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Butel-Simoes G, Kua H, Safdar A, Graham M, Korman T, Meher-Homji Z. Cryptococcal laryngitis in an immunocompetent asthmatic patient using inhaled corticosteroids. Med Mycol Case Rep 2023; 42:100599. [PMID: 37727452 PMCID: PMC10506085 DOI: 10.1016/j.mmcr.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/07/2023] [Accepted: 08/15/2023] [Indexed: 09/21/2023] Open
Abstract
We present a case of laryngeal cryptococcosis caused by cryptococcosis neoformans var. grubii affecting a patient using excessive inhaled corticosteroids. The patient experienced symptoms for several months prior to specialist review and the visualization of a mass lesion by nasopharyngoscopy. Fortunately a biopsy was performed and through histopathology & microbiological assessment a diagnosis of cryptococcal laryngitis was made. Treatment with 6 months of fluconazole resulted in clinical cure and resolution of symptoms. It is important to raise awareness of the risk of non-Candida fungal infections in patients on high dose corticosteroids, especially in the post covid era were steroids are more commonly prescribed.
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Affiliation(s)
- G.I. Butel-Simoes
- Monash Infectious Diseases and Microbiology, Monash Health, Victoria, Australia
| | - H. Kua
- Department of Anatomical Pathology, Monash Health, Victoria, Australia
| | - A. Safdar
- Department of Otolaryngology/ Head and Neck Surgery, Monash Health Victoria, Australia
| | - M. Graham
- Monash Infectious Diseases and Microbiology, Monash Health, Victoria, Australia
- Monash University, Clayton, Victoria, Australia
| | - T. Korman
- Monash Infectious Diseases and Microbiology, Monash Health, Victoria, Australia
- Monash University, Clayton, Victoria, Australia
| | - Z. Meher-Homji
- Department of Infectious Diseases, Latrobe Regional Hospital, Victoria, Australia
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2
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O’Hern JA, Koenen A, Janson S, Hajkowicz KM, Robertson IK, Kidd SE, Baird RW, Tong SYC, Davis JS, Carson P, Currie BJ, Ralph AP. Epidemiology, management and outcomes of Cryptococcus gattii infections: A 22-year cohort. PLoS Negl Trop Dis 2023; 17:e0011162. [PMID: 36877729 PMCID: PMC10019644 DOI: 10.1371/journal.pntd.0011162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/16/2023] [Accepted: 02/12/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Cryptococcus gattii is a globally endemic pathogen causing disease in apparently immune-competent hosts. We describe a 22-year cohort study from Australia's Northern Territory to evaluate trends in epidemiology and management, and outcome predictors. METHODS A retrospective cohort study of all C. gattii infections at the northern Australian referral hospital 1996-2018 was conducted. Cases were defined as confirmed (culture-positive) or probable. Demographic, clinical and outcome data were extracted from medical records. RESULTS 45 individuals with C. gattii infection were included: 44 Aboriginal Australians; 35 with confirmed infection; none HIV positive out of 38 tested. Multifocal disease (pulmonary and central nervous system) occurred in 20/45 (44%). Nine people (20%) died within 12 months of diagnosis, five attributed directly to C. gattii. Significant residual disability was evident in 4/36 (11%) survivors. Predictors of mortality included: treatment before the year 2002 (4/11 versus 1/34); interruption to induction therapy (2/8 versus 3/37) and end-stage kidney disease (2/5 versus 3/40). Prolonged antifungal therapy was the standard approach in this cohort, with median treatment duration being 425 days (IQR 166-715). Ten individuals had adjunctive lung resection surgery for large pulmonary cryptococcomas (median diameter 6cm [range 2.2-10cm], versus 2.8cm [1.2-9cm] in those managed non-operatively). One died post-operatively, and 7 had thoracic surgical complications, but ultimately 9/10 (90%) treated surgically were cured compared with 10/15 (67%) who did not have lung surgery. Four patients were diagnosed with immune reconstitution inflammatory syndrome which was associated with age <40 years, brain cryptococcomas, high cerebrospinal fluid pressure, and serum cryptococcal antigen titre >1:512. CONCLUSION C. gattii infection remains a challenging condition but treatment outcomes have significantly improved over 2 decades, with eradication of infection the norm. Adjunctive surgery for the management of bulky pulmonary C. gattii infection appears to increase the likelihood of durable cure and likely reduces the required duration of antifungal therapy.
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Affiliation(s)
- Jennifer A. O’Hern
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Australia
- * E-mail: (APR); (JAO)
| | - Adrian Koenen
- Department of General Surgery, Royal Darwin Hospital, Darwin, Australia
| | - Sonja Janson
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Australia
| | | | - Iain K. Robertson
- College of Health and Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Sarah E. Kidd
- National Mycology Reference Centre, SA Pathology, Adelaide, Australia
| | - Robert W. Baird
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Australia
- Territory Pathology, Department of Health, Darwin, Australia
| | - Steven YC Tong
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Joshua S. Davis
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Phillip Carson
- Department of General Surgery, Royal Darwin Hospital, Darwin, Australia
| | - Bart J. Currie
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Anna P. Ralph
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- * E-mail: (APR); (JAO)
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3
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Sim BZ, Conway L, Smith LK, Fairhead L, Der YS, Payne L, Binotto E, Smith S, Hanson J. The aetiology and clinical characteristics of cryptococcal infections in Far North Queensland, tropical Australia. PLoS One 2022; 17:e0265739. [PMID: 35353860 PMCID: PMC8966997 DOI: 10.1371/journal.pone.0265739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/07/2022] [Indexed: 12/17/2022] Open
Abstract
Cryptococcal infections are an important cause of morbidity and mortality in tropical Australia. This retrospective audit was conducted to characterise the aetiology, temporospatial epidemiology, and clinical course of 49 cryptococcal infections in Far North Queensland between 1 January 1999 and 31 December 2019. Cryptococcus gattii was identified in 15/32 (47%) in whom it was possible to speciate the organism. Among these 15 patients, 13 (87%) had a rural residential address, 10 (67%) were Indigenous Australians and 11 (73%) presented during the May-November dry season. When compared to the 17 patients with Cryptococcus neoformans infection, patients with C. gattii were less likely to be immunocompromised (0/15 versus 8/17 (47%), p = 0.003). Neurosurgery was necessary in 5/15 C. gattii cases and 3/17 (18%) C. neoformans cases (p = 0.42). Outcomes were generally good with 42/49 (86%) cases—and 14/15 (93%) with C. gattii infection—surviving to hospital discharge. These positive outcomes are likely to be explained by the development of standardised treatment guidelines during the study period, low rates of comorbidity in the patients with C. gattii infection and access to liposomal amphotericin and neurosurgical support in the well-resourced Australian healthcare system.
