Predictors of postinfectious inflammatory response syndrome in HIV-negative immunocompetent cryptococcal meningitis

Cryptococcal meningitis in apparently immunocompetent patients

Cryptococcal meningitis (CM) is an invasive fungal disease that currently poses a threat to human health worldwide, with high morbidity and mortality, particularly in immunocompromised patients. Although CM mainly occurs in HIV-positive patients and other immunocompromised patients, it is also increasingly seen in seemingly immunocompetent hosts. The clinical characteristics of CM between immunocompromised and immunocompetent populations are different. However, few studies have focussed on CM in immunocompetent individuals. This review summarizes the clinical characteristics of apparently immunocompetent CM patients in terms of aetiology, immune pathogenesis, clinical presentation, laboratory data, imaging findings, treatment strategies and prognosis. It is of great significance to further understand the disease characteristics of CM, explore new treatment strategies and improve the prognosis of CM in immunocompetent individuals.

Post-infectious inflammatory response syndrome in an HIV-negative patient after Cryptococcus gattii meningoencephalitis: a case report and review of the literature

BACKGROUND

Cryptococcal meningitis (CM) is an inflammatory mycosis of the central nervous system caused by meninge infection or brain parenchyma with Cryptococcus species. It is associated with high morbidity and mortality, and patients with acquired immune deficiency syndrome are particularly susceptible. There have been increasing reports of CM in HIV-negative patients in China over the last few years.

CASE PRESENTATION

A 31-year-old healthy Chinese male presented with fever and gradually developed headache, projectile vomiting, and other manifestations that were later confirmed as Cryptococcus gattii meningoencephalitis. However, multiple disease changes occurred during the course of treatment, and the regimen was accordingly modified after the diagnosis of post-infectious inflammatory response syndrome (PIIRS). The patient eventually recovered.

CONCLUSION

There has been a growing trend in the incidence of C. gattii meningoencephalitis in HIV-negative patients. It shows rapid onset and severe prognosis. This case report can provide a reference to treat PIIRS following CM in HIV-negative patients.

Analysis of the association of HLA subtypes with cryptococcal meningitis in HIV-negative immunocompetent patients

Objective: We aimed to study the possible relationship between cryptococcal meningitis (CM) and HLA genotypes in HIV-negative immunocompetent patients. Methods: HLA loci of 53 HIV-negative immunocompetent Han Chinese CM patients were compared with those in 481 healthy individuals. Results: We found a significant association between DQB1*05:02 and CM patients compared with controls. There were no significant differences in the frequencies of HLA alleles between CM with and without postinfectious inflammatory response syndrome and controls. Correlation analysis showed DQB1*05:02 was correlated with susceptibility to CM. CM patients carrying the DQB1*05:02 allele had more severe focal neurological deficit, higher initial modified Rankin Scale and British Medical Research Council staging scores. Conclusion: This study provides the first evidence for the interaction between specific HLA class II alleles and HIV-negative immunocompetent CM patients.

Case report: a special case of cryptococcal infection-related inflammatory syndrome in a non-HIV infected and non-transplant patient

Background

Cryptococcal meningoencephalitis (CM) is a severe infection of central nervous system with high mortality and morbidity. Infection-related inflammatory syndrome is a rare complication of CM. Herein, we report a case of CM complicated by infection-related inflammatory syndrome.

Case presentation

A 42-year-old man with chronic hepatitis B presented with a 3-day history of aphasia and left hemiparesis at an outside medical facility. The brain magnetic resonance imaging (MRI) showed symmetric and confluent hyperintense signal abnormalities mainly located in the basal ganglia, internal capsule, external capsule, periventricular, corona radiata, frontal and temporal lobes. Cerebrospinal fluid (CSF) examinations revealed elevated leukocyte and protein. India ink staining was positive for Cryptococcus. CSF culture and metagenomic next-generation sequencing (mNGS) confirmed Cryptococcus neoformans. Initial response was observed with intravenous fluconazole (400 mg per day). However, 11 days later, he developed impaired consciousness and incontinence of urine and feces. A repeat brain MRI showed the lesions were progressive and enlarged. The patient was referred to our department at this point of time. Repeat CSF analysis (India ink staining, culture and mNGS) re-confirmed Cryptococcus. However, clinical worsening after initial improvement, laboratory examinations and brain MRI findings suggested a diagnosis of infection-related inflammatory syndrome. Therefore, a combination of corticosteroids and antifungal therapy was initiated. At follow-up, a complete neurological recovery without any relapse was documented. The repeat brain MRI showed complete resolution of the previous lesions.

Conclusions

This case demonstrated that cryptococcal inflammatory syndromes must be suspected in cases of CM if an otherwise unexplained clinical deterioration is observed after initial recovery. The same can happen even before the primary infection is controlled. Thus, timely identification and prompt treatment is vital to reduce the mortality and disability of CM. The administration of corticosteroids in combination with antifungal therapy is an effective strategy in such cases.

Graphical abstract

Clinical course and treatment process of the patient. Hemiparalysis and aphasia improved after the initiation of antifungal treatment. However, the patient developed impaired consciousness companied by deterioration of brain MRI findings. He was treated with adjunctive glucocorticoid taper therapy consisting of dexamethasone (20 mg/day, intravenously) for 1 week followed by oral prednisone 1 mg/kg/day, tapered based on clinical and radiological response, along with amphotericin B (0.6 mg/kg/day, intravenously), voriconazole (400 mg/day in 2 divided doses, intravenously), and 5-flucytosine (100 mg/kg/day in 4 divided doses, orally). Two weeks later, his symptoms improved significantly. After discharge, he began oral voriconazole for consolidation and maintenance therapy for 8 weeks and 9 months respectively. He recovered without any neurological sequelae at 6-month follow-up. Note: MRI = magnetic resonance imaging.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02773-4.

