplasmosis has a worldwide distribution, histoplasmosis-associated immune reconstitution inflammatory syndrome (IRIS) in people living with human immunodeficiency virus (PLHIV) is rarely reported.This study aimed to describe the incidence and features of histoplasmosis-associated IRIS in a cohort of PLHIV. METHODS A retrospective multicenter study was conducted in French Guiana from 1 January 1997 to 30 September 2017. The target population was represented by PLHIV who presented an episode of histoplasmosis within 6 months after antiretroviral therapy initiation. We used a consensual IRIS case definition, submitted to the agreement of 2 experts. Each case was described using a standardized questionnaire, and all patients gave informed consent. RESULTS Twenty-two cases of histoplasmosis-associated IRIS were included (14 infectious/unmasking and 8 paradoxical), with an overall incidence rate of 0.74 cases per 1000 HIV-infected person-years (95% confidence interval, 0.43-1.05). Mean age was 40.5 years. The ratio of males to females was 1:4. Median time to IRIS was 11 days (interquartile range 7-40 days) after antiretroviral therapy initiation. The main clinical presentation was fever, without any specific pattern, and disseminated disease. We reported 2 severe cases and partial or complete recovery at 1 month was the rule. Twenty-two cases were identified in the literature with similar characteristics. CONCLUSIONS Histoplasmosis-associated IRIS incidence was low but generated significant morbidity in PLHIV. In endemic areas, screening for latent or subclinical histoplasmosis should be implemented before antiretroviral therapy initiation.
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Affiliation(s)
- Alessia Melzani
- Unité de Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne.,Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne
| | | | - Balthazar Ntab
- Département d'Information Médicale, Centre Hospitalier de l'Ouest Guyanais, Saint Laurent du Maroni
| | - Felix Djossou
- Unité de Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne.,Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne
| | - Loic Epelboin
- Unité de Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne.,Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne
| | - Mathieu Nacher
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Centre d'Investigation Clinique Antilles Guyane, Inserm CIC 1424, Centre Hospitalier de Cayenne
| | - Denis Blanchet
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Laboratoire Hospitalo-Universitaire de Parasitologie-Mycologie, Centre Hospitalier de Cayenne, France
| | - Magalie Demar
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Laboratoire Hospitalo-Universitaire de Parasitologie-Mycologie, Centre Hospitalier de Cayenne, France
| | - Pierre Couppie
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Service de Dermatologie-Vénérologie, Centre Hospitalier de Cayenne
| | - Antoine Adenis
- Equipe EA3593, Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne.,Centre d'Investigation Clinique Antilles Guyane, Inserm CIC 1424, Centre Hospitalier de Cayenne
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Okurut S, Boulware DR, Olobo J, Meya DB. Landmark clinical observations and immunopathogenesis pathways linked to HIV and Cryptococcus fatal central nervous system co-infection. Mycoses 2020; 63:840-853. [PMID: 32472727 PMCID: PMC7416908 DOI: 10.1111/myc.13122] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022]
Abstract
Cryptococcal meningitis remains one of the leading causes of death among HIV-infected adults in the fourth decade of HIV era in sub-Saharan Africa, contributing to 10%-20% of global HIV-related deaths. Despite widespread use and early induction of ART among HIV-infected adults, incidence of cryptococcosis remains significant in those with advanced HIV disease. Cryptococcus species that causes fatal infection follows systemic spread from initial environmental acquired infection in lungs to antigenaemia and fungaemia in circulation prior to establishment of often fatal disease, cryptococcal meningitis in the CNS. Cryptococcus person-to-person transmission is uncommon, and deaths related to blood infection without CNS involvement are rare. Keen to the persistent high mortality associated with HIV-cryptococcal meningitis, seizures are common among a third of the patients, altered mental status is frequent, anaemia is prevalent with ensuing brain hypoxia and at autopsy, brain fibrosis and infarction are evident. In addition, fungal burden is 3-to-4-fold higher in those with seizures. And high immune activation together with exacerbated inflammation and elevated PD-1/PD-L immune checkpoint expression is immunomodulated phenotypes elevated in CSF relative to blood. Lastly, though multiple Cryptococcus species cause disease in this setting, observations are mostly generalised to cryptococcal infection/meningitis or regional dominant species (C neoformans or gattii complex) that may limit our understanding of interspecies differences in infection, progression, treatment or recovery outcome. Together, these factors and underlying mechanisms are hypotheses generating for research to find targets to prevent infection or adequate therapy to prevent persistent high mortality with current optimal therapy.
