1
|
Rouvray S, Drummond RA. The role of lipids in regulating macrophage antifungal immunity. mBio 2024:e0305723. [PMID: 39207168 DOI: 10.1128/mbio.03057-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Macrophages are critical components of the antifungal immune response. Disturbance in the number or function of these innate immune cells can significantly increase susceptibility to invasive fungal infections. Pathogenic fungi cause billions of infections every year and have an unmet clinical need, with many infections associated with unacceptably high mortality rates that primarily affect vulnerable patients with underlying immune defects. Lipid metabolism has been increasingly appreciated to significantly influence macrophage function, particularly of macrophages residing in lipid-rich organs, such as the brain, or macrophages specialized at clearing dead cells including alveolar macrophages in the lungs. In this review, we provide an overview of macrophage lipid metabolism, and discuss how lipid recycling and dysregulation affect key macrophage functions relevant for antifungal immunity including phagocytosis, functional polarization, and inflammasome activation. We focus on the fungal pathogen Cryptococcus neoformans, as this is the most common cause of death from fungal infection in humans and because several lines of evidence have already linked lipid metabolism in the regulation of C. neoformans and macrophage interactions.
Collapse
Affiliation(s)
- Sophie Rouvray
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Rebecca A Drummond
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
2
|
Soraci L, Beccacece A, Princiotto M, Villalta Savedra E, Gambuzza ME, Aguennouz M, Corsonello A, Luciani F, Muglia L, Filicetti E, Greco GI, Volpentesta M, Biscetti L. The emerging links between immunosenescence in innate immune system and neurocryptococcosis. Front Immunol 2024; 15:1410090. [PMID: 39229268 PMCID: PMC11369721 DOI: 10.3389/fimmu.2024.1410090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 07/29/2024] [Indexed: 09/05/2024] Open
Abstract
Immunosenescence refers to the age-related progressive decline of immune function contributing to the increased susceptibility to infectious diseases in older people. Neurocryptococcosis, an infectious disease of central nervous system (CNS) caused by Cryptococcus neoformans (C. Neoformans) and C. gattii, has been observed with increased frequency in aged people, as result of the reactivation of a latent infection or community acquisition. These opportunistic microorganisms belonging to kingdom of fungi are capable of surviving and replicating within macrophages. Typically, cryptococcus is expelled by vomocytosis, a non-lytic expulsive mechanism also promoted by interferon (IFN)-I, or by cell lysis. However, whereas in a first phase cryptococcal vomocytosis leads to a latent asymptomatic infection confined to the lung, an enhancement in vomocytosis, promoted by IFN-I overproduction, can be deleterious, leading the fungus to reach the blood stream and invade the CNS. Cryptococcus may not be easy to diagnose in older individuals and, if not timely treated, could be potentially lethal. Therefore, this review aims to elucidate the putative causes of the increased incidence of cryptococcal CNS infection in older people discussing in depth the mechanisms of immunosenscence potentially able to predispose to neurocryptococcosis, laying the foundations for future research. A deepest understanding of this relationship could provide new ways to improve the prevention and recognition of neurocryptococcosis in aged frail people, in order to quickly manage pharmacological interventions and to adopt further preventive measures able to reduce the main risk factors.
Collapse
Affiliation(s)
- Luca Soraci
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Alessia Beccacece
- Centre for Biostatistics and Applied Geriatric Clinical Epidemiology, Italian National Research Center on Aging (IRCCS INRCA), Ancona, Italy
| | | | | | | | - M’Hammed Aguennouz
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Diseases, University of Messina, Messina, Italy
| | - Andrea Corsonello
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Sciences, School of Medicine and Digital Technologies, University of Calabria, Arcavacata di Rende, Italy
| | | | - Lucia Muglia
- Centre for Biostatistics and Applied Geriatric Clinical Epidemiology, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Elvira Filicetti
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Giada Ida Greco
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Mara Volpentesta
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Leonardo Biscetti
- Section of Neurology, Italian National Research Center on Aging (IRCCS INRCA), Ancona, Italy
| |
Collapse
|
3
|
Al-Huthaifi AM, Radman BA, Al-Alawi AA, Mahmood F, Liu TB. Mechanisms and Virulence Factors of Cryptococcus neoformans Dissemination to the Central Nervous System. J Fungi (Basel) 2024; 10:586. [PMID: 39194911 DOI: 10.3390/jof10080586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/31/2024] [Accepted: 08/15/2024] [Indexed: 08/29/2024] Open
Abstract
Cryptococcosis is a prevalent fungal infection of the central nervous system (CNS) caused by Cryptococcus neoformans, a yeast with a polysaccharide capsule in the basidiomycete group. Normally, C. neoformans infects the respiratory tract and then breaches the blood-brain barrier (BBB), leading to meningitis or meningoencephalitis, which leads to hundreds of thousands of deaths each year. Although the mechanism by which C. neoformans infiltrates the BBB to invade the brain has yet to be fully understood, research has revealed that C. neoformans can cross the BBB using transcellular penetration, paracellular traversal, and infected phagocytes (the "Trojan horse" mechanism). The secretion of multiple virulence factors by C. neoformans is crucial in facilitating the spread of infection after breaching the BBB and causing brain infections. Extensive research has shown that various virulence factors play a significant role in the dissemination of infection beyond the lungs. This review explores the mechanisms of C. neoformans entering the CNS and explains how it bypasses the BBB. Additionally, it aims to understand the interplay between the regulatory mechanisms and virulence factors of C. neoformans.
Collapse
Affiliation(s)
| | - Bakeel A Radman
- Cancer Center, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou 510315, China
| | | | - Fawad Mahmood
- Medical Research Institute, Southwest University, Chongqing 400715, China
| | - Tong-Bao Liu
- Medical Research Institute, Southwest University, Chongqing 400715, China
- Jinfeng Laboratory, Chongqing 401329, China
- Engineering Research Center for Cancer Biomedical and Translational Medicine, Southwest University, Chongqing 400715, China
| |
Collapse
|
4
|
Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, Hagen F, Spec A, Oladele R, Govender NP, Chen SC, Mody CH, Groll AH, Chen YC, Lionakis MS, Alanio A, Castañeda E, Lizarazo J, Vidal JE, Takazono T, Hoenigl M, Alffenaar JW, Gangneux JP, Soman R, Zhu LP, Bonifaz A, Jarvis JN, Day JN, Klimko N, Salmanton-García J, Jouvion G, Meya DB, Lawrence D, Rahn S, Bongomin F, McMullan BJ, Sprute R, Nyazika TK, Beardsley J, Carlesse F, Heath CH, Ayanlowo OO, Mashedi OM, Queiroz-Telles Filho F, Hosseinipour MC, Patel AK, Temfack E, Singh N, Cornely OA, Boulware DR, Lortholary O, Pappas PG, Perfect JR. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. THE LANCET. INFECTIOUS DISEASES 2024; 24:e495-e512. [PMID: 38346436 DOI: 10.1016/s1473-3099(23)00731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/13/2023] [Indexed: 03/21/2024]
Abstract
Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.
Collapse
Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia; Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC, Australia; Centre for the AIDS Programme of Research in South Africa, Durban, South Africa.
| | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Tihana A Bicanic
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tania C Sorrell
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Adilia Warris
- Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Infectious Diseases, Great Ormond Street Hospital, London, UK
| | - Ferry Hagen
- Faculty of Science, Institute for Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, Netherlands; Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Rita Oladele
- College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nelesh P Govender
- Institute of Infection and Immunity, St George's University London, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sharon C Chen
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Christopher H Mody
- Department of Microbiology, Immunology and Infectious Diseases, Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Andreas H Groll
- Infectious Disease Research Program, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany; Center for Bone Marrow Transplantation, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alexandre Alanio
- Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Groupe de recherche Mycologie Translationnelle, Département de Mycologie, Université Paris Cité, Paris, France; Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | | | - Jairo Lizarazo
- Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Faculty of Health, Univesidad de Pamplona, Cúcuta, Colombia
| | - José E Vidal
- Departmento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil; Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto de Medicina Tropical, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Takahiro Takazono
- Department of Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Martin Hoenigl
- Division of Infectious Diseases, Translational Medical Mycology Research Unit, European Confederation of Medical Mycology Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria; BioTechMed, Graz, Austria
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia; School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jean-Pierre Gangneux
- Institute for Health, Environment and Work Research-Irset, Inserm UMR_S 1085, University of Rennes, Rennes, France; Laboratory for Parasitology and Mycology, Centre National de Référence Mycoses Invasives et Antifongiques LA Asp-C, University Hospital of Rennes, Rennes, France
| | - Rajeev Soman
- Jupiter Hospital, Pune, India; Deenanath Mangeshkar Hospital, Pune, India; Hinduja Hospital, Mumbai, India
| | - Li-Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai China
| | - Alexandro Bonifaz
- Hospital General de México, Dermatology Service, Mycology section, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Jeremy N Day
- Department of Clinical Microbiology and Infection, Royal Devon and Exeter University Hospital NHS Trust, Exeter, UK
| | - Nikolai Klimko
- Department of Clinical Mycology, Allergy and Immunology, I Mechnikov North Western State Medical University, Staint Petersburg, Russia
| | - Jon Salmanton-García
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Grégory Jouvion
- Histology and Pathology Unit, Ecole nationale vétérinaire d'Alfort, Maisons-Alfort, France; Dynamyc Team, Université Paris Est Créteil and Ecole nationale vétérinaire d'Alfort, Créteil, France
| | - David B Meya
- Infectious Diseases Institute, School of Medicine, College of Heath Sciences, Makerere University, Kampala, Uganda
| | - David Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Sebastian Rahn
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Brendan J McMullan
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Rosanne Sprute
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Tinashe K Nyazika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Fabianne Carlesse
- Pediatric Department, Federal University of São Paulo, São Paulo, Brazil; Oncology Pediatric Institute-IOP-GRAACC, Federal Univeristy of São Paulo, São Paulo, Brazil
| | - Christopher H Heath
- Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Perth, WA, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia; UWA Medical School, Internal Medicine, The University of Western Australia, Perth, WA, Australia
| | - Olusola O Ayanlowo
- Dermatology Unit, Department of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Olga M Mashedi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mina C Hosseinipour
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA; UNC Project Malawi, Lilongwe, Malawi
| | - Atul K Patel
- Department of Infectious Diseases, Sterling Hospitals, Ahmedabad, India
| | - Elvis Temfack
- Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Nina Singh
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Oliver A Cornely
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany; Clinical Trials Centre Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Olivier Lortholary
- Université de Paris Cité, APHP, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Centre d'Infectiologie Necker-Pasteur, Institut Imagine, Paris, France; Institut Pasteur, CNRS, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, UMR 2000, Paris, France
| | - Peter G Pappas
- Mycoses Study Group Central Unit, Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA.
| |
Collapse
|
5
|
Vlasova-St. Louis I, Mohei H. Molecular Diagnostics of Cryptococcus spp. and Immunomics of Cryptococcosis-Associated Immune Reconstitution Inflammatory Syndrome. Diseases 2024; 12:101. [PMID: 38785756 PMCID: PMC11120354 DOI: 10.3390/diseases12050101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/05/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Cryptococcal infection poses a significant global public health challenge, particularly in regions near the equator. In this review, we offer a succinct exploration of the Cryptococcus spp. genome and various molecular typing methods to assess the burden and genetic diversity of cryptococcal pathogens in the environment and clinical isolates. We delve into a detailed discussion on the molecular pathogenesis and diagnosis of immune reconstitution inflammatory syndrome (IRIS) associated with cryptococcosis, with a specific emphasis on cryptococcal meningitis IRIS (CM-IRIS). Our examination includes the recent literature on CM-IRIS, covering host cellulomics, proteomics, transcriptomics, and genomics.