Comparison of features and outcomes between HIV-negative patients with Cryptococcus gattii meningitis and Cryptococcus neoformans meningitis in South China

OBJECTIVES

To compare the epidemiologic, clinical, laboratory, and imaging features, and outcomes in patients with Cryptococcus gattii meningitis (CGM) and Cryptococcus neoformans meningitis (CNM).

METHODS

We performed a retrospective study of HIV-negative patients with CGM and CNM (2015-2021) distinguished by metagenomic next-generation sequencing in cerebrospinal fluid in South China.

RESULTS

81 patients (17 CGM, 64 CNM) were enrolled (72.8% male, median age 49 years, range 21-77 years), and CGM patients were younger (median, 43 vs 53 years, p = 0.005). Of 17 CGM, VGI and VGII accounted for 70.6% and 29.4%, respectively. CGM patients had less underlying diseases (7/17 [41.2%] vs 48/64 [75%], p=0.018) and focal neurologic deficit (3/17 [17.6%] vs 35/64 [54.7%], p = 0.022), had higher intracranial pressure (15/17 [88.2%] vs 25/64 [39.1%], p=0.002), more meningeal enhancement (14/17 [82.4%] vs 32/64 [50%], p = 0.034), less parenchymal involvement (median, 1 vs 3, p = 0.018), more lung cryptococcomas (6/12 [50%] vs 6/47 [12.8%], p = 0.014), faster CSF fungal clearance (p = 0.004), less complications (median, 1 vs 3, p < 0.001), and more favorable outcomes (16/17 [94.1%] vs 41/64 [64.1%], p =0.035).

CONCLUSIONS

This study demonstrated that species identification helps to guide therapy and predict outcomes.

Immunological Predictors of Post Infectious Inflammatory Response Syndrome in HIV-Negative Immunocompetent Cryptococcal Meningitis

Objective

This research aims to study the correlation between serum immune factors and post-infectious inflammatory response syndrome (PIIRS) in immunocompetent cryptococcal meningitis (CM), and explore whether serum immune factors could be used to predict the development of PIIRS.

Methods

A cohort of 30 patients with PIIRS and 87 patients without PIIRS was selected from 347 CM patients. We analyzed the general clinical information and immunological indexes (cytokines, complement, immunoglobulin, inflammation, related cytological and biochemical indexes). Spearman correlation analysis and principal component analysis were used to explore the effects of the variables on PIIRS. Additionally, the variables were identified by a random forest-based classifier for predicting the development of PIIRS. The clinical value of predictors was verified by survival analysis.

Results

Compared with patients without PIIRS, patients with PIIRS had lower baseline serum interleukin-6 (IL-6, P = 0.006), immunoglobulin M (IgM, P = 0.004), and a higher baseline neutrophil ratio (P <0.001). The baseline neutrophil ratio (r = 0.359, P = 0.001), IgM (r = −0.272, P = 0.025), and IL-6 (r = −0.259, P = 0.027) were significantly correlated with PIIRS. Combining principal component analysis and random forest results, neutrophil ratio, neutrophil count, IgM, IL-6, and D-dimer were useful predictors. The accuracy of random forest prediction was 75.00%, AUC, and sensitivity were 0.76 and 70%, respectively. Further survival analysis of the time from treatment to PIIRS revealed that the development of PIIRS was associated with IgM (more than 98 days of treatment) and neutrophil ratio/count.

Conclusion

Baseline neutrophils ratio, neutrophil count, IgM, IL-6, and D-dimer may be clinically useful predictors of PIIRS in HIV-negative immunocompetent CM patients.

Post-Infectious Inflammatory Response Syndrome in an HIV-Negative Immunocompetent Elderly Patient With Cryptococcal Meningitis: A Case Report and Literature Review

We report a previously healthy 82-year-old male with cryptococcal meningitis (CM) who represented neurological deterioration due to post-infectious inflammatory response syndrome (PIIRS) occurring in 4 months after initial antifungal therapy. He was treated with corticosteroids for 2 months and recovered clinically. However, the clinical manifestation, cerebrospinal fluid (CSF), and brain magnetic resonance imaging (MRI) results got worse again on the next day after corticosteroid withdrawal. The analysis of inflammatory cytokines and culture on CSF, as well as brain MRI, still suggested a diagnosis of PIIRS. Therefore, corticosteroid therapy was used again and he subsequently obtained a complete resolution of symptoms.

SARS-CoV-2: its potential neurological manifestations and plausible mechanism: a review article

Coronavirus disease (COVID-19) was first identified in late December 2019. The disease began in Wuhan, Hubei province in China and since then it has spread quickly to many countries all over the world. COVID-19 is caused by a novel coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus was majorly seen to overwhelm the respiratory system with mild to severe acute respiratory syndrome considered pathognomic for the disease. However, with time a plethora of symptoms was observed in the patients infected with COVID-19 including strong evidence for neurological symptoms. Evidence suggests that the virus has both central and peripheral nervous system manifestations. Patients, particularly those who suffer from a severe illness, have a central nervous system (CNS) involvement and neurological manifestations. There is precise and targeted documentation of neurological symptoms with details of clinical, neurological, and electrophysiological findings. This review article thus gives an insight into the neuro-invasive potential of COVID-19 and discusses the possible pathogenesis.