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Affiliation(s)
- Beatrice Z. Sim
- Department of Medicine, Cairns Hospital, Cairns, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Luke Conway
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Laura K. Smith
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Lee Fairhead
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Yi Shan Der
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Lara Payne
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Enzo Binotto
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Australia
- Kirby Institute, University of New South Wales, Sydney, Australia
- * E-mail:
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4
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Elderly versus nonelderly patients with invasive fungal infections: species distribution and antifungal resistance, SENTRY antifungal surveillance program 2017-2019. Diagn Microbiol Infect Dis 2022; 102:115627. [DOI: 10.1016/j.diagmicrobio.2021.115627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/14/2021] [Accepted: 12/18/2021] [Indexed: 11/21/2022]
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5
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Van Rooij N, Johnston J, Mortimore R, Robertson I. A case of disseminated cryptococcal disease after Bruton tyrosine kinase inhibitor therapy: A brief review in the Australian context. JAAD Case Rep 2021; 13:43-45. [PMID: 34136624 PMCID: PMC8182371 DOI: 10.1016/j.jdcr.2021.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Nicholas Van Rooij
- The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Southport, Queensland, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Jesse Johnston
- The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Rohan Mortimore
- The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Ivan Robertson
- The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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6
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Grimshaw A, Palasanthiran P, Huynh J, Marais B, Chen S, McMullan B. Cryptococcal infections in children: retrospective study and review from Australia. Future Microbiol 2020; 14:1531-1544. [PMID: 31992070 DOI: 10.2217/fmb-2019-0215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Cryptococcosis causes significant morbidity and mortality worldwide, but pediatric data are limited. Methods: A retrospective literature review of Australian pediatric cryptococcosis and additional 10-year audit of cases from a large pediatric network. Results: 22 cases of cryptococcosis in children were identified via literature review: median age was 13.5 years (IQR 7.8-16 years), 18/22 (82%) had meningitis or central nervous system infection. Where outcome was reported, 11/18 (61%) died. Of six audit cases identified from 2008 to 2017, 5 (83%) had C. gattii disease and survived. One child with acute lymphoblastic leukemia and C. neoformans infection died. For survivors, persisting respiratory or neurological sequelae were reported in 4/6 cases (67%). Conclusion: Cryptococcosis is uncommon in Australian children, but is associated with substantial morbidity.
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Affiliation(s)
- Alice Grimshaw
- University of New South Wales, Kensington, New South Wales, 2052, Australia
| | - Pamela Palasanthiran
- Department of Immunology & Infectious Disease, Sydney Children's Hospital, Randwick, New South Wales, 2031, Australia.,School of Women's & Children's Health, University of New South Wales, Randwick, New South Wales, 2031, Australia
| | - Julie Huynh
- Department of Infectious Diseases & Microbiology, Children's Hospital at Westmead, Westmead, New South Wales, 2145, Australia.,Discipline of Child & Adolescent Health, The University of Sydney, Children's Hospital Westmead, New South Wales, 2145, Australia
| | - Ben Marais
- The Children's Hospital at Westmead Clinical School, Westmead, New South Wales, 2145, Australia.,Marie Bashir Institute for Infectious Diseases & Biosecurity, The University of Sydney, Westmead, New South Wales, 2145, Australia.,The Children's Hospital at Westmead, Westmead, New South Wales, 2145, Australia
| | - Sharon Chen
- Marie Bashir Institute for Infectious Diseases & Biosecurity, The University of Sydney, Westmead, New South Wales, 2145, Australia.,Clinical Mycology Reference Laboratory, Centre for Infectious Diseases & Microbiology Laboratory Services, ICPMR - New South Wales Health Pathology, Westmead Hospital, New South Wales, 2145, Australia
| | - Brendan McMullan
- Department of Immunology & Infectious Disease, Sydney Children's Hospital, Randwick, New South Wales, 2031, Australia.,School of Women's & Children's Health, University of New South Wales, Randwick, New South Wales, 2031, Australia
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7
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Marinelli T, Anagnostou N, Daniel S, Wigg AJ, Teh J. Very early-onset of Cryptococcus neoformans disease following liver transplantation: Report of two cases and a review of the literature. Transpl Infect Dis 2019; 22:e13227. [PMID: 31785187 DOI: 10.1111/tid.13227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/10/2019] [Accepted: 11/24/2019] [Indexed: 01/14/2023]
Abstract
Cryptococcosis is the third most common invasive fungal infection following solid organ transplantation, and mortality is high. Most cases occur late and are due to reactivation of latent infection; however, very early reactivation and donor-derived transmission can occur. Routine screening pre-transplant and antifungal prophylaxis for cryptococcosis post-transplant in solid organ transplantation are not standard practice. We present two cases of very early-onset Cryptococcus neoformans disease following liver transplantation to highlight the need to consider individualized pre-transplant screening and be aware that reactivation of Cryptococcosis neoformans can occur in the immediate post-transplant period.
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Affiliation(s)
- Tina Marinelli
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nicholas Anagnostou
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Santhosh Daniel
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Alan J Wigg
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.,Hepatology and Transplantation Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Joanne Teh
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
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8
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Diaz JH. The Disease Ecology, Epidemiology, Clinical Manifestations, and Management of Emerging Cryptococcus gattii Complex Infections. Wilderness Environ Med 2019; 31:101-109. [PMID: 31813737 DOI: 10.1016/j.wem.2019.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 09/18/2019] [Accepted: 10/09/2019] [Indexed: 01/12/2023]
Abstract
Cryptococcus neoformans, a soil-dwelling fungus found worldwide, can cause cryptococcosis, an opportunistic fungal infection of the lungs and central nervous system. One former member of the C neoformans complex, Cryptococcus gattii, has caused meningitis in immunosuppressed and immunocompetent persons in endemic regions in Africa and Asia. Between 1999 and 2004, C gattii caused outbreaks of human cryptococcosis in unexpected, nonendemic, nontropical regions on Vancouver Island, Canada, and throughout the US Pacific Northwest and California. C gattii was recognized as an emerging species with several genotypes and a unique environmental relationship with trees that are often encountered in the wilderness and in landscaped parks. Because C gattii infections have a high case-fatality rate, wilderness medicine clinicians should be aware of this emerging pathogen, its disease ecology and risk factors, its expanding geographic distribution in North America, and its ability to cause fatal disease in both immunosuppressed and immunocompetent persons.
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Affiliation(s)
- James H Diaz
- Environmental and Occupational Health Sciences, School of Public Health, Louisiana State University Health Sciences Center (LSUHSC), New Orleans, LA; School of Medicine, Louisiana State University Health Sciences Center (LSUHSC), New Orleans, LA.