Collapse
Affiliation(s)
| | - Hesham Mohei
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| |
Collapse
|
6
|
Meya DB, Williamson PR. Cryptococcal Disease in Diverse Hosts. N Engl J Med 2024; 390:1597-1610. [PMID: 38692293 DOI: 10.1056/nejmra2311057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Affiliation(s)
- David B Meya
- From the Infectious Diseases Institute and the Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda (D.B.M.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.B.M.); and the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.R.W.)
| | - Peter R Williamson
- From the Infectious Diseases Institute and the Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda (D.B.M.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.B.M.); and the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (P.R.W.)
| |
Collapse
|
7
|
Hargarten JC, Ssebambulidde K, Anjum SH, Vaughan MJ, Xu J, Song B, Ganguly A, Park YD, Scott T, Hammoud DA, Olszewski MA, Williamson PR. JAK/STAT Signaling Predominates in Human and Murine Fungal Post-infectious Inflammatory Response Syndrome. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.18.24301483. [PMID: 38293201 PMCID: PMC10827263 DOI: 10.1101/2024.01.18.24301483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Post-infection inflammatory syndromes have been increasingly recognized as a cause of host damage in a variety of infectious diseases including tuberculosis, bacterial meningitis, and COVID-19. Recently, a post-infectious inflammatory response syndrome (PIIRS) was described in non-HIV-infected cryptococcal fungal meningoencephalitis (CM) as a major cause of mortality. Inflammatory syndromes are particularly severe in neurological infections due to the skull's rigid structure which limits unchecked tissue expansion from inflammatory-induced edema. In the present studies, neurologic transcriptional pathway analysis utilizing a murine PIIRS model demonstrated a predominance of Janus kinase/signal transducer and activator of transcription (JAK/STAT) activation. JAK/STAT inhibitor treatment resulted in improvements in CNS damage markers, reductions in intrathecal CD44hiCD62lo CD4+ effector CD4+ T-cells and MHC II+ inflammatory myeloid cells, and weight gains in mice, the latter after treatment with antifungals. Based on these data, pathway-driven steroid-sparing human treatment for steroid-refractory PIIRS was initiated using short courses of the JAK/STAT inhibitor ruxolitinib. These were well tolerated and reduced activated HLA-DR+ CD4+ and CD8+ cells and inflammatory monocytes as well as improved brain imaging. Together, these findings support the role of JAK/STAT in PIIRS as well as further study of JAK/STAT inhibitors as potential adjunctive therapy for PIRS and other neural inflammatory syndromes.
Collapse
Affiliation(s)
- Jessica C. Hargarten
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Kenneth Ssebambulidde
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Seher H. Anjum
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Malcolm J. Vaughan
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jintao Xu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Research Service, Ann Arbor VA Healthcare System, Department of Veterans Affairs Health System, Ann Arbor, MI, USA
| | - Brian Song
- Research Service, Ann Arbor VA Healthcare System, Department of Veterans Affairs Health System, Ann Arbor, MI, USA
| | - Anutosh Ganguly
- Research Service, Ann Arbor VA Healthcare System, Department of Veterans Affairs Health System, Ann Arbor, MI, USA
| | - Yoon-dong Park
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Terri Scott
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Michal A. Olszewski
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Research Service, Ann Arbor VA Healthcare System, Department of Veterans Affairs Health System, Ann Arbor, MI, USA
| | - Peter R. Williamson
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| |
Collapse
|
8
|
Okurut S, Boulware DR, Okafor E, Rhein J, Kajumbula H, Bagaya BS, Bwanga F, Olobo JO, Manabe YC, Meya DB, Janoff EN. Divergent neuroimmune signatures in the cerebrospinal fluid predict differential gender-specific survival among patients with HIV-associated cryptococcal meningitis. Front Immunol 2023; 14:1275443. [PMID: 38152404 PMCID: PMC10752005 DOI: 10.3389/fimmu.2023.1275443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/20/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction Survival among people with HIV-associated cryptococcal meningitis (CM) remains low, particularly among women, despite the currently optimal use of antifungal drugs. Cryptococcus dissemination into the central nervous system [brain, spinal cord, and cerebrospinal fluid (CSF)] elicits the local production of cytokines, chemokines, and other biomarkers. However, no consistent diagnostic or prognostic neuroimmune signature is reported to underpin the risk of death or to identify mechanisms to improve treatment and survival. We hypothesized that distinct neuroimmune signatures in the CSF would distinguish survivors from people who died on antifungal treatment and who may benefit from tailored therapy. Methods We considered baseline clinical features, CSF cryptococcal fungal burden, and CSF neuroimmune signatures with survival at 18 weeks among 419 consenting adults by "gender" (168 women and 251 men by biological sex defined at birth). Results Survival at 18 weeks was significantly lower among women than among men {47% vs. 59%, respectively; hazard ratio (HR) = 1.4 [95% confidence interval (CI), 1.0 to 1.9; p = 0.023]}. Unsupervised principal component analysis (PCA) demonstrated divergent neuroimmune signatures by gender, survival, and intragender-specific survival. Overall, women had lower levels of programmed death ligand 1, Interleukin (IL) (IL-11RA/IL-1F30, and IL-15 (IL-15) than men (all p < 0.028). Female survivors compared with those who died expressed significant elevations in levels of CCL11 and CXCL10 chemokines (both p = 0.001), as well as increased T helper 1, regulatory, and T helper 17 cytokines (all p < 0.041). In contrast, male survivors expressed lower levels of IL-15 and IL-8 compared with men who died (p < 0.044). Conclusions Survivors of both genders demonstrated a significant increase in the levels of immune regulatory IL-10. In conclusion, the lower survival among women with CM was accompanied by distinct differential gender-specific neuroimmune signatures. These female and male intragender-specific survival-associated neuroimmune signatures provide potential targets for interventions to advance therapy to improve the low survival among people with HIV-associated CM.
Collapse
Affiliation(s)
- Samuel Okurut
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Elizabeth Okafor
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Henry Kajumbula
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Bernard S. Bagaya
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Freddie Bwanga
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph O. Olobo
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yukari C. Manabe
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, John Hopkins University School of Medicine, Baltimore, MD, United States
| | - David B. Meya
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edward N. Janoff
- Mucosal and Vaccine Research Program Colorado, Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, United States
- Department of Medicine and Infectious Disease, Denver Veterans Affairs Medical Center, Denver, CO, United States
| |
Collapse
|
9
|
Hargarten JC, Anjum SH, Ssebambulidde K, Park YD, Vaughan MJ, Scott TL, Hammoud DA, Billioux BJ, Williamson PR. Tocilizumab as a Potential Adjunctive Therapy to Corticosteroids in Cryptococcal Post-infectious Inflammatory Response Syndrome (PIIRS): a Report of Two Cases. J Clin Immunol 2023; 43:2146-2155. [PMID: 37814084 DOI: 10.1007/s10875-023-01592-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/20/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Non-HIV cryptococcal meningoencephalitis (CM) in previously healthy individuals is often complicated by a post-infectious inflammatory response syndrome (c-PIIRS) characterized by neurologic deterioration after appropriate antifungal therapy with sterilization of CSF fungal cultures. c-PIIRS results from an excessive inflammatory response to fungal antigens released during fungal lysis, mediated by IFN-γ, IL-6, and activated T-helper cells, leading to immune-mediated host damage that responds to pulse-corticosteroid taper therapy (PCT). Typically, oral steroids may take up to a year to taper, and occasionally, patients will be refractory to steroid therapy or may demonstrate high-risk lesions such as those involving intracranial arteries. Also, patients can have problematic side effects from prolonged corticosteroids. Hence, appropriate adjunctive agents are needed to reduce corticosteroid doses in the treatment of c-PIIRS. Due to a possible role of IL-6 in pathogenesis, IL-6 receptor blockade by tocilizumab may be useful in the treatment of c-PIIRS. METHODS Two previously healthy patients with non-HIV cPIIRS were seen at the NIH. Due to concerns for intracranial vascular rupture in an area of inflammation (Patient 1) and intractable symptoms on high-dose oral corticosteroids (Patient 2) with evidence of persistent CSF inflammation, patients were treated with 4-8 mg/kg tocilizumab every 2 weeks while maintained on a constant dose of prednisone. RESULTS Two patients exhibited rapid immunological improvement following treatment with tocilizumab. Patient 1 remained vascularly stable, and Patient 2 had near resolution of headaches with improvement in mental status as evidenced by improved MOCA score. The two had improved CSF inflammatory parameters and no significant side effects. Both CSF cultures remained negative throughout treatment. CONCLUSIONS Tocilizumab may be a safe adjunctive treatment for CM-related PIIRS suggesting further study.
