Audiologic and Otologic Complications of Cryptococcal Meningoencephalitis in Non-HIV Previously Healthy Patients

Neuroimaging of Cryptococcal Meningitis in Patients without Human Immunodeficiency Virus: Data from a Multi-Center Cohort Study

BACKGROUND

A clearer understanding is needed about the use of brain MRI in non-HIV patients with cryptococcal meningitis.

METHODS

Cerebral CT and MRI were studied in 62 patients in a multicenter study of cryptococcal meningitis in non-HIV patients. CT was performed in 51 and MRI in 44. MRI results are reported for the images read at NIH for 29 of the 44 patients. CT reports obtained from the original REDCap database were added to calculate the incidence of normal findings.

RESULTS

CTs were read as normal in 24 of 51 (47%), MRIs were normal in 10% (three of 29). The most characteristic lesions of cryptococcal meningitis on MRI were small basal ganglia lesions representing dilated perivascular spaces in 24% and basal ganglia lesions with restricted diffusion (infarcts) in 38%. In the 18 patients who received contrast, contrast-enhancing lesions, likely representing masses of cryptococci and inflammatory cells, were found in the basal ganglia in 22% and elsewhere in the brain in 22%. Meningeal enhancement was seen in 56%, ependymal enhancement in 24%, and choroid plexus enhancement in 11%. Hydrocephalus was found in five (18%), though increased intacranial pressure was not detected. Suboptimal imaging (n = 6), lack of contrast administration (n = 11) and lack of follow-up, however, markedly limited the accurate assessment of abnormalities in multiple cases.

CONCLUSION

MRI characteristics of non-HIV cryptococcal meningitis include hydrocephalus, meningeal and ependymal enhancement and basal ganglia lesions. Optimal imaging is, however, necessary to maximize the diagnostic and prognostic usefulness of MRI.

Treatment recommendations for non-HIV associated cryptococcal meningoencephalitis including management of post-infectious inflammatory response syndrome

Cryptococcal meningoencephalitis (CM) continues to cause major morbidity and mortality in a range of patients such as those immunosuppressed from HIV and with biologic immunosuppressants, including treatments of autoimmunity, malignancies, and conditioning regimens for transplantation. It is currently the most common cause of non-viral meningitis in the United States. Infections in previously healthy patients also develop with autoantibodies to granulocyte-macrophage colony stimulating factor or with monogenetic defects. In all populations, mortality and significant long-term morbidity occur in 30-50% despite therapy, and immune reconstitution and post-infectious inflammatory response syndromes complicate management. To help with these difficult cases, we present here a practical tutorial of the care of a range of patients with CM in the absence of HIV/AIDS.

In vitro synergistic effect of minocycline combined with antifungals against Cryptococcus neoformans

BACKGROUND

Cryptococcus neoformans infections occur in immunocompromised patients, especially those with HIV infection, chemoradiotherapy after cancer, and organ transplantation. Infection can cause pneumonia and meningoencephalitis in severe cases with a high mortality rate if not treated. Although fluconazole and amphotericin B are the first-line treatments for cryptococcosis, the rate of fluconazole resistance has increased significantly due to long-term use. Minocycline is a derivative of tetracycline that exerts its antibacterial effect through inhibition of bacterial protein synthesis. It is also able to pass the blood-brain barrier to act on the central nervous system. The present study investigates the effects of minocycline in combination with antifungals in treating C. neoformans.

OBJECTIVE

To determine in vitro interactions of minocycline combined with itraconazole, voriconazole, posaconazole, fluconazole and amphotericin B against C. neoformans.

METHODS

The minimum inhibitory concentrations (MIC) of the antifungals were determined by the CLSI Clinical and Laboratory Standards Institute M27-A3 microdilution method. The in vitro synergistic effects of minocycline combined with itraconazole, voriconazole, posaconazole, fluconazole, and amphotericin B on C. neoformans were detected by the broth microdilution checkerboard technique and disk diffusion testing.

RESULTS AND CONCLUSION

The working concentration ranges were 0.125-4 µg/mL for itraconazole, 0.03-0.125 µg/ml for voriconazole, 0.03-1 µg/ml for posaconazole, 0.25-16 µg/ml for fluconazole, and 0.125-2 µg/ml for amphotericin B. The synergistic rates of minocycline combinations against C. neoformans were 55% with itraconazole, 10% with voriconazole, 85% with posaconazole, 20% with fluconazole, and 70% with amphotericin B. The effective MIC value of minocycline in the synergistic combination decreased to 2-32 µg/ml, while the MIC of itraconazole decreased to 0.03-0.125 µg/ml, voriconazole 0.03-0.125 µg/ml, posaconazole 0.03-0.125 µg/ml, 0.125-4 µg/ml fluconazole, and 0.06-0.50 µg/ml amphotericin B. The disk diffusion assay showed that the plates containing minocycline and antifungal drugs produced inhibition zones with diameters larger than the single drug plates. Minocycline showed no antagonistic effect in the combinations. In conclusion, the combination of minocycline and azoles or amphotericin B has synergistic effects against C. neoformans in vitro.

Quality of life of HIV-negative, previously healthy individuals following cryptococcal meningoencephalitis

The morbidity and mortality of cryptococcal meningoencephalitis (CM) in previously healthy, HIV-negative individuals is increasingly recognized. We administered a healthcare associated quality of life (QOL) survey to the largest longitudinally followed cohort of these patients in the United States. We identified moderate or severe self-reported impairment in at least one QOL domain in 61% of subjects at least one year following diagnosis. Self-reported cognitive impairment was noted in 52% and sleep disturbance was noted in 55%. This is the first comprehensive study of cross-sectional long-term QOL in previously healthy patients following cryptococcal infection.