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9
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O'Brien MP, Ford TJ, Currie BJ, Francis JR. Cryptococcus gattii infection complicated by immune reconstitution inflammatory syndrome in three apparently immunocompetent children. J Paediatr Child Health 2019; 55:943-947. [PMID: 30536470 DOI: 10.1111/jpc.14321] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Paediatric Cryptococcus gattii disease is rare, with only two previous cases recorded in the Northern Territory (NT) over the last 54 years. Immune reconstitution inflammatory syndrome (IRIS) is a recognised complication of C. gattii infection, even in the absence of an identified immunodeficiency syndrome; however, limited paediatric data exist. We present a series of three paediatric patients treated for C. gattii infection in the NT during 2016/2017. CASE DISCUSSIONS All three cases were males aged 8-13 years at the time of presentation. Two were Aboriginal Australians from remote NT communities, and the third was a Timorese child from a remote district in Timor-Leste. All cases had evidence of brain cryptococcomas, and two had associated pulmonary lesions. Each child was treated with a 6-week induction phase of intravenous liposomal amphotericin and flucytosine and then continued on a 2-year course of eradication oral fluconazole. Persistent high intracranial pressure (ICP) complicated each case, requiring serial lumbar punctures and, in two cases, insertion of ventriculoperitoneal shunts. All three cases were diagnosed with IRIS between 5 and 10 weeks after commencement of antifungal treatment and were managed with high-dose corticosteroids, which were weaned slowly (6-20 months post-commencement). CONCLUSIONS Paediatric C. gattii disease is rare, although three recent cases in the NT highlight some of the challenges involved in managing the infection, including persistent raised ICP and complications such as IRIS. There is a need for further collaborative research into paediatric C. gattii disease.
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Affiliation(s)
- Matthew P O'Brien
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Timothy J Ford
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Bart J Currie
- Northern Territory Medical Program, Flinders and Charles Darwin Universities, Darwin, Northern Territory, Australia.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Infectious Disease Department, Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Joshua R Francis
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Northern Territory Medical Program, Flinders and Charles Darwin Universities, Darwin, Northern Territory, Australia.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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10
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Cryptococcus gattii VGII isolated from native forest and river in Northern Brazil. Braz J Microbiol 2019; 50:495-500. [PMID: 30852797 DOI: 10.1007/s42770-019-00066-6] [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: 08/24/2018] [Accepted: 12/07/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. In the northern region of Brazil, this disease is caused by Cryptococcus neoformans genotype VNI and Cryptococcus gattii genotype VGII. However, few environmental studies have been conducted in this large tropical area. AIMS This study was performed to isolate, genotype, and determine the frequency of cryptococcal agents in environmental samples near Manaus, Amazonas, Brazil. METHODS A total of 970 environmental samples (290 from soil, 290 from decaying plants, 5 from insects, 280 from the Negro river, and 105 from small streams within the city of Manaus) were collected and plated on Niger seed agar. In addition, 20 sub-cultures obtained from each positive sample were analyzed by PCR-RFLP (URA5) and PCR for genotyping and determination of mating type. RESULTS Six samples were positive for isolates from the C. gattii species complex. Of those, three samples were from Adolpho Ducke Forest Reserve and three were from the Negro river. All isolates were C. gattii genotype VGII (mating type MATα). CONCLUSION Genotype VGII proved to be the most important genotype found in the environmental samples. The genotype VGII has been described as one of the most virulent and less susceptible to antifungals and responsible for important outbreaks. This is the first study to demonstrate isolation of C. gattii (VGII) from the Negro river.
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11
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Sohail A, Smibert OC, Snell G, Paraskeva M, Jenney A. Cryptococcal infection in lung transplant recipients: A 5-year retrospective review at an Australian transplant center. Transpl Infect Dis 2018; 20:e12976. [PMID: 30120885 DOI: 10.1111/tid.12976] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/26/2018] [Accepted: 08/06/2018] [Indexed: 11/30/2022]
Abstract
Cryptococcosis is a common invasive fungal infection (IFI) in solid organ transplant (SOT) recipients. Little is known about cryptococcosis in lung transplant (LTx) recipients despite having one of the highest risks of infection. The aim of this study was to describe demographic and clinical features of cryptococcal infection in LTx recipients. We performed a retrospective, observational study of cryptococcal infection in LTx recipients at The Alfred Hospital in Melbourne, Australia, from 2012 to 2017. A total of 11 cases were identified. Seven patients (64%) were male and the median age was 54.7 years (range 34-69 years). Diagnosis occurred at a median of 233 days (range 1-3650 days) post-transplant. Nine patients (82%) had isolated pulmonary infection of whom 7 (78%) were asymptomatic. All were treated with oral antifungal therapy and 1 required surgical resection of infected lung. Two patients (18%) had disseminated infection; 1 with pulmonary and central nervous system (CNS) infection and 1 with isolated CNS infection. Both patients presented with headache and brain imaging demonstrated cerebral edema, myelinosis, and leptomeningeal enhancement. One of these patients died. This study highlights the fact that cryptococcal infection should remain a consideration in asymptomatic LTx recipients, especially in the presence of non-specific nodules on chest imaging, and that the presence of headache in these patients requires urgent investigation for CNS infection.
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Affiliation(s)
- Asma Sohail
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Olivia C Smibert
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Greg Snell
- Lung Transplant Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Miranda Paraskeva
- Lung Transplant Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adam Jenney
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Microbiology Unit, The Alfred Hospital, Melbourne, Victoria, Australia
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12
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Basnayake TL, Lim A, Currie BJ. Pulmonary cryptococcal infection presenting with multiple lung nodules. Respir Med Case Rep 2018; 23:122-124. [PMID: 29619316 PMCID: PMC5881413 DOI: 10.1016/j.rmcr.2018.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 01/20/2018] [Accepted: 01/22/2018] [Indexed: 10/31/2022] Open
Abstract
Pulmonary infections from the environmental fungus Cryptococcus gattii (C. gattii) are notable for cryptococcomas, which are usually solitary and can be very large. As with infections with Cryptococcus neoformans (C. neoformans) patients can have concomitant cryptococcal meningitis; however, unlike for C. neoformans, infections with C. gattii often occur in immunocompetent patients. The highest published incidence of C. gattii infection has been in the Indigenous Australian population of Arnhem Land in the tropical north of the country. More recently C. gattii has been responsible for outbreaks of cryptococcosis in the Pacific Northwest of Canada and the United States of America (USA). A previously healthy Indigenous male from Arnhem Land presented with pulmonary cryptococcosis with chest imaging showing >50 bilateral lung nodules. This unusual occurrence was attributed to probable inhalation of fungal elements from prior use of a high-pressure leaf blower to clear eucalyptus and other debris in a remote bush camp.