Collapse
Affiliation(s)
- Jessica C Hargarten
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bldg 10, Rm 11C208, Bethesda, MD, 20892, USA
| | - Seher H Anjum
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bldg 10, Rm 11C208, Bethesda, MD, 20892, USA
| | - Kenneth Ssebambulidde
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bldg 10, Rm 11C208, Bethesda, MD, 20892, USA
| | - Yoon-Dong Park
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bldg 10, Rm 11C208, Bethesda, MD, 20892, USA
| | - Malcolm J Vaughan
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bldg 10, Rm 11C208, Bethesda, MD, 20892, USA
| | - Terri L Scott
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bldg 10, Rm 11C208, Bethesda, MD, 20892, USA
| | - Dima A Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Bridgette Jeanne Billioux
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bldg 10, Rm 11C208, Bethesda, MD, 20892, USA.
| |
Collapse
|
10
|
Cumagun PM, Moore MK, McCarty TP, McGwin G, Pappas PG. Cryptococcal Meningoencephalitis in Phenotypically Normal Patients. Pathogens 2023; 12:1303. [PMID: 38003768 PMCID: PMC10674724 DOI: 10.3390/pathogens12111303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/20/2023] [Accepted: 09/28/2023] [Indexed: 11/26/2023] Open
Abstract
Cryptococcosis is an invasive fungal infection found worldwide that causes significant morbidity and mortality among a broad range of hosts. There are approximately 223,000 new cases of cryptococcosis annually throughout the world, and at least 180,000 deaths are attributed to this infection each year. Most of these are due to complications of cryptococcal meningoencephalitis among HIV-infected patients in resource-limited environments. The majority of individuals diagnosed with cryptococcosis have underlying conditions associated with immune dysfunction such as HIV, solid organ transplant, hematologic malignancy, organ failure syndromes, and/or the use of immunosuppressive agents such as glucocorticosteroids and biologic agents. In most clinical series, there is a small proportion of patients with cryptococcosis who are phenotypically normal; that is, they have no clinically obvious predisposition to disease. Cryptococcal meningoencephalitis (CME) presentation and management differ substantially between these normal individuals and their immunocompromised counterparts. In this review, we will focus on CME in the phenotypically normal host and underscore differences in the clinical presentation, management, outcome, and potential risk factors for these patients compared to immunocompromised persons who develop this potential devastating invasive fungal infection.
Collapse
Affiliation(s)
- Pia M. Cumagun
- Department of Medicine, Division of Infectious Diseases, The University of Alabama at Birmingham, Birmingham, AL 35294, USA; (P.M.C.)
| | | | - Todd P. McCarty
- Department of Medicine, Division of Infectious Diseases, The University of Alabama at Birmingham, Birmingham, AL 35294, USA; (P.M.C.)
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, University of Alabama, Birmingham, AL 35294, USA
| | - Peter G. Pappas
- Department of Medicine, Division of Infectious Diseases, The University of Alabama at Birmingham, Birmingham, AL 35294, USA; (P.M.C.)
| |
Collapse
|
11
|
Stack M, Hiles J, Valinetz E, Gupta SK, Butt S, Schneider JG. Cryptococcal Meningitis in Young, Immunocompetent Patients: A Single-Center Retrospective Case Series and Review of the Literature. Open Forum Infect Dis 2023; 10:ofad420. [PMID: 37636518 PMCID: PMC10456216 DOI: 10.1093/ofid/ofad420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
Background Cryptococcal meningitis is an uncommon but serious infection with high mortality and morbidity. Classically described in immunocompromised patients, including those with solid organ transplants or HIV/AIDS, cryptococcosis has also been reported in young and otherwise healthy patients, albeit rarely. Methods We retrospectively searched for all cases of cryptococcal meningitis in young (≤50 years) and previously healthy patients with no known immunocompromising conditions from January 2015 to January 2022 at Indiana University Health (IU Health). Additionally, a PubMed literature review was performed with the keywords "cryptococcal meningitis" and "immunocompetent" from January 1988 to January 2022. Clinical courses, including outcomes and treatment regimens, were evaluated. Results We identified 4 local cases of cryptococcal meningitis in otherwise healthy patients age ≤50 years. Three cases were due to Cryptococcus neoformans, with 1 experiencing a postinfectious inflammatory response syndrome (PIIRS). The PubMed search identified 51 additional cases, with 32 (63%) being caused by Cryptococcus neoformans and 8 (17%) by Cryptococcus gattii. Of the 51 cases, only 2 resulted in death directly due to cryptococcosis. Fifteen (29%) had PIIRS, with steroid treatment documented in 11 of 15. Antifungal induction regimens and duration were varied but predominately consisted of amphotericin and flucytosine, with a mean induction duration of 5.0 weeks. Conclusions Cryptococcal meningitis in young, previously healthy patients is likely under-recognized. PIIRS (akin to immune reconstitution inflammatory syndrome observed in HIV/AIDS) with prolonged recovery should be of concern. Determining risk factors for cryptococcosis in these patients remains elusive.
Collapse
Affiliation(s)
- Matthew Stack
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jon Hiles
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Health, Indianapolis, Indiana, USA
| | - Ethan Valinetz
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samir K Gupta
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Saira Butt
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jack G Schneider
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
12
|
Shi J, Chen J, Hu L, Ma AHY, Hu H, Wang C, Huang J, Song Q, Qian G. Retrospective analysis of pulmonary cryptococcosis and extrapulmonary cryptococcosis in a chinese tertiary hospital. BMC Pulm Med 2023; 23:277. [PMID: 37501136 PMCID: PMC10375642 DOI: 10.1186/s12890-023-02578-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 07/21/2023] [Indexed: 07/29/2023] Open
Abstract
Cryptococcosis is an invasive fungal disease with increased morbidity in China over the past two decades. Cryptococci can infect immunocompromised hosts as well as immunocompetent ones. In this study, we reviewed data of 71 inpatients with cryptococcosis at Ningbo First Hospital from May 2010 to May 2020 and compared the clinical profiles of pulmonary cryptococcosis (PC) and extrapulmonary cryptococcosis (EPC). Of 71 patients (38 males, 33 females), 70 were non-HIV. The annual inpatient population increased dramatically, especially in the PC group. PC was confirmed in 77.46% (55/71) of cases by pathology. The rest were EPC including intracranial infection (15.49%, 11/71) and cryptococcemia (7.04%, 5/71). Compared with PC, a larger proportion of EPC patients were found to have immunocompromised conditions judged by predisposing factors (p < 0.01), or detectable humoral or cellular immunodeficiency. Fever and headache were more common in EPC patients (p < 0.001). Patients with EPC had lower serum sodium level (p = 0.041), lower monocyte counts (p = 0.025) and higher C-reactive protein (p = 0.012). In our study, the sensitivity of cryptococcus antigen detection for EPC was 100% regardless of sample type, while serum lateral flow assay (LFA) tested negative in 25% (5/20) of PC. Immunocompromised hosts are more likely to suffer from EPC than PC.
Collapse
Affiliation(s)
- Jiejun Shi
- Department of Infectious Diseases, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang Province, China.
| | - Jianhua Chen
- Department of Radiology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang Province, China
| | - Liqing Hu
- Department of Clinical Laboratory, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang, China
| | - Ada Hoi Yan Ma
- Nottingham University Business School, University of Nottingham Ningbo China, Ningbo, Zhejiang Province, China
| | - Haoxuan Hu
- Department of Internal Medicine, Fenghua District Hospital, Ningbo, Zhejiang Province, China
| | - Chuwen Wang
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Jiajia Huang
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Qifa Song
- Medical Data Research Center, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang Province, China
| | - Guoqing Qian
- Department of Infectious Diseases, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang Province, China
| |
Collapse
|
13
|
Lionakis MS, Drummond RA, Hohl TM. Immune responses to human fungal pathogens and therapeutic prospects. Nat Rev Immunol 2023; 23:433-452. [PMID: 36600071 PMCID: PMC9812358 DOI: 10.1038/s41577-022-00826-w] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 01/06/2023]
Abstract
Pathogenic fungi have emerged as significant causes of infectious morbidity and death in patients with acquired immunodeficiency conditions such as HIV/AIDS and following receipt of chemotherapy, immunosuppressive agents or targeted biologics for neoplastic or autoimmune diseases, or transplants for end organ failure. Furthermore, in recent years, the spread of multidrug-resistant Candida auris has caused life-threatening outbreaks in health-care facilities worldwide and raised serious concerns for global public health. Rapid progress in the discovery and functional characterization of inborn errors of immunity that predispose to fungal disease and the development of clinically relevant animal models have enhanced our understanding of fungal recognition and effector pathways and adaptive immune responses. In this Review, we synthesize our current understanding of the cellular and molecular determinants of mammalian antifungal immunity, focusing on observations that show promise for informing risk stratification, prognosis, prophylaxis and therapies to combat life-threatening fungal infections in vulnerable patient populations.
Collapse
Affiliation(s)
- Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
| | - Rebecca A Drummond
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Tobias M Hohl
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
14
|
El-Atoum M, Hargarten JC, Park YD, Ssebambulidde K, Ding L, Chittiboina P, Hammoud DA, Anjum SH, Glassman SR, Merchant S, Williamson PR, Hu JC. Persistent neurological symptoms and elevated intracranial pressures in a previously healthy host with cryptococcal meningitis. BMC Infect Dis 2023; 23:407. [PMID: 37316806 DOI: 10.1186/s12879-023-08349-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/25/2023] [Indexed: 06/16/2023] Open
Abstract
Cryptococcal meningoencephalitis can occur in both previously healthy and immunocompromised hosts. Here, we describe a 55 year-old HIV-negative male with no known prior medical problems, who presented with three months of worsening headaches, confusion, and memory changes without fever. Magnetic resonance imaging of the brain demonstrated bilateral enlargement/enhancement of the choroid plexi, with hydrocephalus, temporal and occipital horn entrapments, as well as marked periventricular transependymal cerebrospinal fluid (CSF) seepage. CSF analysis yielded a lymphocytic pleocytosis and cryptococcal antigen titer of 1:160 but sterile fungal cultures. Despite standard antifungal therapy and CSF drainage, the patient had worsening confusion and persistently elevated intracranial pressures. External ventricular drainage led to improved mental status but only with valve settings at negative values. Ventriculoperitoneal shunt placement could thus not be considered due to a requirement for drainage into the positive pressure venous system. Due to this persistent CSF inflammation and cerebral circulation obstruction, the patient required transfer to the National Institute of Health. He was treated for cryptococcal post-infectious inflammatory response syndrome with pulse-taper corticosteroid therapy, with resultant reductions in CSF pressures along with decreased protein and obstructive material, allowing successful shunt placement. After tapering of corticosteroids, the patient recovered without sequelae. This case highlights (1) the necessity to consider cryptococcal meningitis as a rare cause of neurological deterioration in the absence of fever even in apparently immunocompetent individuals and (2) the potential for obstructive phenomena from inflammatory sequelae and the prompt response to corticosteroid therapy.