Outcomes in Previously Healthy Cryptococcal Meningoencephalitis Patients treated with Pulse - Taper Corticosteroids for Post-infectious Inflammatory Syndrome

BACKGROUND

Cryptococcal meningoencephalitis (CM) is a major cause of mortality in immunosuppressed patients and previously healthy individuals. In the latter, a post-infectious inflammatory response syndrome (PIIRS) is associated with poor clinical response despite antifungal therapy and negative CSF cultures. Data on effective treatment are limited.

METHODS

Between March 2015 and March 2020, 15 consecutive previously healthy patients with CM and PIIRS were treated with adjunctive pulse corticosteroid taper therapy (PCT) consisting of intravenous methylprednisolone 1 gm daily for 1 week followed by oral prednisone 1 mg/kg/d, tapered based on clinical and radiological response plus oral fluconazole. Montreal Cognitive Assessments (MOCA), Karnofsky Performance scores, MRI brain scanning, ophthalmic and audiologic exams, CSF parameters including cellular and soluble immune responses were compared at PIIRS diagnosis and after methylprednisolone completion.

RESULTS

The median time from antifungal treatment to steroid initiation was 6 weeks. The most common symptoms at PIIRS diagnosis were altered mental status and vision changes. All patients demonstrated significant improvements in MOCA and Karnofsky scores at 1 month (p<0.0003), which was accompanied by improvements in CSF glucose, WBC, protein, cellular and soluble inflammatory markers 1 week after receiving corticosteroids (CS) (p<0.003). All patients with papilledema and visual field deficits also exhibited improvement (p<0.0005). Five out of 7 patients who underwent audiological testing demonstrated hearing improvement. Brain MRI showed significant improvement of radiological findings (p=0.001). CSF cultures remained negative.

CONCLUSIONS

PCT in this small cohort of PIIRS was associated with improvements in CM-related complications with minimal toxicity in the acute setting.

AAIT: A novel prognostic model for HIV-negative patients with cryptococcal meningoencephalitis New Scoring Model for Non-HIV Patients with CM

Cryptococcal meningitis (CM) is a common opportunistic infection in HIV-negative patients, with mortality rates as high as those in the HIV-negative population. This requires accurate initial clinical decision-making, warranting the development of a prognostic score. Two groups of patients were investigated separately to develop a novel prognostic model (AAIT) for HIV-negative patients with CM. A retrospective analysis of 201 HIV-negative patients with CM was conducted to develop the CM prognostic score. In addition, the CM cohort (n = 21) was recruited longitudinally to verify the new prognostic score. Meanwhile, the association between the prognostic score and 1-year mortality of CM was expounded. AAIT (age, albumin, combined bacterial infection, and total triiodothyronine) is a novel prognostic score based on age, albumin level, combined bacterial infection, and total triiodothyronine (TT3) level, which were significantly higher in nonsurvivors than in survivors (0.68 [-0.70 to 1.55] vs - 1.72 [-3.75 to -0.73], P < .00). Regarding the AAIT-predicted 1-year mortality, the area under the receiver operating characteristic curve (AUROC) value was 0.857, whereas it was 0.965 for the validation cohort. In the induction period, different treatment options did not seem to significantly improve the 1-year survival rate. AAIT is a straightforward and clear prognostic score that can add value to predict the outcomes in HIV-negative patients with CM. In addition, controlling infection and increasing the albumin and TT3 levels may help improve clinical outcomes in HIV-negative patients with CM.

LAY ABSTRACT

AAIT (age, albumin, combined bacterial infection, and total triiodothyronine) is a straightforward and clear prognostic score that can add value to predict the outcomes HIV-negative patients with CM.

Cryptococcal meningitis presented as sudden hearing loss: A case study

BACKGROUND

This case report emphasizes that cryptococcal meningitis could be uncommonly presented to otolaryngologists as sudden onset of hearing loss, especially in patients with underlying diseases that could cause immunocompromise, and highlights the importance of differentiated diagnosis on sudden hearing loss before steroid therapy. It also demonstrates that prompt and sufficient fungicidal therapy with appropriate supportive treatment is crucial for a good prognosis on cryptococcal meningitis.

CASE PRESENTATION

A diabetic adult with untreated chronic hepatitis B was admitted complaining of sudden onset of left-sided hearing loss, following unexpected aggravating headache with meningeal signs after hospitalization with days of intratympanic steroid therapy. Cryptococcal meningitis was confirmed through lumbar puncture showing positive India ink staining and microbial culture of the cerebrospinal fluid (CSF). Fortunately, the patient recovered after prompt and adequate fungicidal therapy plus appropriate supportive treatment at last, though persistent hearing loss remained.

CONCLUSIONS

Cryptococcal meningitis could be presented in a very concealed way as sudden hearing loss, especially in patients with underlying diseases that could cause immunosuppression. Differentiated diagnosis on sudden hearing loss before steroid therapy is important.

Clinical Aspects of Immune Damage in Cryptococcosis

Purpose of review

To perform an extensive review of recent literature and provide an update on the current epidemiology, clinical features and management of cryptococcal disease with a focus on the differences between patients depending on their immune status.

Recent findings

Emerging literature has highlighted the inflammatory pathophysiology and varied manifestations of cryptococcal infections in patients who are apparently healthy but paradoxically have a more critical clinical course compared to their immunosuppressed counterparts.

Summary

Non-HIV cryptococcal meningitis has greater mortality compared to that seen in HIV patients. Basic science experiments closely analyzing the underlying pathophysiological response to this infection have demonstrated the predominant role of T cell-mediated inflammatory injury in causing worse clinical outcomes. Further studies are needed to define the need for immunosuppressive agents in the treatment of this illness.