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Affiliation(s)
- Thilini L Basnayake
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, NT, Australia.,Flinders University, School of Medicine, Darwin, NT, Australia
| | - Aijye Lim
- Department of Anatomical Pathology, Territory Pathology, Royal Darwin Hospital, Darwin, NT, Australia
| | - Bart J Currie
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, NT, Australia.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
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13
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Ramachandran P. The Northern Territory, Australia. Pract Neurol 2017; 17:130-132. [DOI: 10.1136/practneurol-2016-001563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 11/04/2022]
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14
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Wei B, Qian C, Liu Y, Lin X, Wan J, Wang Y. Ommaya reservoir in the treatment of cryptococcal meningitis. Acta Neurol Belg 2017; 117:283-287. [PMID: 27492153 DOI: 10.1007/s13760-016-0682-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
The objective is to study the role of Ommaya reservoir in the treatment of cryptococcal meningitis. The clinical data of 42 patients with cryptococcal meningitis were retrospectively studied. The Ommaya group included 20 patients, who were treated with Amphotericin B (Am B) and Ommaya reservoir implantation. The non-Ommaya group contained 22 patients, who were just treated with Amphotericin B (Am B). In the Ommaya group (surgical group), all 20 patients with Ommaya reservoir were fully recovered, and their average hospital stay period and average treatment period with Amphotericin B were 105.3 ± 18.3 and 75.0 ± 18.1 days, respectively. In the non-Ommaya group (control group), 16 patients were fully recovered and the average hospital stay period and average treatment period with Amphotericin B of these 22 patients were 139.6 ± 29.5 and 150.0 ± 32.2 days, respectively. In the surgical group, average period of cryptococcus disappearance was 20 ± 8 days, while in the control group, that was 35 ± 10 days. The clinical efficacy was better in surgical group than control group (P < 0.05). Ommaya reservoir implantation is a valuable approach in the treatment of cryptococcal meningitis and can improve the cure rate, decrease mortality, and shorten the period of treatment.
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15
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Xu L, Huang Q, Lin JR, Zhu CY, Li XH, Ye SK, Zhu AH, Chen DH, Zhang CF, Chen L, Ling Y. Clinical Immunophenotype at Disease Onset in Previously Healthy Patients With Cryptococcal Meningitis. Medicine (Baltimore) 2016; 95:e2744. [PMID: 26871820 PMCID: PMC4753916 DOI: 10.1097/md.0000000000002744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cryptococcal meningitis (CM) is a global disease with significant morbidity and mortality. Although low peripheral blood cluster of differentiation 4 (CD4) cell counts are found to be related to a high burden of cryptococcus in HIV-infected patients, little is known about possible immune defects in previously healthy patients (PHPs). We performed a retrospective study of 41 CM patients treated from January 2005 to December 2014 who did not have HIV-infection. There were 33 PHPs and 8 not previously healthy patients (non-PHPs). We analyzed clinical test data pertaining to peripheral blood T cells, antibodies, inflammation markers, and cerebral spinal fluid (CSF) completed during the disease onset phase and 5 years following diagnosis. PHPs had significantly higher counts of cluster of differentiation 3 (CD3), cluster of differentiation 4 (CD4), and cluster of differentiation 45 (CD45) cells, and lower percentages of CD8 cells than non-PHPs (P < 0.05). Measurements of inflammatory markers and immunoglobulin in blood were comparable except for lower immunoglobulin A (IgA) levels in non-PHPs (P = 0.0410). Examination of CSF revealed lower white blood cell (WBC) counts in non-PHPs. Five-year mortality in PHPs was higher than in non-PHPs (22.0% vs 12.5%) but this was not statistically significant (P > 0.05). Multivariate analysis revealed that higher immunoglobulin G (IgG) levels in serum during disease onset may be an independent predictor of mortality (P = 0.015). In conclusion, PHPs demonstrate an immunophenotype that is distinct from that of non-PHPs, leading to an improved understanding of the immunology of cryptococcal meningitis.
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Affiliation(s)
- Lie Xu
- From the Department of Infectious Disease (LX, QH, C-YZ, S-KY, A-HZ, YL), Medical Inspection Department (D-HC), Department of Hepatology, Shanghai Public Health Clinical Center (LC); Dermatological Department, Huashan Hospital, Fudan University, Shanghai (J-RL, C-FZ); and Department of Infectious Diseases (X-HL), The Third Affiliated Hospital of Sun-Yat-Sen University, Guangzhou, China
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Abstract
Understanding of the taxonomy and phylogeny of Cryptococcus gattii has been advanced by modern molecular techniques. C. gattii probably diverged from Cryptococcus neoformans between 16 million and 160 million years ago, depending on the dating methods applied, and maintains diversity by recombining in nature. South America is the likely source of the virulent C. gattii VGII molecular types that have emerged in North America. C. gattii shares major virulence determinants with C. neoformans, although genomic and transcriptomic studies revealed that despite similar genomes, the VGIIa and VGIIb subtypes employ very different transcriptional circuits and manifest differences in virulence phenotypes. Preliminary evidence suggests that C. gattii VGII causes severe lung disease and death without dissemination, whereas C. neoformans disseminates readily to the central nervous system (CNS) and causes death from meningoencephalitis. Overall, currently available data indicate that the C. gattii VGI, VGII, and VGIII molecular types more commonly affect nonimmunocompromised hosts, in contrast to VGIV. New, rapid, cheap diagnostic tests and imaging modalities are assisting early diagnosis and enabling better outcomes of cerebral cryptococcosis. Complications of CNS infection include increased intracranial pressure, severe neurological sequelae, and development of immune reconstitution syndrome, although the mortality rate is low. C. gattii VGII isolates may exhibit higher fluconazole MICs than other genotypes. Optimal therapeutic regimens are yet to be determined; in most cases, initial therapy with amphotericin B and 5-flucytosine is recommended.
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Criptococosis meníngea en un paciente inmunocompetente: reporte de un caso y revisión de la literatura. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2014. [DOI: 10.1016/j.hgmx.2014.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Micosis sistémicas en pacientes con virus de la inmunodeficiencia humana/sida. ACTAS DERMO-SIFILIOGRAFICAS 2014; 105:5-17. [DOI: 10.1016/j.ad.2012.06.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 05/08/2012] [Accepted: 06/24/2012] [Indexed: 11/19/2022] Open
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Rodríguez-Cerdeira C, Arenas R, Moreno-Coutiño G, Vásquez E, Fernández R, Chang P. Systemic Fungal Infections in Patients with human inmunodeficiency virus. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.adengl.2012.06.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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McMullan BJ, Sorrell TC, Chen SCA. Cryptococcus gattii infections: contemporary aspects of epidemiology, clinical manifestations and management of infection. Future Microbiol 2013; 8:1613-31. [DOI: 10.2217/fmb.13.123] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cryptococcus gattii is an important primary and opportunistic pathogen, predominantly causing meningoencephalitis and pulmonary disease with substantial mortality. Initially considered geographically restricted to immune-competent, highly exposed individuals in the tropics, an apparent epidemic in North America has led to new perspectives on its ecology, epidemiology and clinical associations, which are distinct from its sibling species Cryptococcus neoformans. The role of C. gattii molecular genotypes/subtypes in different settings is under investigation. Diagnostic and treatment strategies are similar to those for C. neoformans in immunocompetent hosts, although data indicate that more prolonged induction, as well as total duration of therapy, is required. Exclusion of CNS involvement is mandatory. Brain cryptococcomas are characteristic of C. gattii infection, and raised intracranial pressure is common, for which surgery is often required. Immune reconstitution syndrome may occur. Ongoing C. gattii research and greater awareness and availability of specific diagnostic tests are required to improve patient outcomes.