Collapse
Affiliation(s)
- Mohammad El-Atoum
- Department of Medicine, Good Samaritan Hospital, SSM Health Medical Group, Mount Vernon, IL, USA.
| | - Jessica C Hargarten
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Yoon-Dong Park
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Kenneth Ssebambulidde
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Li Ding
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Dima A Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Seher H Anjum
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Seth R Glassman
- Department of Medicine, Division of Infectious Diseases, University at Buffalo, 955 Main Street, Buffalo, NY, 14203, USA
| | - Shehzad Merchant
- Department of Medicine, Division of Infectious Diseases, University at Buffalo, 955 Main Street, Buffalo, NY, 14203, USA
| | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - John C Hu
- Department of Medicine, Division of Infectious Diseases, University at Buffalo, 955 Main Street, Buffalo, NY, 14203, USA.
| |
Collapse
|
15
|
Lionakis MS. Exploiting antifungal immunity in the clinical context. Semin Immunol 2023; 67:101752. [PMID: 37001464 PMCID: PMC10192293 DOI: 10.1016/j.smim.2023.101752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Indexed: 03/31/2023]
Abstract
The continuous expansion of immunocompromised patient populations at-risk for developing life-threatening opportunistic fungal infections in recent decades has helped develop a deeper understanding of antifungal host defenses, which has provided the foundation for eventually devising immune-based targeted interventions in the clinic. This review outlines how genetic variation in certain immune pathway-related genes may contribute to the observed clinical variability in the risk of acquisition and/or severity of fungal infections and how immunogenetic-based patient stratification may enable the eventual development of personalized strategies for antifungal prophylaxis and/or vaccination. Moreover, this review synthesizes the emerging cytokine-based, cell-based, and other immunotherapeutic strategies that have shown promise as adjunctive therapies for boosting or modulating tissue-specific antifungal immune responses in the context of opportunistic fungal infections.
Collapse
Affiliation(s)
- Michail S Lionakis
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
| |
Collapse
|
16
|
Fernando Nicolas-Cruz C, Ariza-Varon M, Gustavo Mondragón-Soto M, Suarez-Venegas A, Villalobos-Diaz R, Marian-Magaña R, Moreno-Jiménez S, Luis Soto-Hernández J. Cryptococcoma mimicking a brain tumor in an immunocompetent patient: A case and illustrative report. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
17
|
Samukawa S, Yoshimi R, Kojitani N, Uzawa Y, Takase-Minegishi K, Kirino Y, Soejima Y, Kato H, Nakajima H. Cryptococcal meningitis with atypical paradoxical inflammatory reactions after antifungal treatment in acquired immune deficiency syndrome: A case report. J Infect Chemother 2023; 29:347-352. [PMID: 36384196 DOI: 10.1016/j.jiac.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/24/2022] [Accepted: 11/07/2022] [Indexed: 11/14/2022]
Abstract
Cryptococcal meningitis (CM) is a life-threatening disease that primarily affects patients with human immunodeficiency virus (HIV). Antifungal therapy with antiretroviral treatment (ART) usually leads to the clinical remission of CM; however, in some cases, these treatments exacerbate intracranial inflammation because of paradoxical inflammatory reaction or immune reconstitution inflammatory syndrome (IRIS). Here we report two CM cases that presented atypical clinical courses attributed to paradoxical inflammatory reactions. The first case was a 43-year-old man with headache and vertigo diagnosed with CM and HIV. The patient's CM not only was refractory to the antifungal combination therapy of liposomal amphotericin B (L-AMB) and fluconazole (FLCZ) but suddenly worsened because of a paradoxical inflammatory reaction after 18 days of treatment. He passed away from brain herniation on day 23. The second case was a 43-year-old man diagnosed with CM and HIV. After receiving antifungal therapy and ART, the patient's status was stable for more than 3 years with undetectable HIV-RNA. He suddenly presented with brain inflammation and was diagnosed with IRIS due to CM (CM-IRIS). His brain lesions were migratory and refractory to various antifungal therapies such as L-AMB, FLCZ, flucytosine, and intrathecal amphotericin B. Although the cryptococcal antigen in the patient's cerebrospinal fluid gradually diminished after continuous antifungal therapies, his cognitive function declined, and right hemiparesis persisted. These two cases of CM presented atypical clinical courses, presumably because of paradoxical inflammatory reactions. It should be noted that the onset of CM-IRIS may not necessarily depend on the timing of ART initiation.
Collapse
Affiliation(s)
- Sei Samukawa
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan.
| | - Noriko Kojitani
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Yuji Uzawa
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Yutaro Soejima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Hideaki Kato
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| |
Collapse
|
18
|
Liu J, Liu J, Yang L, Xu X, Bang-E Q, Jiang Y, Peng F. Review: The application of corticosteroids in cryptococcal meningitis. J Mycol Med 2023; 33:101364. [PMID: 36870302 DOI: 10.1016/j.mycmed.2023.101364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 11/30/2022] [Accepted: 02/21/2023] [Indexed: 03/05/2023]
Abstract
Cryptococcal meningitis (CM) is a serious disease with high morbidity and mortality. Although the patients who received corticosteroids were at high risk of having CM, corticosteroids also have been used as an adjunct to antifungal drugs for treating people with CM in some situations (such as immune reconstitution inflammatory syndrome, cerebral cyptococcoma, et al.). Here, we summarize the current knowledge on the application of the corticosteroids in CM, aiming to help clinicians to reasonably use corticosteroids in patients with CM.
Collapse
Affiliation(s)
- Junyu Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong 510630, PR China
| | - Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong 510630, PR China
| | - Lu Yang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong 510630, PR China
| | - Xiaofeng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong 510630, PR China
| | - Qin Bang-E
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong 510630, PR China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong 510630, PR China.
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong 510630, PR China.
| |
Collapse
|
19
|
Hansakon A, Ngamphiw C, Tongsima S, Angkasekwinai P. Arginase 1 Expression by Macrophages Promotes Cryptococcus neoformans Proliferation and Invasion into Brain Microvascular Endothelial Cells. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 210:408-419. [PMID: 36548474 DOI: 10.4049/jimmunol.2200592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022]
Abstract
Cryptococcal meningoencephalitis caused by Cryptococcus neoformans infection is the most common cause of death in HIV/AIDS patients. Macrophages are pivotal for the regulation of immune responses to cryptococcal infection by either playing protective function or facilitating fungal dissemination. However, the mechanisms underlying macrophage responses to C. neoformans remain unclear. To analyze the transcriptomic changes and identify the pathogenic factors of macrophages, we performed a comparative transcriptomic analysis of alveolar macrophage responses during C. neoformans infection. Alveolar macrophages isolated from C. neoformans-infected mice showed dynamic gene expression patterns, with expression change from a protective M1 (classically activated)-like to a pathogenic M2 (alternatively activated)-like phenotype. Arg1, the gene encoding the enzyme arginase 1, was found as the most upregulated gene in alveolar macrophages during the chronic infection phase. The in vitro inhibition of arginase activity resulted in a reduction of cryptococcal phagocytosis, intracellular growth, and proliferation, coupled with an altered macrophage response from pathogenic M2 to a protective M1 phenotype. In an in vitro model of the blood-brain barrier, macrophage-derived arginase was found to be required for C. neoformans invasion of brain microvascular endothelium. Further analysis of the degree of virulence indicated a positive correlation between arginase 1 expression in macrophages and cryptococcal brain dissemination in vivo. Thus, our data suggest that a dynamic macrophage activation that involves arginase expression may contribute to the cryptococcal disease by promoting cryptococcal growth, proliferation, and the invasion to the brain endothelium.
Collapse
Affiliation(s)
- Adithap Hansakon
- Department of Medical Technology, Faculty of Allied Health Sciences, Thammasat University, Pathum Thani, Thailand.,Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Chumpol Ngamphiw
- National Biobank of Thailand, National Science and Technology Development Agency, Pathum Thani, Thailand; and
| | - Sissades Tongsima
- National Biobank of Thailand, National Science and Technology Development Agency, Pathum Thani, Thailand; and
| | - Pornpimon Angkasekwinai
- Department of Medical Technology, Faculty of Allied Health Sciences, Thammasat University, Pathum Thani, Thailand.,Research Unit in Molecular Pathogenesis and Immunology of Infectious Diseases, Thammasat University, Pathum Thani, Thailand
| |
Collapse
|
20
|
Xu J, Goughenour K, Underwood WR, Olszewski MA. Immunological Analysis of Cryptococcal Meningoencephalitis in a Murine Model. Methods Mol Biol 2023; 2667:71-86. [PMID: 37145276 PMCID: PMC10588511 DOI: 10.1007/978-1-0716-3199-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Cryptococcal meningoencephalitis (CM), caused by the fungal pathogen Cryptococcus neoformans species complex, can lead to high mortality or severe neurological sequelae in survivors that are associated with excessive inflammation in the central nervous system (CNS), especially in those who develop immune reconstitution inflammatory syndrome (IRIS) or postinfectious immune response syndrome (PIIRS). While the means to establish a cause-and-effect relationship of a specific pathogenic immune pathway during CM by human studies are limited, mouse models allow dissection of the potential mechanistic links within the CNS immunological network. In particular, these models are useful for separating pathways contributing predominantly to immunopathology from those important for fungal clearance. In this protocol, we described methods to induce a robust, physiologically relevant murine model of C. neoformans CNS infection that reproduces multiple aspects of human cryptococcal disease immunopathology and subsequent detailed immunological analysis. Combined with tools including gene knockout mice, antibody blockade, cell adoptive transfer, as well as high throughput techniques such as single-cell RNA sequencing, studies using this model will provide new insights regarding the cellular and molecular processes that elucidate the pathogenesis of cryptococcal CNS diseases in order to develop more effective therapeutic strategies.
