Autoimmune diseases in HIV-negative cryptococcal meningitis

Glucocorticoids as a risk factor for infection and adverse outcomes in non-HIV and non-transplant patients with cryptococcal meningitis

BACKGROUND

Cryptococcal meningitis (CM), an opportunistic fungal infection affecting immunocompromised hosts, leads to high mortality. The role of previous exposure to glucocorticoids as a risk factor and as an outcome modulator has been observed, but systematic studies are lacking.

OBJECTIVE

The primary aim of this study is to evaluate the impact of glucocorticoid use on the clinical outcomes, specifically mortality, of non-HIV and non-transplant (NHNT) patients diagnosed with CM.

METHODS

We queried a global research network to identify adult NHNT patients with CM based on ICD codes or recorded specific Cryptococcus CSF lab results with or without glucocorticoid exposure the year before diagnosis. We performed a propensity score-matched analysis to reduce the risk of confounding and analysed outcomes by glucocorticoid exposure. We used a Cox proportional hazards model for survival analysis.

RESULTS

We identified 764 patients with a history of glucocorticoid exposure and 1267 patients without who developed CM within 1 year. After propensity score matching of covariates, we obtained 627 patients in each cohort. The mortality risk in 1 year was greater in patients exposed to prior glucocorticoids (OR: 1.3, CI: 1.2-2.0, p = 0.002). We found an excess of 45 deaths among CM patients with previous glucocorticoid use (7.4% increased absolute risk of dying within 1 year of diagnosis) compared to CM controls without glucocorticoid exposure. Hospitalisation, intensive care unit admission, emergency department visits, stroke and cognitive dysfunction also showed significant, unfavourable outcomes in patients with glucocorticoid-exposed CM compared to glucocorticoid-unexposed CM patients.

CONCLUSIONS

Previous glucocorticoid administration in NHNT patients seems to associate with 1-year mortality after CM adjusted for possible confounders related to demographics, comorbidities and additional immunosuppressive medications. Serial CrAg screening might be appropriate for higher-risk patients on glucocorticoids after further cost-benefit analyses.

Concomitant of Cryptococcal Meningitis and COVID-19 in a Female Patient with Primary Nephrotic Syndrome and Type 2 Diabetes

Background

Patients with primary nephrotic syndrome (PNS) are at an increased risk of developing various infections due to the long-term use of immunosuppressive agents. Cryptococcal meningitis (CM) is an uncommon but severe complication that can occur in patients with PNS, particularly those receiving immunosuppressive medications.

Case Description

This case report describes a middle-aged female patient with PNS and type 2 diabetes mellitus (T2DM) who developed CM. She received a combination regimen of cyclophosphamide and prednisone, achieving partial remission of PNS. However, she later returned to the hospital with high fever and headache. At admission, her nasopharyngeal swab test was positive for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) and she received therapy of dexamethasone and favipiravir, but her fever and headache were not improved. Following a lumbar puncture was performed for her and CM was diagnosed based on a positive Cryptococcus culture in the cerebrospinal fluid. The patient's cyclophosphamides were temporarily discontinued, and antifungal therapy with amphotericin B liposome and fluconazole was initiated. Despite a noticeable increase in her blood glucose levels due to infection during her hospitalization, she showed improvement with intensified glycemic control treatment. The anti-infection showed significant effectiveness, and the patient's proteinuria remained stable during follow-up.

Conclusion

The patient with PNS and T2DM was concurrently diagnosed with both CM and coronavirus disease 2019 (COVID-19), marking the first reported case of such co-infections in these patients. Prompt diagnosis and appropriate antifungal therapy are crucial for improved outcomes of PNS patients with CM and COVID-19.

Clinical and mycological implications of cryptococcal meningitis in Iran

Cryptococcal meningitis (CM) is an uncommon and severe infection that tends to affect both immunocompromised and immunocompetent hosts. To gain insights into the clinical and epidemiological characteristics of CM in Iran, this study evaluated patients with subacute or chronic meningitis referred to 15 Iranian hospitals. Relevant clinical and epidemiological characteristics of the patients were analyzed. Diagnosis of CM cases was performed by microscopic examination, culture, latex agglutination assay, lateral flow assay, and multiplex PCR on cerebrospinal fluid (CSF) samples. The isolates were processed and subjected to molecular identification and in vitro susceptibility antifungal profile. Among the 272 evaluated patients, 7 (2.6 %) CM cases were diagnosed. Out of seven CM cases, 6 (86 %) were male with a median age of 36 years. The most common neurological signs were headache (100 %), followed by nausea and vomiting (71.4 %). All CSF samples from CM patients exhibited positive results across all mycological tests conducted. The isolates were identified as Cryptococcus neoformans (86 %) and Cryptococcus gattii (14 %). All isolates were susceptible to voriconazole and fluconazole, while resistance was observed with itraconazole (MIC value of 0.5 μg/mL) and amphotericin B (MIC values of 4 and 1 μg/mL). The highest mortality (6/7, 86 %) was observed among patients. While a comprehensive study on this subject is currently lacking in Iran, the data acquired through this research play a crucial role in enhancing the clinical and epidemiological understanding of this infection, particularly within low-income countries. Moreover, these findings will serve as a cornerstone for future international comparative studies in this field.

Clinical features and risk factors of surgical site infections in HIV-negative patients with cryptococcal meningitis underwent ventriculoperitoneal shunt operations: a retrospective study

Background

To investigate the clinical features and risk factors of ventriculoperitoneal shunt (VPS) associated surgical site infections (SSIs) in HIV-negative patients with cryptococcal meningitis (CM).

Methods

We retrospectively reviewed the medical records of HIV-negative patients with CM underwent VPS operation admitted to The Third Affiliated Hospital of Sun Yat-sen University in Southwest China over the past 7 years.

Results

193 patients were included, of whom 25 (12.95%) had SSIs in 6 (median duration, 1–48 days) days after operation. Compared with patients without SSIs, patient with SSIs tended to be shorter preoperative stay. 52% patients in SSIs group and 25% patients in no-SSIs group underwent VPS operations within 3 days after admission (p = 0.017). Although body temperature and infectious indicators slightly elevated postoperative in both groups. The patients with SSIs experienced more fever; more central nervous system symptoms; higher PCT value and lower cerebrospinal fluid (CSF) glucose in contrast to the no-SSIs group. Multivariate regression analysis found a 2.653 fold increase in the risk of infection for every 1 °C increase in postoperative body temperature. Among the 25 patients, 9 patients had positive culture results, three samples reported to be oxacillin resistant coagulase-negative Staphylococci.

Conclusions

SSIs was one of the serious surgical complications after VPS operation. High body temperature, the occurrence of dizziness and headache, low postoperative hemoglobin are risk factors. Postoperative patients with high fever, high PCT and low CSF glucose should be paid more attention to.

'When Cryptococcus strikes and lupus is found': a unique covert unveiling of systemic lupus erythematosus presenting as subacute meningitis

Cryptococcal neoformans is a rare fungal pathogen that has been associated with immunocompromised individuals. Due to its rare occurrence, clinicians have a low index of suspicion for diagnosis, which can lead to increased morbidity and mortality. We present an 81-year-old fully functional woman with no known predisposing risk factors or previous immunocompromising conditions who was found to have cryptococcal meningitis on cerebrospinal fluid analysis in the setting of newly diagnosed uncontrolled type 2 diabetes and systemic lupus erythematosus (SLE).