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Affiliation(s)
- Brendan Joseph McMullan
- Department of Immunology & Infectious Diseases, Sydney Children‘s Hospital, Randwick, New South Wales, Australia
- School of Women‘s & Children‘s Health, University of New South Wales, Kensington, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Tania Christine Sorrell
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney Emerging Infections Biosecurity Institute, University of Sydney, New South Wales, Australia
| | - Sharon Chih-Ann Chen
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, New South Wales, Australia
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Chen SCA, Korman TM, Slavin MA, Marriott D, Byth K, Bak N, Currie BJ, Hajkowicz K, Heath CH, Kidd S, McBride WJH, Meyer W, Murray R, Playford EG, Sorrell TC. Antifungal therapy and management of complications of cryptococcosis due to Cryptococcus gattii. Clin Infect Dis 2013; 57:543-51. [PMID: 23697747 DOI: 10.1093/cid/cit341] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We describe antifungal therapy and management of complications due to Cryptococcus gattii infection in 86 Australian patients followed for at least 12 months. METHODS Patient data from culture-confirmed cases (2000-2007) were recorded at diagnosis, 6 weeks, 6 months, and 12 months. Clinical, laboratory, and treatment variables associated with raised intracranial pressure (ICP) and immune reconstitution inflammatory syndrome (IRIS) were determined. RESULTS Seven of 10 patients with lung infection received amphotericin B (AMB) induction therapy (6 with 5-flucytosine [5-FC] for a median of 2 weeks); median duration of therapy including azole eradication therapy was 41 weeks, with a complete/partial clinical response in 78%. For neurologic disease, 88% of patients received AMB, 78% with 5-FC, for a median of 6 weeks. The median total course was 18 months. Nine patients receiving fluconazole induction therapy were reinduced with AMB plus 5-FC for clinical failure. Raised ICP (31 patients) was associated with initial abnormal neurology, and neurologic sequelae and/or death at 12 months (both P = .02); cerebrospinal fluid drains/shunts were placed in 58% of patients and in 64% of 22 patients with hydrocephalus. IRIS developed 2-12 months after starting antifungals in 8 patients, who presented with new/enlarging brain lesions. Risk factors included female sex, brain involvement at presentation, and higher median CD4 counts (all P < .05); corticosteroids reduced cryptococcoma-associated edema. CONCLUSIONS Induction AMB plus 5-FC is indicated for C. gattii neurologic cryptococcosis (6 weeks) and when localized to lung (2 weeks). Shunting was often required to control raised ICP. IRIS presents with cerebral manifestations.
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Affiliation(s)
- Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology and The Sydney Institute for Emerging Infections and Biosecurity, Sydney Medical School, University of Sydney, Australia.
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McMullan BJ, Halliday C, Sorrell TC, Judd D, Sleiman S, Marriott D, Olma T, Chen SCA. Clinical utility of the cryptococcal antigen lateral flow assay in a diagnostic mycology laboratory. PLoS One 2012; 7:e49541. [PMID: 23166705 PMCID: PMC3498116 DOI: 10.1371/journal.pone.0049541] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 10/11/2012] [Indexed: 11/18/2022] Open
Abstract
Background Cryptococcus neoformans causes life-threatening meningitis. A recently introduced lateral flow immunoassay (LFA) to detect cryptococcal antigen (CRAG) is reportedly more rapid and convenient than standard latex agglutination (LA), but has not yet been evaluated in a diagnostic laboratory setting. Methods One hundred and six serum, 42 cerebrospinal fluid (CSF), and 20 urine samples from 92 patients with known or suspected cryptococcosis were tested by LA and LFA, and titres were compared. Results were correlated with laboratory-confirmed cryptococcosis. Serial samples were tested in nine treated patients. Results Twenty-five of 92 patients had confirmed cryptococcosis; all sera (n = 56) from these patients were positive by LFA (sensitivity 100%, 95% confidence interval (CI) 93.6–100%) compared with 51/56 positive by LA (sensitivity 91.1%, 95% CI 80.7–96.1%). Fifty sera from 67 patients without cryptococcosis tested negative in both assays. While LA yielded more false negative results (5/56) this did not reach statistical significance (p = 0.063). Nine CSF samples from patients with cryptococcal meningitis yielded positive results using both assays while 17/18 urine samples from patients with cryptococcosis were positive by the LFA. The LFA detected CRAG in C. gattii infection (n = 4 patients). Agreement between titres obtained by both methods (n = 38 samples) was imperfect; correlation between log-transformed titres (r) was 0.84. Turn-around-time was 20 minutes for the LFA and 2 h for LA. The cost per qualitative sample was 18USD and 91 USD, respectively and per quantitative sample was 38USD and 144USD, respectively. Conclusions Qualitative agreement between the LFA and LA assays performed on serum and CSF was good but agreement between titres was imperfect. Ease of performance of the LFA and the capacity for testing urine suggest it has a role in the routine laboratory as a rapid diagnostic test or point-of-care test.
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Affiliation(s)
- Brendan J McMullan
- Centre for Infectious Diseases and Microbiology Laboratory Services, Westmead Hospital, Westmead, New South Wales, Australia.
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Chen SCA, Slavin MA, Heath CH, Playford EG, Byth K, Marriott D, Kidd SE, Bak N, Currie B, Hajkowicz K, Korman TM, McBride WJH, Meyer W, Murray R, Sorrell TC. Clinical manifestations of Cryptococcus gattii infection: determinants of neurological sequelae and death. Clin Infect Dis 2012; 55:789-98. [PMID: 22670042 DOI: 10.1093/cid/cis529] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Longer-term morbidity and outcomes of Cryptococcus gattii infection are not described. We analyzed clinical, microbiological, and outcome data in Australian patients followed for 12 months, to identify prognostic determinants. METHODS Culture-confirmed C. gattii cases from 2000 to 2007 were retrospectively evaluated. Clinical, microbiological, radiological, and outcome data were recorded at diagnosis and at 6 weeks, 6 months, and 12 months. Clinical and laboratory variables associated with mortality and with death and/or neurological sequelae were determined. RESULTS Annual C. gattii infection incidence was 0.61 per 10(6) population. Sixty-two of 86 (72%) patients had no immunocompromise; 6 of 24 immunocompromised hosts had idiopathic CD4 lymphopenia, and 1 had human immunodeficiency virus/AIDS. Clinical and microbiological characteristics of infection were similar in immunocompromised and healthy hosts. Isolated lung, combined lung and central nervous system (CNS), and CNS only disease was reported in 12%, 51% and 34% of the cases, respectively. Complications in CNS disease included raised intracranial pressure (42%), hydrocephalus (30%), neurological deficits (27%; 6% developed during therapy) and immune reconstitutionlike syndrome (11%). Geometric mean serum cryptococcal antigen (CRAG) titers in CNS disease were 563.9 (vs 149.3 in isolated lung infection). Patient immunocompromise was associated with increased mortality risk. An initial cerebrospinal fluid CRAG titer of ≥256 predicted death and/or neurological sequelae (P = .05). CONCLUSIONS Neurological C. gattii disease predominates in the Australian endemic setting. Lumbar puncture and cerebral imaging, especially if serum CRAG titers are ≥512, are essential. Long-term follow up is required to detect late neurological complications. Immune system evaluation is important because host immunocompromise is associated with reduced survival.