Collapse
Affiliation(s)
- Jintao Xu
- Department of Veterans Affairs Health System, Research Service, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kristie Goughenour
- Department of Veterans Affairs Health System, Research Service, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - W Rex Underwood
- Department of Veterans Affairs Health System, Research Service, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michal A Olszewski
- Department of Veterans Affairs Health System, Research Service, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
| |
Collapse
|
21
|
Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Clinical Studies to Animal Experiments. Microorganisms 2022; 10:microorganisms10122419. [PMID: 36557672 PMCID: PMC9780901 DOI: 10.3390/microorganisms10122419] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Cryptococcus neoformans is an encapsulated pathogenic fungus that initially infects the lung but can migrate to the central nervous system (CNS), resulting in meningoencephalitis. The organism causes the CNS infection primarily in immunocompromised individuals including HIV/AIDS patients, but also, rarely, in immunocompetent individuals. In HIV/AIDS patients, limited inflammation in the CNS, due to impaired cellular immunity, cannot efficiently clear a C. neoformans infection. Antiretroviral therapy (ART) can rapidly restore cellular immunity in HIV/AIDS patients. Paradoxically, ART induces an exaggerated inflammatory response, termed immune reconstitution inflammatory syndrome (IRIS), in some HIV/AIDS patients co-infected with C. neoformans. A similar excessive inflammation, referred to as post-infectious inflammatory response syndrome (PIIRS), is also frequently seen in previously healthy individuals suffering from cryptococcal meningoencephalitis. Cryptococcal IRIS and PIIRS are life-threatening complications that kill up to one-third of affected people. In this review, we summarize the inflammatory responses in the CNS during HIV-associated cryptococcal meningoencephalitis. We overview the current understanding of cryptococcal IRIS developed in HIV/AIDS patients and cryptococcal PIIRS occurring in HIV-uninfected individuals. We also describe currently available animal models that closely mimic aspects of cryptococcal IRIS observed in HIV/AIDS patients.
Collapse
|
22
|
Ssebambulidde K, Anjum SH, Hargarten JC, Chittiboina P, Shoham S, Seyedmousavi S, Marr KA, Hammoud DA, Billioux BJ, Williamson PR. Treatment recommendations for non-HIV associated cryptococcal meningoencephalitis including management of post-infectious inflammatory response syndrome. Front Neurol 2022; 13:994396. [PMID: 36530631 PMCID: PMC9751747 DOI: 10.3389/fneur.2022.994396] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/04/2022] [Indexed: 08/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kenneth Ssebambulidde
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Seher H. Anjum
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Jessica C. Hargarten
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Shmuel Shoham
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Kieren A. Marr
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Bridgette Jeanne Billioux
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Peter R. Williamson
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| |
Collapse
|
23
|
Cryptococcus neoformans Infection in the Central Nervous System: The Battle between Host and Pathogen. J Fungi (Basel) 2022; 8:jof8101069. [PMID: 36294634 PMCID: PMC9605252 DOI: 10.3390/jof8101069] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/28/2022] [Accepted: 10/07/2022] [Indexed: 11/17/2022] Open
Abstract
Cryptococcus neoformans (C. neoformans) is a pathogenic fungus with a global distribution. Humans become infected by inhaling the fungus from the environment, and the fungus initially colonizes the lungs. If the immune system fails to contain C. neoformans in the lungs, the fungus can disseminate to the blood and invade the central nervous system, resulting in fatal meningoencephalitis particularly in immunocompromised individuals including HIV/AIDS patients. Following brain invasion, C. neoformans will encounter host defenses involving resident as well as recruited immune cells in the brain. To overcome host defenses, C. neoformans possesses multiple virulence factors capable of modulating immune responses. The outcome of the interactions between the host and C. neoformans will determine the disease progression. In this review, we describe the current understanding of how C. neoformans migrates to the brain across the blood–brain barrier, and how the host immune system responds to the invading organism in the brain. We will also discuss the virulence factors that C. neoformans uses to modulate host immune responses.
Collapse
|
24
|
Reyes EY, Shinohara ML. Host immune responses in the central nervous system during fungal infections. Immunol Rev 2022; 311:50-74. [PMID: 35672656 PMCID: PMC9489659 DOI: 10.1111/imr.13101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/24/2022] [Accepted: 05/18/2022] [Indexed: 12/19/2023]
Abstract
Fungal infections in the central nervous system (CNS) cause high morbidity and mortality. The frequency of CNS mycosis has increased over the last two decades as more individuals go through immunocompromised conditions for various reasons. Nevertheless, options for clinical interventions for CNS mycoses are still limited. Thus, there is an urgent need to understand the host-pathogen interaction mechanisms in CNS mycoses for developing novel treatments. Although the CNS has been regarded as an immune-privileged site, recent studies demonstrate the critical involvement of immune responses elicited by CNS-resident and CNS-infiltrated cells during fungal infections. In this review, we discuss mechanisms of fungal invasion in the CNS, fungal pathogen detection by CNS-resident cells (microglia, astrocytes, oligodendrocytes, neurons), roles of CNS-infiltrated leukocytes, and host immune responses. We consider that understanding host immune responses in the CNS is crucial for endeavors to develop treatments for CNS mycosis.
Collapse
Affiliation(s)
- Estefany Y. Reyes
- Department of Immunology, Duke University School of Medicine, Durham, NC 27705, USA
| | - Mari L. Shinohara
- Department of Immunology, Duke University School of Medicine, Durham, NC 27705, USA
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC 27705, USA
| |
Collapse
|
25
|
Liu J, Wei H, Liu J, Peng L, Li G, Li M, Yang L, Jiang Y, Peng F. Analysis of the association of HLA subtypes with cryptococcal meningitis in HIV-negative immunocompetent patients. Future Microbiol 2022; 17:1231-1240. [PMID: 35984285 DOI: 10.2217/fmb-2021-0247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University
| | - Hang Wei
- School of Medicine Information Engineering, Guangzhou University of Chinese Medicine
| | - Junyu Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University
| | - Lisheng Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University
| | - Guohong Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University Yue dong Hospital
| | - Min Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University
| | - Lu Yang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University
| |
Collapse
|
26
|
Marra CM, Rohatgi S, Bloom AK, Kahle KT, Haj AK. Case 25-2022: A 25-Year-Old Woman with Headache and Blurred Vision. N Engl J Med 2022; 387:641-650. [PMID: 36070713 DOI: 10.1056/nejmcpc2201241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Christina M Marra
- From the Department of Neurology (C.M.M.), University of Washington, Seattle; and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Massachusetts General Hospital, and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Harvard Medical School - both in Boston
| | - Saurabh Rohatgi
- From the Department of Neurology (C.M.M.), University of Washington, Seattle; and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Massachusetts General Hospital, and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Harvard Medical School - both in Boston
| | - Allyson K Bloom
- From the Department of Neurology (C.M.M.), University of Washington, Seattle; and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Massachusetts General Hospital, and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Harvard Medical School - both in Boston
| | - Kristopher T Kahle
- From the Department of Neurology (C.M.M.), University of Washington, Seattle; and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Massachusetts General Hospital, and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Harvard Medical School - both in Boston
| | - Amelia K Haj
- From the Department of Neurology (C.M.M.), University of Washington, Seattle; and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Massachusetts General Hospital, and the Departments of Radiology (S.R.), Medicine (A.K.B.), Neurosurgery (K.T.K.), and Pathology (A.K.H.), Harvard Medical School - both in Boston
| |
Collapse
|
27
|
Peralta DP, Najjar H, Garcia-Chan J. Cryptococcal Meningitis in an Immunocompetent Man Exposed to a Pet Cockatoo: An Overlooked Zoonosis. Cureus 2022; 14:e28122. [PMID: 36158362 PMCID: PMC9491681 DOI: 10.7759/cureus.28122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 11/05/2022] Open
Abstract
Cryptococcus species are commonly isolated in the excreta of birds, but zoonotic transmission has yet to be proven. We report a case of an immunocompetent man with meningitis caused by Cryptococcus neoformans var. grubii with significant exposure to a pet cockatoo highly suspicious for zoonotic transmission. Treatment with intravenous liposomal amphotericin B and oral flucytosine was initiated upon diagnosis, but diagnostic delay because of low suspicion contributed to neurological sequelae. Recognition of pet birds as potential sources of Cryptococcus species' zoonotic transmission is essential for prompt diagnosis and treatment.
Collapse
|
28
|
Jiang YK, Wang RY, Zhou LH, Cheng JH, Luo Y, Zhu RS, Qiu WJ, Zhao HZ, Wang X, Harrison TS, Zhu LP. Cerebrospinal fluid cytokine and chemokine patterns correlate with prognosis of HIV-uninfected cryptococcal meningitis: A prospective observational study. Front Immunol 2022; 13:993495. [PMID: 36032125 PMCID: PMC9411642 DOI: 10.3389/fimmu.2022.993495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 07/26/2022] [Indexed: 12/01/2022] Open
Abstract
The cerebrospinal fluid (CSF) immune responses in HIV-uninfected cryptococcal meningitis (CM) have not been well studied. In this study, we aimed to explore the phenotype of CSF immune response during the course of disease and to examine relationships between phenotypes and disease severity. We profiled the CSF immune response in 128 HIV-uninfected CM and 30 pulmonary cryptococcosis patients using a 27-plex Luminex cytokine kit. Principal component analyses (PCA) and logistic regression model were performed. Concentrations of 23 out of 27 cytokines and chemokines in baseline CSF were significantly elevated in CM patients compared with pulmonary cryptococcosis cases. In CM patients with Cryptococcus neoformans infection, IL-1ra, IL-9, and VEGF were significantly elevated in immunocompetent cases. Cytokine levels usually reached peaks within the first 2 weeks of antifungal treatment and gradually decreased over time. PCA demonstrated a co-correlated CSF cytokine and chemokine response consisting of Th1, Th2, and Th17 type cytokines. Prognostic analysis showed that higher scores for the PCs loading pro-inflammatory cytokines, IFN-γ, TNF-α, and IL-12; and anti-inflammatory cytokine, IL-4; and chemokines, Eotaxin, FGF-basis, and PDGF-bb; as well as lower scores for the PCs loading RANTES were associated with disease severity, as defined by a Glasgow Coma Scale of <15 or death. In conclusion, combined inflammatory responses in CSF involving both pro- and anti-inflammatory cytokines and chemokines are upregulated in HIV-uninfected CM, and associated with disease severity.
Collapse
Affiliation(s)
- Ying-Kui Jiang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Rui-Ying Wang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ling-Hong Zhou
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-Hui Cheng
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu Luo
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Rong-Sheng Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-Jia Qiu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Hua-Zhen Zhao
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuan Wang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Thomas Stephen Harrison
- Institute for Infection and Immunity, St. George’s University of London, London, United Kingdom
| | - Li-Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
29
|
Case report: a special case of cryptococcal infection-related inflammatory syndrome in a non-HIV infected and non-transplant patient. BMC Neurol 2022; 22:247. [PMID: 35794548 PMCID: PMC9258111 DOI: 10.1186/s12883-022-02773-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/27/2022] [Indexed: 11/12/2022] Open
Abstract
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.