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Affiliation(s)
- Samuel Okurut
- Research DepartmentInfectious Diseases InstituteMakerere UniversityKampalaUganda
- Department of MicrobiologySchool of Biomedical SciencesCollege of Health SciencesMakerere UniversityKampalaUganda
| | - David R. Boulware
- Division of Infectious Diseases and International MedicineDepartment of MedicineUniversity of MinnesotaMinneapolisMinnesota
| | - Joseph Olobo
- Department of Immunology and Molecular BiologySchool of Biomedical SciencesCollege of Health SciencesMakerere UniversityKampalaUganda
| | - David B. Meya
- Research DepartmentInfectious Diseases InstituteMakerere UniversityKampalaUganda
- Division of Infectious Diseases and International MedicineDepartment of MedicineUniversity of MinnesotaMinneapolisMinnesota
- Department of MedicineSchool of MedicineCollege of Health SciencesMakerere UniversityKampalaUganda
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6
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Immune reconstitution inflammatory syndrome following Cryptococcal neoformans infection in an immunocompetent host: A case report and review of the literature. IDCases 2020; 19:e00699. [PMID: 32055440 PMCID: PMC7005434 DOI: 10.1016/j.idcr.2020.e00699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/30/2019] [Accepted: 01/01/2020] [Indexed: 12/12/2022] Open
Abstract
We present a case of Cryptococcus neoformans in an immunocompetent middle-aged woman with a disseminated manifestation of pulmonary cryptoccoma and cryptococcal meningitis resulting in bilateral blindness. The presentation was complicated by delayed diagnosis resulting in optic neuritis and an infected percutaneous lumbar drainage with methicillin resistant staphylococcus aureus (MRSA) and a paradoxical reaction of suspected immune reconstitution inflammatory syndrome (IRIS). We discuss the pathogen, the clinical manifestations and diagnostic approach (through laboratory and radiology findings), differential diagnosis, treatment, and proposed pathogenesis of IRIS and C. neoformans in an immunocompetent patient.
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Wu X, Shen Y. Management of human immunodeficiency virus-associated cryptococcal meningitis: Current status and future directions. Mycoses 2019; 62:874-882. [PMID: 31365770 DOI: 10.1111/myc.12977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 12/30/2022]
Abstract
Cryptococcal meningitis (CM) is one of the most common opportunistic infections of acquired immunodeficiency syndrome (AIDS), as well as an important cause of hospitalisation and death. In recent years, the mortality of CM has remained high in HIV/AIDS population, with up to 30%, including within developed countries. The treatment usually encompasses controls of Cryptococcus, HIV, and increased intracranial pressure. Recent progress on the management of HIV-associated CM mainly centres in optimising induction regimens, looking for appropriate timing of initiating antiretroviral therapy and prevention of symptomatic onset and adverse consequences. This review compared several international guidelines combined with the results from some clinical researches to illustrate the similarities, differences and potential in CM treatment. The present practice is still far from satisfactory, and there remains much to explore due to our limited understanding of the pathogenesis of HIV-associated CM. Thus, screening and monitoring should be strengthened, and better therapies in line with the actual situation of each country should be discovered.
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Affiliation(s)
- Xueyun Wu
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
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Boyer-Chammard T, Temfack E, Alanio A, Jarvis JN, Harrison TS, Lortholary O. Recent advances in managing HIV-associated cryptococcal meningitis. F1000Res 2019; 8:F1000 Faculty Rev-743. [PMID: 31275560 PMCID: PMC6544127 DOI: 10.12688/f1000research.17673.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2019] [Indexed: 12/22/2022] Open
Abstract
The recent development of highly sensitive and specific point-of-care tests has made it possible to diagnose HIV-associated cryptococcal meningitis within minutes. However, diagnostic advances have not been matched by new antifungal drugs and treatment still relies on old off-patent drugs: amphotericin B, flucytosine and fluconazole. Cryptococcal meningitis treatment is divided in three phases: induction, consolidation and maintenance. The induction phase, aimed at drastically reducing cerebrospinal fluid fungal burden, is key for patient survival. The major challenge in cryptococcal meningitis management has been the optimisation of induction phase treatment using the limited number of available medications, and major progress has recently been made. In this review, we summarise data from key trials which form the basis of current treatment recommendations for HIV-associated cryptococcal meningitis.
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Affiliation(s)
- Timothée Boyer-Chammard
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, UMR2000, CNRS, Institut Pasteur, Paris, France
- Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants malades, AP-HP, IHU Imagine, Paris, France
| | | | - Alexandre Alanio
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, UMR2000, CNRS, Institut Pasteur, Paris, France
- University Paris Diderot, Sorbonne Paris Cité, Université de Paris, Laboratory of Parasitology-Mycology, Saint-Louis Hospital, APHP, Paris, France
| | - Joseph N. Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Thomas S. Harrison
- Institute of Infection and Immunity, St. George’s University of London, London, UK
| | - Olivier Lortholary
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, UMR2000, CNRS, Institut Pasteur, Paris, France
- Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants malades, AP-HP, IHU Imagine, Paris, France
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