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Affiliation(s)
- Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology, Westmead Millennium Institute, Sydney, Australia.
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Carriconde F, Gilgado F, Arthur I, Ellis D, Malik R, van de Wiele N, Robert V, Currie BJ, Meyer W. Clonality and α-a recombination in the Australian Cryptococcus gattii VGII population--an emerging outbreak in Australia. PLoS One 2011; 6:e16936. [PMID: 21383989 PMCID: PMC3044715 DOI: 10.1371/journal.pone.0016936] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 01/06/2011] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cryptococcus gattii is a basidiomycetous yeast that causes life-threatening disease in humans and animals. Within C. gattii, four molecular types are recognized (VGI to VGIV). The Australian VGII population has been in the spotlight since 2005, when it was suggested as the possible origin for the ongoing outbreak at Vancouver Island (British Columbia, Canada), with same-sex mating being suggested as the driving force behind the emergence of this outbreak, and is nowadays hypothesized as a widespread phenomenon in C. gattii. However, an in-depth characterization of the Australian VGII population is still lacking. The present work aimed to define the genetic variability within the Australian VGII population and determine processes shaping its population structure. METHODOLOGY/PRINCIPAL FINDINGS A total of 54 clinical, veterinary and environmental VGII isolates from different parts of the Australian continent were studied. To place the Australian population in a global context, 17 isolates from North America, Europe, Asia and South America were included. Genetic variability was assessed using the newly adopted international consensus multi-locus sequence typing (MLST) scheme, including seven genetic loci: CAP59, GPD1, LAC1, PLB1, SOD1, URA5 and IGS1. Despite the overall clonality observed, the presence of MATa VGII isolates in Australia was demonstrated for the first time in association with recombination in MATα-MATa populations. Our results also support the hypothesis of a "smouldering" outbreak throughout the Australian continent, involving a limited number of VGII genotypes, which is possibly caused by a founder effect followed by a clonal expansion. CONCLUSIONS/SIGNIFICANCE The detection of sexual recombination in MATα-MATa population in Australia is in accordance with the natural life cycle of C. gattii involving opposite mating types and presents an alternative to the same-sex mating strategy suggested elsewhere. The potential for an Australian wide outbreak highlights the crucial issue to develop active surveillance procedures.
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Affiliation(s)
- Fabian Carriconde
- Molecular Mycology Research Laboratory, Sydney Medical School - Westmead Hospital, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead Millennium Institute, Sydney Emerging Infections and Biosecurity Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Félix Gilgado
- Molecular Mycology Research Laboratory, Sydney Medical School - Westmead Hospital, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead Millennium Institute, Sydney Emerging Infections and Biosecurity Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Ian Arthur
- PathWest Laboratory Medicine WA, QEII Medical Centre, Nedlands, Western Australia, Australia
| | - David Ellis
- SA Pathology at Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Richard Malik
- Centre for Veterinary Education, The University of Sydney, Sydney, New South Wales, Australia
| | - Nathalie van de Wiele
- Molecular Mycology Research Laboratory, Sydney Medical School - Westmead Hospital, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead Millennium Institute, Sydney Emerging Infections and Biosecurity Institute, The University of Sydney, Sydney, New South Wales, Australia
- Hogeschool, Leiden, The Netherlands
| | - Vincent Robert
- CBS-Fungal Biodiversity Center, Utrecht, The Netherlands
| | - Bart J. Currie
- Tropical and Emerging Infectious Diseases Division, Menzies School of Health Research, Northern Territory Clinical School and Infectious Diseases Department, Royal Darwin Hospital, Casuarina, Northern Territory, Australia
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Sydney Medical School - Westmead Hospital, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead Millennium Institute, Sydney Emerging Infections and Biosecurity Institute, The University of Sydney, Sydney, New South Wales, Australia
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Krockenberger MB, Malik R, Ngamskulrungroj P, Trilles L, Escandon P, Dowd S, Allen C, Himmelreich U, Canfield PJ, Sorrell TC, Meyer W. Pathogenesis of pulmonary Cryptococcus gattii infection: a rat model. Mycopathologia 2010; 170:315-30. [PMID: 20552280 DOI: 10.1007/s11046-010-9328-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Accepted: 05/25/2010] [Indexed: 01/31/2023]
Abstract
A model of pulmonary cryptococcosis in immunocompetent rats was developed to better understand the virulence of Cryptococcus gattii. Six isolates were studied, representing four molecular genotypes (VGI-MATα, VGIIa-MATα, VGIIa-MAT a, VGIIb-MATα), obtained from Australia, Vancouver (Canada) and Colombia. These originated from human patients, a cat and the environment and were administered intratracheally (i.t.) or transthoracically into Fischer 344 or Wistar-Furth rats in doses varying from 10(4) to 10(7) colony-forming units (CFU) in 0.1 ml of saline. With the exception of animals given the VGIIa-MAT a isolate, rats consistently became ill or died of progressive cryptococcal pneumonia following i.t. doses exceeding 10(7) CFU. Affected lungs increased in weight up to tenfold and contained numerous circumscribed, gelatinous lesions. These became larger and more extensive, progressing from limited hilar and/or tracheal lesions, to virtually confluent gelatinous masses. Disease was localized to the lungs for at least 3-4 weeks, with dissemination to the brain occurring in some animals after day 29. The dose-response relationship was steep for two VGI isolates studied (human WM179, environmental WM276); doses up to 10(6) CFU i.t. did not produce lesions, while 10(7) or more yeast cells produced progressive pneumonia. Intratracheal inoculation of rats with C. gattii provides an excellent model of human pulmonary cryptococcosis in healthy hosts, mimicking natural infections. Disease produced by C. gattii in rats is distinct from that caused by C. neoformans in that infections are progressive and ultimately fatal.