Collapse
|
30
|
Liu J, Liu J, Qin BE, Yao S, Wang A, Yang L, Su Z, Xu X, Jiang Y, Peng F. Post-Infectious Inflammatory Response Syndrome in an HIV-Negative Immunocompetent Elderly Patient With Cryptococcal Meningitis: A Case Report and Literature Review. Front Immunol 2022; 13:823021. [PMID: 35281037 PMCID: PMC8904365 DOI: 10.3389/fimmu.2022.823021] [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: 11/26/2021] [Accepted: 02/01/2022] [Indexed: 11/20/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Junyu Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bang-E Qin
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shiqi Yao
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Anni Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lu Yang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhihui Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaofeng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
31
|
Tucker M, Sheikh AM, Villanueva MS. Rapidly enlarging pulmonary mass due to immune reconstitution inflammatory syndrome (IRIS) in an immunocompetent host with pulmonary Cryptococcus neoformans. BMJ Case Rep 2022; 15:e247495. [PMID: 35351746 PMCID: PMC8966528 DOI: 10.1136/bcr-2021-247495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/04/2022] Open
Abstract
An immunocompetent man presented with Cryptococcus neoformans disease manifesting as a large pulmonary mass (cryptococcoma). Despite an initial induction course of 4 weeks of liposomal amphotericin B (LAmB), followed by 8 weeks of fluconazole, the cryptococcoma enlarged in size. Ten days into a second course of induction therapy with LAmB and flucytosine, the cryptococcoma markedly increased in size with encroachment on critical vascular structures. Due to concern for immune reconstitution inflammatory syndrome (IRIS), prednisone was added with significant decrease in the size of the mass. To our knowledge, this is the first reported case of pulmonary cryptococcal-IRIS in an immunocompetent host.
Collapse
Affiliation(s)
- Mollie Tucker
- Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Abdul Majeed Sheikh
- Infectious Diseases, Charlotte Hungerford Hospital, Torrington, Connecticut, USA
| | | |
Collapse
|
32
|
Miller C, Daugherty R, McCulloch M, Stephens I, Williamson PR. Immune Reconstitution Inflammatory Syndrome Complicating Cryptococcal Meningitis in a Pediatric Heart Transplant Patient. Pediatr Infect Dis J 2022; 41:145-147. [PMID: 34609105 DOI: 10.1097/inf.0000000000003335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Immune reconstitution inflammatory syndrome can be a complication of cryptococcal meningitis after immune reconstitution from antiretroviral therapy in HIV or reduced immune suppression in transplant recipients. In this case report, the authors discuss the diagnosis and management of cryptococcal-associated immune reconstitution inflammatory syndrome in a 10-year-old pediatric heart transplant recipient.
Collapse
Affiliation(s)
- Chelsea Miller
- From the Department of Infectious Disease and Department of Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Reza Daugherty
- From the Department of Infectious Disease and Department of Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Michael McCulloch
- From the Department of Infectious Disease and Department of Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Ina Stephens
- From the Department of Infectious Disease and Department of Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| |
Collapse
|
33
|
Abu-Rumeileh S, Garibashvili T, Hagemann JB, Still V, Bachhuber F, Otto M, Tumani H, Senel M. A one-year longitudinal evaluation of cerebrospinal fluid and blood neurochemical markers in a patient with cryptococcal meningitis complicated by ischemic stroke. J Neurol Sci 2022; 432:120090. [PMID: 34923332 DOI: 10.1016/j.jns.2021.120090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Samir Abu-Rumeileh
- Department of Neurology, University of Ulm, Ulm, Germany; Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | | | | | - Veronika Still
- Department of Neurology, University of Ulm, Ulm, Germany
| | | | - Markus Otto
- Department of Neurology, University of Ulm, Ulm, Germany; Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Hayrettin Tumani
- Department of Neurology, University of Ulm, Ulm, Germany; Specialty Clinic of Neurology Dietenbronn, Schwendi, Germany
| | - Makbule Senel
- Department of Neurology, University of Ulm, Ulm, Germany.
| |
Collapse
|
34
|
Mohamed SH, Nyazika TK, Ssebambulidde K, Lionakis MS, Meya DB, Drummond RA. Fungal CNS Infections in Africa: The Neuroimmunology of Cryptococcal Meningitis. Front Immunol 2022; 13:804674. [PMID: 35432326 PMCID: PMC9010970 DOI: 10.3389/fimmu.2022.804674] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/03/2022] [Indexed: 01/13/2023] Open
Abstract
Cryptococcal meningitis (CM) is the leading cause of central nervous system (CNS) fungal infections in humans, with the majority of cases reported from the African continent. This is partly due to the high burden of HIV infection in the region and reduced access to standard-of-care including optimal sterilising antifungal drug treatments. As such, CM is responsible for 10-15% of all HIV-related mortality, with a large proportion being preventable. Immunity to the causative agent of CM, Cryptococcus neoformans, is only partially understood. IFNγ producing CD4+ T-cells are required for the activation of myeloid cells, especially macrophages, to enable fungal killing and clearance. However, macrophages may also act as a reservoir of the fungal yeast cells, shielding them from host immune detection thus promoting latent infection or persistent chronic inflammation. In this chapter, we review the epidemiology and pathogenesis of CNS fungal infections in Africa, with a major focus on CM, and the antifungal immune pathways operating to protect against C. neoformans infection. We also highlight the areas of research and policy that require prioritisation to help reduce the burden of CNS fungal diseases in Africa.
Collapse
Affiliation(s)
- Sally H Mohamed
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Tinashe K Nyazika
- Department of Clinical Science, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Kenneth Ssebambulidde
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - David B Meya
- College of Health Sciences, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Rebecca A Drummond
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Institute of Microbiology & Infection, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
35
|
Huang Y, Zou J, Zhang KM, Li H, Hu DY, Liao WQ, Zhang L, Pan WH. Prediction of hospital discharge outcome from changes in cerebrospinal fluid/serum albumin quotient and cerebrospinal fluid lactate dehydrogenase in patients with cryptococcal meningitis. Future Microbiol 2021; 17:223-233. [PMID: 34905957 DOI: 10.2217/fmb-2021-0272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study aims to provide reliable prognostic factors for patients with cryptococcal meningitis (CM). Patients & methods: Clinical characteristics and laboratory findings of CM patients were retrospectively reviewed. Results: Sixty-three patients with CM were enrolled and 38/63 were confirmed to be HIV serology positive. Among clinical characteristics, headache, nausea and/or vomiting, and fever were the most common symptoms. Among cerebrospinal fluid (CSF) parameters, changes in leukocyte count, lactate dehydrogenase and chloride were significantly associated with the outcome. An increased CSF/serum albumin quotient (QAlb) was indicative of an unfavorable outcome in HIV-negative patients. Conclusion: CSF lactate dehydrogenase and QAlb may improve the prediction of outcomes in patients with CM.
Collapse
Affiliation(s)
- Yue Huang
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Jun Zou
- Department of Dermatology, Nanning Forth People's Hospital, Nanning, 530002, PR China
| | - Ke-Ming Zhang
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Hang Li
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Dong-Ying Hu
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Wan-Qing Liao
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Lei Zhang
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Department of Dermatology, Shaanxi Provincial People's Hospital, Xi'an, 710068, PR China
| | - Wei-Hua Pan
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| |
Collapse
|
36
|
Stott KE, Loyse A, Jarvis JN, Alufandika M, Harrison TS, Mwandumba HC, Day JN, Lalloo DG, Bicanic T, Perfect JR, Hope W. Cryptococcal meningoencephalitis: time for action. THE LANCET. INFECTIOUS DISEASES 2021; 21:e259-e271. [PMID: 33872594 DOI: 10.1016/s1473-3099(20)30771-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Cryptococcal meningoencephalitis was first described over a century ago. This fungal infection is preventable and treatable yet continues to be associated with excessive morbidity and mortality. The largest burden of disease resides in people living with HIV in low-income and middle-income countries. In this group, mortality with the best antifungal induction regimen (7 days of amphotericin B deoxycholate [1·0 mg/kg per day] and flucytosine [100·0 mg/kg per day]) in a clinical trial setting was 24% at 10 weeks. The world is now at an inflection point in terms of recognition, research, and action to address the burden of morbidity and mortality from cryptococcal meningoencephalitis. However, the scope of interventional programmes needs to increase, with particular attention to implementation science that is specific to individual countries. This Review summarises causes of excessive mortality, interventions with proven survival benefit, and gaps in knowledge and practice that contribute to the ongoing high death toll from cryptococcal meningoencephalitis. TRANSLATIONS: For the Vietnamese and Chichewa translations of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Katharine Elizabeth Stott
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Angela Loyse
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - Joe N Jarvis
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK
| | | | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| |
Collapse
|
37
|
Xu J, Ganguly A, Zhao J, Ivey M, Lopez R, Osterholzer JJ, Cho CS, Olszewski MA. CCR2 Signaling Promotes Brain Infiltration of Inflammatory Monocytes and Contributes to Neuropathology during Cryptococcal Meningoencephalitis. mBio 2021; 12:e0107621. [PMID: 34311579 PMCID: PMC8406332 DOI: 10.1128/mbio.01076-21] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/25/2021] [Indexed: 12/21/2022] Open
Abstract
Cryptococcal meningoencephalitis (CM) is a leading cause of central nervous system (CNS) infection-related mortality worldwide, with surviving patients often developing neurological deficiencies. While CNS inflammation has been implicated in the pathogenesis of CM, little is known about the relative contribution of the specific inflammatory/immune pathways to CNS pathology versus fungal clearance. Increased cerebrospinal fluid level of C-C chemokine receptor 2 (CCR2) ligand CCL2 is associated with disease deterioration in patients with CM. Using a murine model, we investigated the role of the CCR2 pathway in the development of CNS inflammation and pathology during CM. We found that CCR2-deficient mice exhibited improved 28-day survival and alleviated neurological disease scores despite a brain fungal burden higher than that of the WT mice. Reduced CM pathology in CCR2-deficient mice was accompanied by markedly decreased neuronal cell death around cryptococcal microcysts and restored expression of genes involved in neurotransmission, connectivity, and neuronal cell structure in the brains. Results show that CCR2 axis is the major pathway recruiting CD45hiCD11b+Ly6C+ inflammatory monocyte to the brain and indirectly modulates the accumulation of CD4+ T cells and CD8+ T cells. In particular, CCR2 axis promotes recruitment of interferon gamma (IFN-γ)-producing CD4+ T cells and classical activation of myeloid cells. In this context, CCR2 deletion limits the immune network dysregulation we see in CM and attenuates neuropathology. Thus, the CCR2 axis is a potential target for interventions aimed to limit inflammatory CNS pathology in CM patients. IMPORTANCE Cryptococcal meningoencephalitis (CM) causes nearly 200,000 deaths worldwide each year, and survivors frequently develop long-lasting neurological sequelae. The high rate of mortality and neurologic sequelae in CM patients indicate that antifungal therapies alone are often insufficient to control disease progression. Here, we reveal that CM disease progression in mice is accompanied by inflammatory monocytes infiltration at the periphery of the infected foci that overlap locally perturbed neuronal function and death. Importantly, we identified that CCR2 signaling is a critical pathway driving neuroinflammation, especially inflammatory monocyte recruitment, as well as CNS pathology and mortality in CM mice. Our results imply that targeting the CCR2 pathway may be beneficial as a therapy complementary to antifungal drug treatment, helping to reduce CNS damage and mortality in CM patients.
Collapse
Affiliation(s)
- Jintao Xu
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Anutosh Ganguly
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica Zhao
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Michel Ivey
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
| | - Rafael Lopez
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
| | - John J. Osterholzer
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Clifford S. Cho
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michal A. Olszewski
- Research Service, Ann Arbor VA Health System, Department of Veterans Affairs Health System, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| |
Collapse
|
38
|
Zhou LH, Zhao HZ, Wang X, Wang RY, Jiang YK, Huang LP, Yip CW, Cheng JH, Que CX, Zhu LP. Immune reconstitution inflammatory syndrome in non-HIV cryptococcal meningitis: Cross-talk between pathogen and host. Mycoses 2021; 64:1402-1411. [PMID: 34390048 PMCID: PMC9290805 DOI: 10.1111/myc.13361] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cryptococcal meningitis (CM)-associated immune reconstitution inflammatory syndrome (IRIS) is associated with high mortality, the epidemiology and pathophysiology of which is poorly understood, especially in non-HIV populations. OBJECTIVES We aim to explore the incidence, clinical risk factors, immunological profiles and potential influence of leukotriene A4 hydroxylase (LTA4H) on non-HIV CM IRIS populations. METHODS In this observational cohort study, 101 previously untreated non-HIV CM patients were included. We obtained data for clinical variables, 27 cerebrospinal fluid (CSF) cytokines levels and LTA4H genotype frequencies. Changes of CSF cytokines levels before and at IRIS occurrence were compared. RESULTS Immune reconstitution inflammatory syndrome was identified in 11 immunocompetent males, generating an incidence of 10.9% in non-HIV CM patients. Patients with higher CrAg titres (> 1:160) were more likely to develop IRIS, and titre of 1:1280 is the optimum level to predict IRIS occurrence. Baseline CSF cytokines were significantly higher in IRIS group, which indicated a severe host immune inflammation response. Four LTA4H SNPs (rs17525488, rs6538697, rs17525495 and rs1978331) exhibited significant genetic susceptibility to IRIS in overall non-HIV CM, while five cytokines were found to be associated with rs1978331, and baseline monocyte chemotactic protein 1 (MCP-1) became the only cytokine correlated with both IRIS and LTA4H SNPs. CONCLUSIONS Our study suggested that non-HIV CM patients with high fungal burden and severe immune inflammation response were more likely to developed IRIS. LTA4H polymorphisms may affect the pathogenesis of IRIS by regulating the level of baseline CSF MCP-1.
Collapse
Affiliation(s)
- Ling-Hong Zhou
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Hua-Zhen Zhao
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuan Wang
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Rui-Ying Wang
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Ying-Kui Jiang
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Ping Huang
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Ching-Wan Yip
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-Hui Cheng
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Chun-Xing Que
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Ping Zhu
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical college, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
39
|
Gressler AE, Volke D, Firacative C, Schnabel CL, Müller U, Krizsan A, Schulze-Richter B, Brock M, Brombacher F, Escandón P, Hoffmann R, Alber G. Identification of Disease-Associated Cryptococcal Proteins Reactive With Serum IgG From Cryptococcal Meningitis Patients. Front Immunol 2021; 12:709695. [PMID: 34367172 PMCID: PMC8342929 DOI: 10.3389/fimmu.2021.709695] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/21/2021] [Indexed: 01/16/2023] Open
Abstract
Cryptococcus neoformans, an opportunistic fungal pathogen ubiquitously present in the environment, causes cryptococcal meningitis (CM) mainly in immunocompromised patients, such as AIDS patients. We aimed to identify disease-associated cryptococcal protein antigens targeted by the human humoral immune response. Therefore, we used sera from Colombian CM patients, with or without HIV infection, and from healthy individuals living in the same region. Serological analysis revealed increased titers of anti-cryptococcal IgG in HIV-negative CM patients, but not HIV-positive CM patients, compared to healthy controls. In contrast, titers of anti-cryptococcal IgM were not affected by CM. Furthermore, we detected pre-existing IgG and IgM antibodies even in sera from healthy individuals. The observed induction of anti-cryptococcal IgG but not IgM during CM was supported by analysis of sera from C. neoformans-infected mice. Stronger increase in IgG was found in wild type mice with high lung fungal burden compared to IL-4Rα-deficient mice showing low lung fungal burden. To identify the proteins targeted by human anti-cryptococcal IgG antibodies, we applied a quantitative 2D immunoproteome approach identifying cryptococcal protein spots preferentially recognized by sera from CM patients or healthy individuals followed by mass spectrometry analysis. Twenty-three cryptococcal proteins were recombinantly expressed and confirmed to be immunoreactive with human sera. Fourteen of them were newly described as immunoreactive proteins. Twelve proteins were classified as disease-associated antigens, based on significantly stronger immunoreactivity with sera from CM patients compared to healthy individuals. The proteins identified in our screen significantly expand the pool of cryptococcal proteins with potential for (i) development of novel anti-cryptococcal agents based on implications in cryptococcal virulence or survival, or (ii) development of an anti-cryptococcal vaccine, as several candidates lack homology to human proteins and are localized extracellularly. Furthermore, this study defines pre-existing anti-cryptococcal immunoreactivity in healthy individuals at a molecular level, identifying target antigens recognized by sera from healthy control persons.
Collapse
Affiliation(s)
- A Elisabeth Gressler
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Daniela Volke
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Carolina Firacative
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Christiane L Schnabel
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Uwe Müller
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Andor Krizsan
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Bianca Schulze-Richter
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Matthias Brock
- Fungal Genetics and Biology Group, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Frank Brombacher
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Cape Town, South Africa
| | | | - Ralf Hoffmann
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Gottfried Alber
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| |
Collapse
|
40
|
Romani L, Williamson PR, Di Cesare S, Di Matteo G, De Luca M, Carsetti R, Figà-Talamanca L, Cancrini C, Rossi P, Finocchi A. Cryptococcal Meningitis and Post-Infectious Inflammatory Response Syndrome in a Patient With X-Linked Hyper IgM Syndrome: A Case Report and Review of the Literature. Front Immunol 2021; 12:708837. [PMID: 34335625 PMCID: PMC8320724 DOI: 10.3389/fimmu.2021.708837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/25/2021] [Indexed: 12/27/2022] Open
Abstract
The hyper IgM syndromes are a rare group of primary immunodeficiency. The X-linked Hyper IgM syndrome (HIGM), due to a gene defect in CD40L, is the commonest variant; it is characterized by an increased susceptibility to a narrow spectrum of opportunistic infection. A few cases of HIGM patients with Cryptococcal meningoencephalitis (CM) have been described in the literature. Herein we report the case of a young male diagnosed in infancy with HIGM who developed CM complicated by a post-infectious inflammatory response syndrome (PIIRS), despite regular immunoglobulin replacement therapy and appropriate antimicrobial prophylaxis. The patient was admitted because of a headache and CM was diagnosed through detection of Cryptococcus neoformans in the cerebrospinal fluid. Despite the antifungal therapy resulting to negative CSF culture, the patient exhibited persistent headaches and developed diplopia. An analysis of inflammatory cytokines on CSF, as well as the brain MRI, suggested a diagnosis of PIIRS. Therefore, a prolonged corticosteroids therapy was started obtaining a complete resolution of symptoms without any relapse.
Collapse
Affiliation(s)
- Lorenza Romani
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Peter Richard Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institutes of Health, Bethesda, MD, United States
| | - Silvia Di Cesare
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Gigliola Di Matteo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Maia De Luca
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Rita Carsetti
- B Cell Physiopathology Unit, Immunology Research Area, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Figà-Talamanca
- Neuroradiology Unit, Imaging Department, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Caterina Cancrini
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paolo Rossi
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Finocchi
- Unit of Immune and Infectious Diseases, Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| |
Collapse
|
41
|
Abstract
Complex processes mediate immunity to fungal infections. Responses vary depending on the organism, morphogenic state, and infection site. Innate immune effectors such as epithelia, phagocytes, and soluble molecules detect pathogens, kill fungi, release cytokines, and prime the adaptive response. Adaptive responses to mucocutaneous or invasive disease are markedly different but intersect at certain pathways (molecules required for IL-23 and IL-12 signaling). Many of these pathways have been elucidated from the study of inborn errors of immunity. This review explores the general aspects of antifungal immunity and delves into the mechanisms that mediate protection from frequently encountered fungi.
Collapse
Affiliation(s)
- Oscar A Fernández-García
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, 14080 Tlalpan, Mexico City, Mexico
| | - Jennifer M Cuellar-Rodríguez
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, 10 Center Drive, Building 10CRC 3-3264, Bethesda, MD 20892, USA.
| |
Collapse
|
42
|
Strickland AB, Shi M. Mechanisms of fungal dissemination. Cell Mol Life Sci 2021; 78:3219-3238. [PMID: 33449153 PMCID: PMC8044058 DOI: 10.1007/s00018-020-03736-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/23/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022]
Abstract
Fungal infections are an increasing threat to global public health. There are more than six million fungal species worldwide, but less than 1% are known to infect humans. Most of these fungal infections are superficial, affecting the hair, skin and nails, but some species are capable of causing life-threatening diseases. The most common of these include Cryptococcus neoformans, Aspergillus fumigatus and Candida albicans. These fungi are typically innocuous and even constitute a part of the human microbiome, but if these pathogens disseminate throughout the body, they can cause fatal infections which account for more than one million deaths worldwide each year. Thus, systemic dissemination of fungi is a critical step in the development of these deadly infections. In this review, we discuss our current understanding of how fungi disseminate from the initial infection sites to the bloodstream, how immune cells eliminate fungi from circulation and how fungi leave the blood and enter distant organs, highlighting some recent advances and offering some perspectives on future directions.