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Affiliation(s)
- Mark B Krockenberger
- Faculty of Veterinary Science, Building B14, University of Sydney, Sydney, NSW, 2006, Australia
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McGill S, Malik R, Saul N, Beetson S, Secombe C, Robertson I, Irwin P. Cryptococcosis in domestic animals in Western Australia: a retrospective study from 1995-2006. Med Mycol 2010; 47:625-39. [PMID: 19306217 DOI: 10.1080/13693780802512519] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
A retrospective study of cryptococcosis in domestic animals residing in Western Australia was conducted over an 11-year-period (from 1995 to 2006) by searching the data base of Murdoch University Veterinary Teaching hospital and the largest private clinical pathology laboratory in Perth. Cryptococcosis was identified in 155 animals: 72 cats, 57 dogs, 20 horses, three alpacas, two ferrets and a sheep. There was no seasonal trend apparent from the dates of diagnosis. Taking into account the commonness of accessions to Murdoch University, cats were five to six times more likely to develop this disease than dogs, and three times more likely than horses, while horses were almost twice as likely as dogs to become infected. Amongst the feline cohort, Ragdoll and Birman breeds were over-represented, while in dogs several pedigree breeds were similarly overrepresented. Dogs and horses tended to develop disease at an early age (one to five years), while cats were presented over a much wider range of ages. In cats and dogs the upper respiratory tract was the most common primary site of infection, while horses and alpacas tended to have lower respiratory involvement. The most striking finding of the study was the high frequency with which C. gattii was identified, with infections attributable to this species comprising 5/9 cats, 11/22 dogs, 9/9 horses and 1/1 alpaca, where appropriate testing was conducted. Preliminary molecular genotyping suggested that most of the C. gattii infections in domestic animals (9/9 cases) were of the VGII genotype. This contrasts the situation on the eastern seaboard of Australia, where disease attributable to C. gattii is less common and mainly due to the VGI genotype. C. gattii therefore appears to be an important cause of cryptococcosis in Western Australia.
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Affiliation(s)
- S McGill
- School of Veterinary and Biomedical Sciences, Murdoch University, Perth, Western Australia, Australia
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The role of an Ommaya reservoir in the management of children with cryptococcal meningitis. Clin Neurol Neurosurg 2010; 112:157-9. [DOI: 10.1016/j.clineuro.2009.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Revised: 07/16/2009] [Accepted: 10/10/2009] [Indexed: 11/23/2022]
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Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, Harrison TS, Larsen RA, Lortholary O, Nguyen MH, Pappas PG, Powderly WG, Singh N, Sobel JD, Sorrell TC. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis 2010; 50:291-322. [PMID: 20047480 PMCID: PMC5826644 DOI: 10.1086/649858] [Citation(s) in RCA: 1700] [Impact Index Per Article: 121.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. These guidelines for its management have been built on the previous Infectious Diseases Society of America guidelines from 2000 and include new sections. There is a discussion of the management of cryptococcal meningoencephalitis in 3 risk groups: (1) human immunodeficiency virus (HIV)-infected individuals, (2) organ transplant recipients, and (3) non-HIV-infected and nontransplant hosts. There are specific recommendations for other unique risk populations, such as children, pregnant women, persons in resource-limited environments, and those with Cryptococcus gattii infection. Recommendations for management also include other sites of infection, including strategies for pulmonary cryptococcosis. Emphasis has been placed on potential complications in management of cryptococcal infection, including increased intracranial pressure, immune reconstitution inflammatory syndrome (IRIS), drug resistance, and cryptococcomas. Three key management principles have been articulated: (1) induction therapy for meningoencephalitis using fungicidal regimens, such as a polyene and flucytosine, followed by suppressive regimens using fluconazole; (2) importance of early recognition and treatment of increased intracranial pressure and/or IRIS; and (3) the use of lipid formulations of amphotericin B regimens in patients with renal impairment. Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies. However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients.
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Affiliation(s)
- John R Perfect
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Severo CB, Gazzoni AF, Severo LC. Capítulo 3: criptococose pulmonar. J Bras Pneumol 2009; 35:1136-44. [DOI: 10.1590/s1806-37132009001100012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 08/05/2009] [Indexed: 12/23/2022] Open
Abstract
Criptococose é uma micose sistêmica causada por duas espécies do basidiomiceto encapsulado, Cryptococcus neoformans e C. gattii, que, respectivamente, causam infecção em indivíduos imunocomprometidos e em hospedeiros imunocompetentes, respectivamente. Pacientes com deficiência em células T são mais suscetíveis. A infecção se inicia por lesões pulmonares assintomáticas e a doença disseminada frequentemente cursa com meningoencefalite. A importância médica da criptococose aumentou significativamente em consequência da epidemia da AIDS e dos transplantes de órgãos.
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Abstract
PURPOSE OF REVIEW Cryptococcosis is an important opportunistic fungal infection, especially in the immunocompromised patient. Meningitis is the most common manifestation of cryptococcosis; however, cryptococcal lung disease is probably underdiagnosed, and knowledge of epidemiology, diagnosis, and treatment is necessary. RECENT FINDINGS Cryptococcal lung disease ranges from asymptomatic colonization or infection to severe pneumonia with respiratory failure. Clinical presentation of pulmonary cryptococcosis is highly variable and often is related to the immune status of the patient. There have been many important clinical trials outlining treatment of cryptococcal meningitis in patients with AIDS, but there is a lack of treatment data available for patients with cryptococcal lung disease. Treatment recommendations for cryptococcal lung disease are made on the basis of host immune status and severity of clinical illness. For less severe disease, fluconazole therapy is recommended. In immunocompromised patients, or those with severe disease, induction therapy with an amphotericin B preparation and flucytosine, followed by fluconazole as consolidation and maintenance therapy, is recommended. SUMMARY Cryptococcal lung disease is an important and probably underdiagnosed infection. Knowledge of the epidemiology, diagnostic methodologies, and treatment is needed to ensure good patient outcomes.
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Cryptococcus gattii: An Emerging Cause of Fungal Disease in North America. Interdiscip Perspect Infect Dis 2009; 2009:840452. [PMID: 19503836 PMCID: PMC2686104 DOI: 10.1155/2009/840452] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 01/18/2009] [Indexed: 01/03/2023] Open
Abstract
During the latter half of the twentieth century, fungal pathogens such as
Cryptococcus neoformans were increasingly recognized as a significant threat to the
health of immune compromised populations throughout the world. Until recently, the closely related
species C. gattii was considered to be a low-level endemic pathogen that was confined to
tropical regions such as Australia. Since 1999, C. gattii has emerged in the Pacific Northwest
region of North America and has been responsible for a large disease epidemic among generally
healthy individuals. The changing epidemiology of C. gattii infection is likely to be a consequence of alterations in fungal ecology and biology and illustrates its potential to cause serious human disease.
This review summarizes selected biological and clinical aspects of C. gattii that are
particularly relevant to the recent North American outbreak and compares these to the Australian and South
American experience.
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Capoor MR, Mandal P, Deb M, Aggarwal P, Banerjee U. Current scenario of cryptococcosis and antifungal susceptibility pattern in India: a cause for reappraisal. Mycoses 2008; 51:258-65. [PMID: 18399907 DOI: 10.1111/j.1439-0507.2007.01478.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study analysed the spectrum, antifungal susceptibility pattern, clinical course and molecular epidemiology of cryptococcosis. Four hundred and thirty-nine samples obtained from 378 meningitis patients were processed by standard procedures. Minimum inhibitory concentration (MIC) of fluconazole and amphotericin B for the isolates was tested by broth micro dilution and by E-strip method. Molecular analysis by random amplified polymorphic DNA-PCR of eight isolates was performed using M13 primer. Cryptococcosis was diagnosed in 35 patients [HIV-1 seropositive (19) and apparently immunocompetent (16)]. Cryptococcus neoformans var. neoformans (serotype A and D) was the predominant isolate on phenotypic identification. Three C. neoformans var. gattii were isolated from HIV-1 seropositive (2) and apparently immunocompetent (1) patients. MIC 90 for amphotericin B and fluconazole were 1 and 8 mug ml(-1) respectively. On RAPD-PCR, less diversity was seen among Indian isolates. AIDS remains the single most important risk factor for cryptococcosis. Rising MIC of the available induction and maintenance drugs is of grave concern. The DNA typing technique showed less diversity among Indian strains. Routine surveillance and application of molecular typing methods are crucial to know the baseline and existing pattern of cryptococcosis.
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Affiliation(s)
- Malini Rajinder Capoor
- Department of Microbiology, Vardhman Mahaveer Medical College and Safdarjung Hospital, New Delhi, India.
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Cartner M, Holley A, Allworth A. False impressions from clear cerebrospinal fluid and a normal computed tomography scan: The pressure is still on for a diagnosis. Emerg Med Australas 2008; 20:276-9. [DOI: 10.1111/j.1742-6723.2008.01095.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Epidemiological Profile of Cryptococcal Meningitis Patients in Rio Grande do Sul, Brazil. Mycopathologia 2008; 166:71-5. [DOI: 10.1007/s11046-008-9123-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Accepted: 04/16/2008] [Indexed: 10/22/2022]
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Brouwer AE, Siddiqui AA, Kester MI, Sigaloff KCE, Rajanuwong A, Wannapasni S, Chierakul W, Harrison TS. Immune dysfunction in HIV-seronegative, Cryptococcus gattii meningitis. J Infect 2006; 54:e165-8. [PMID: 17109966 DOI: 10.1016/j.jinf.2006.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2006] [Accepted: 10/08/2006] [Indexed: 11/27/2022]
Abstract
The pathophysiology of meningitis caused by Cryptococcus gattii in apparently immunocompetent individuals remains unclear. We measured multiple cytokines in CSF from a HIV-seronegative, apparently immunocompetent, Thai patient with C. gattii meningitis, over the first 2 weeks of antifungal therapy. Levels of proinflammatory IFN-gamma, TNF-alpha, and IL-6 were very low compared to patients with HIV-related Cryptococcus neoformans meningitis and of IL-10 very high. While patients with C. gattii meningitis may be a heterogeneous group, these data suggest in this case a maladapted immune response to cryptococcal exposure had allowed progression to clinical cryptococcal disease.
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Affiliation(s)
- Annemarie E Brouwer
- Centre for Infection, St. George's University of London, Cranmer Terrace, London SW17 ORE, UK
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Campbell LT, Currie BJ, Krockenberger M, Malik R, Meyer W, Heitman J, Carter D. Clonality and recombination in genetically differentiated subgroups of Cryptococcus gattii. EUKARYOTIC CELL 2005; 4:1403-9. [PMID: 16087745 PMCID: PMC1214530 DOI: 10.1128/ec.4.8.1403-1409.2005] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cryptococcus gattii is a pathogenic yeast that together with Cryptococcus neoformans causes cryptococcosis in humans and animals. High numbers of viable C. gattii propagules can be obtained from certain species of Australian Eucalyptus camaldulensis trees, and an epidemiological link between Eucalyptus colonization and human exposure has been proposed. However, the highest prevalence of C. gattii cryptococcosis occurs in Papua New Guinea and in regions of Australia where the eucalypt species implicated to date are not endemic. This study investigated the population structure of three geographically distinct clinical and veterinary populations of C. gattii from Australia and Papua New Guinea. All populations that consisted of a genotype found frequently in Australia (VGI) were strongly clonal and were highly differentiated from one another. Two populations of the less common VGII genotype from Sydney and the Northern Territory had population structures inferring recombination. In addition, there was some evidence of reduced genetic differentiation between these geographically remote regions. In a companion study presented in this issue, VGII isolates were overwhelmingly more fertile than those of the VGI genotype, giving biological support to the indirect assessment of sexual exchange. It appears that the VGI genotype propagates clonally on eucalypts in Australia and on an unknown substrate in Papua New Guinea, with infection initiated by an unidentified infectious propagule. VGII isolates are completing their life cycles and may be dispersed via sexually produced basidiospores, which are also likely to initiate respiratory infection.
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Affiliation(s)
- Leona T Campbell
- School of Molecular and Microbial Biosciences, University of Sydney, New South Wales 2006, Australia
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Abstract
Cryptococcal meningitis is a common opportunistic infection in AIDS patients, particularly in Southeast Asia and Africa. Cases also occur in patients with other forms of immunosupression and in apparently immunocompetent individuals. Mortality from HIV-associated cryptococcal meningitis remains high (10-30%), even in developed countries, because of the inadequacy of current antifungal drugs and the complication of raised intracranial pressure. In cohorts of HIV-infected patients from sub-Saharan Africa, cryptococcosis has accounted for 13-44% of all deaths. Optimal current therapy is with amphotericin B 0.7-1 mg/kg/day plus flucytosine 100 mg/kg/day for 2 weeks, followed by fluconazole 400 mg/day for 8 weeks and 200 mg/day thereafter. Saline loading reduces amphotericin B nephrotoxicity. If there is no contraindication on CT head scan, repeat lumbar puncture with drainage of cerebrospinal fluid (CSF) is recommended for patients with very raised CSF opening pressure. Expansion of antiretroviral programmes raises the prospect of transforming the long-term prognosis of these patients, provided that they survive the acute phase of the illness. Studies are needed to define more fungicidal drug regimens and to improve the treatment of raised intracranial pressure.
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Affiliation(s)
- Tihana Bicanic
- Division of Infectious Diseases, Department of Cellular and Molecular Medicine, St. George's Hospital Medical School, London, UK
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