Collapse
Affiliation(s)
- Ashley B Strickland
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, MD, USA.
| | - Meiqing Shi
- Division of Immunology, Virginia-Maryland College of Veterinary Medicine and Maryland Pathogen Research Institute, University of Maryland, College Park, MD, USA.
| |
Collapse
|
43
|
Lee KP, Su HC, Chen PL, Sung PS. Short-term corticosteroid pulse therapy in the treatment of post-infectious spinal arachnoiditis following cryptococcal meningoencephalitis: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
44
|
Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Blood and Cerebrospinal Fluid Biomarkers to Treatment Approaches. Life (Basel) 2021; 11:life11020095. [PMID: 33514007 PMCID: PMC7912256 DOI: 10.3390/life11020095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 12/31/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) presents as an exaggerated immune reaction that occurs during dysregulated immune restoration in immunocompromised patients in late-stage human immunodeficiency virus (HIV) infection who have commenced antiretroviral treatments (ART). Virtually any opportunistic pathogen can provoke this type of immune restoration disorder. In this review, we focus on recent developments in the identification of risk factors for Cryptococcal IRIS and on advancements in our understanding of C-IRIS immunopathogenesis. We overview new findings in blood and cerebrospinal fluid which can potentially be useful in the prediction and diagnosis of cryptococcal meningitis IRIS (CM-IRIS). We assess current therapeutic regimens and novel treatment approaches to combat CM-IRIS. We discuss the utility of biomarkers for clinical monitoring and adjusting treatment modalities in acquired immunodeficiency syndrome (AIDS) patients co-infected with Cryptococcus who have initiated ART.
Collapse
|
45
|
Marr KA, Sun Y, Spec A, Lu N, Panackal A, Bennett J, Pappas P, Ostrander D, Datta K, Zhang SX, Williamson PR. A Multicenter, Longitudinal Cohort Study of Cryptococcosis in Human Immunodeficiency Virus-negative People in the United States. Clin Infect Dis 2021; 70:252-261. [PMID: 30855688 DOI: 10.1093/cid/ciz193] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/04/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cryptococcosis is increasingly recognized in people without human immunodeficiency virus (HIV). METHODS A multicenter, prospective cohort study was performed in 25 US centers. Consenting patients were prospectively followed for ≤2 years. Neurological morbidities were assessed with longitudinal event depiction and functional scores (Montreal Cognitive Assessment [MoCA]). Risks of death were analyzed using Cox regression. RESULTS One hundred forty-five subjects were enrolled. Most were male (95; 65.5%) and had immunosuppression (120; 82.8%), including solid organ transplant (SOT; 33.8%), autoimmunity (15.9%), and hematologic malignancies (11.7%). Disease involved the central nervous system (CNS) in 71 subjects (49%). Fever was uncommon, documented in 40 (27.8%) subjects, and absence was associated with diagnostic delay (mean: 48.2 vs 16.5 days; P = .007). Abnormal MoCA scores (<26) were predictive of CNS disease; low scores (<22) were associated with poor long-term cognition. Longitudinal event depiction demonstrated frequent complications in people with CNS disease; 25 subjects (35.2%) required >1 lumbar puncture and 8 (11.3%) required ventriculostomies. In multivariable models, older age (>60 years) was associated with higher risks of death (hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.05-4.38; P = .036), and lower risks were noted with underlying hematologic malignancy (HR, 0.29; 95% CI, 0.09-0.98; P = .05) and prior SOT (HR, 0.153; 95% CI, 0.05-0.44; P = .001). CONCLUSIONS Despite aggressive antifungal therapies, outcomes of CNS cryptococcosis in people without HIV are characterized by substantial long-term neurological sequelae. Studies are needed to understand mechanism(s) of cognitive decline and to enable better treatment algorithms.
Collapse
Affiliation(s)
- Kieren A Marr
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Yifei Sun
- Department of Biostatistics, Columbia University, New York
| | - Andrej Spec
- Department of Medicine, Washington University, St. Louis, Missouri
| | - Na Lu
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anil Panackal
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - John Bennett
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Peter Pappas
- Department of Medicine, University of Alabama at Birmingham
| | - Darin Ostrander
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kausik Datta
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Sean X Zhang
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | | |
Collapse
|
46
|
Dean O, Anjum S, Hess B, Hammoud DA, Athas D, Wheat J, Williamson PR. Central Nervous System Histoplasma-Associated Post-infectious Inflammatory Response Syndrome (Histo-PIIRS). J Clin Immunol 2021; 41:545-551. [PMID: 33387157 PMCID: PMC7776302 DOI: 10.1007/s10875-020-00954-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022]
Abstract
We present a case of central nervous system (CNS) histoplasmosis in a previously healthy adult with hepatitis C (HCV) presenting with neurological symptoms refractory to antifungal therapy and ventriculoperitoneal (VP) shunting 4 months after initial diagnosis. Persistent symptoms were thought to be inflammatory rather than infectious given negative cerebrospinal fluid (CSF) and serum fungal antigens. The patient promptly improved after initiation of corticosteroid therapy. Elevated CSF cytokines and regional enhancement on brain MRI resolved with corticosteroid treatment. This is the first case of Histoplasma-associated post-infectious inflammatory response syndrome (Histo-PIIRS) documented by CSF cytokine reduction in response to corticosteroid therapy.
Collapse
Affiliation(s)
- Owen Dean
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bld 10, Rm 11C208, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Seher Anjum
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bld 10, Rm 11C208, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Bryan Hess
- Division of Infectious Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Dima A Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Deena Athas
- Division of Infectious Diseases, Gundersen Health System, La Crosse, WI, USA
| | | | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bld 10, Rm 11C208, 9000 Rockville Pike, Bethesda, MD, 20892, USA.
| |
Collapse
|
47
|
Cheng JH, Cheema R, Williamson PR, Dimitriades VR. Case Report: Paradoxical Inflammatory Response Syndrome in a Previously Healthy, HIV-Negative, Pediatric Patient With Cryptococcus gatii Meningitis. Front Pediatr 2021; 9:703895. [PMID: 34513762 PMCID: PMC8424186 DOI: 10.3389/fped.2021.703895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/27/2021] [Indexed: 12/29/2022] Open
Abstract
The immunological response of patients with cryptococcal meningitis (CM), particularly those not known to be immunocompromised, has generated an increased interest recently. Although CM is an infection with significant rates of morbidity and mortality, its sequelae may also include a post-infectious inflammatory response syndrome (PIIRS) in patients who have already achieved microbiological control. PIIRS can cause substantial immune-mediated damage to the central nervous system resulting in long-term neurological disability or even death. Steroids have been used successfully in the management of PIIRS in adults. In this report, we present the case of a previously healthy adolescent male with Cryptococcus gattii meningitis who experienced neurological deterioration due to PIIRS after the initiation of antifungal therapy. Immunological workup did not demonstrate any frank underlying immunodeficiencies, and genetic primary immunodeficiency screening was unremarkable. He was treated with steroids and recovered clinically; however, intermittent inflammatory episodes needed to be managed through several flares of symptoms. In the setting of the current literature, we discuss the management and monitoring of PIIRS in a pediatric patient, along with considerations of targeted future therapies.
Collapse
Affiliation(s)
- Jessica H Cheng
- Department of Pediatrics, UC Davis Health, Sacramento, CA, United States
| | - Ritu Cheema
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UC Davis Health, Sacramento, CA, United States
| | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, United States
| | - Victoria R Dimitriades
- Division of Pediatric Allergy, Immunology & Rheumatology, Department of Pediatrics, UC Davis Health, Sacramento, CA, United States
| |
Collapse
|
48
|
Marr KA, Anjum S, Hammoud DA, Williamson PR. Reply to Pan et al. Clin Infect Dis 2020; 71:3015. [PMID: 32188984 DOI: 10.1093/cid/ciaa297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kieren A Marr
- Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Seher Anjum
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Dima A Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
49
|
Anjum S, Dean O, Kosa P, Magone MT, King KA, Fitzgibbon E, Kim HJ, Zalewski C, Murphy E, Billioux BJ, Chisholm J, Brewer CC, Krieger C, Elsegeiny W, Scott TL, Wang J, Hunsberger S, Bennett JE, Nath A, Marr KA, Bielekova B, Wendler D, Hammoud DA, Williamson P. Outcomes in Previously Healthy Cryptococcal Meningoencephalitis Patients treated with Pulse - Taper Corticosteroids for Post-infectious Inflammatory Syndrome. Clin Infect Dis 2020; 73:e2789-e2798. [PMID: 33383587 DOI: 10.1093/cid/ciaa1901] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 12/28/2020] [Indexed: 12/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Seher Anjum
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Owen Dean
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Peter Kosa
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - M Teresa Magone
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kelly A King
- National Institute on Deafness and Other Communication Disorders, National Institute of Health, Bethesda, MD, USA
| | - Edmond Fitzgibbon
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - H Jeff Kim
- National Institute on Deafness and Other Communication Disorders, National Institute of Health, Bethesda, MD, USA
| | - Chris Zalewski
- National Institute on Deafness and Other Communication Disorders, National Institute of Health, Bethesda, MD, USA
| | - Elizabeth Murphy
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Bridgette Jeanne Billioux
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Jennifer Chisholm
- National Institute on Deafness and Other Communication Disorders, National Institute of Health, Bethesda, MD, USA
| | - Carmen C Brewer
- National Institute on Deafness and Other Communication Disorders, National Institute of Health, Bethesda, MD, USA
| | - Chantal Krieger
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Waleed Elsegeiny
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Terri L Scott
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | | | - John E Bennett
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Kieren A Marr
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bibiana Bielekova
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | | | - Dima A Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Peter Williamson
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| |
Collapse
|
50
|
Liu J, Luo C, Li M, Wang YJ, Xu X, Yang L, Qin BE, Chen Y, Jiang Y, Peng F. Predictors of postinfectious inflammatory response syndrome in HIV-negative immunocompetent cryptococcal meningitis. J Neurol Neurosurg Psychiatry 2020; 92:jnnp-2020-324921. [PMID: 33277354 DOI: 10.1136/jnnp-2020-324921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/15/2020] [Accepted: 11/09/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chongliang Luo
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Pennsylvania, United States
| | - Min Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yi-Jie Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xiaofeng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Lu Yang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Bang-E Qin
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Pennsylvania, United States
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| |
Collapse
|