Disseminated cryptococcosis caused by Cryptococcus neoformans a case report and review / 中国热带医学

@#Abstract: To analyze the clinical, therapeutic and laboratory characteristics of disseminated cryptococcosis caused by Cryptococcus neoformans invading the blood stream in patient with liver cirrhosis and splenectomy. A 30-year-old male underwent splenectomy plus pericardial devascularization due to "splenomegaly and hypersplenism" in March in 2016. The patient had intermittent fever after operation for many times, and successively accompanied with back pain, left lower limb abscess and right hip pain. The highest body temperature was 39 ℃. CT and MRI revealed the lung lesion and multiple bone destruction. During that period, the effect of antibiotics was not good. On April 19th, 2017, Gram's stain, India ink stain, API 32C, Vitek 2 Compact, ribosomal ITS and IGS sequence analysis were performed to identify the strain isolated from the pus and blood stream. The serum of the patient was detected for cryptococcal antigen. Antifungal susceptibility test was used to determine drug sensitivity and minimum inhibitory concentration (MIC). The Cryptococcus neoformans isolated from fresh pus specimen showed a prominent, thick capsule after India ink stain. The colonies isolated from pus and blood stream were identified Cryptococcus neoformans using API 32C, Vitek 2 Compact, and sequence analysis of rDNA ITS and IGS. Cryptococcal capsule antigen was positive. The minimal inhibitory concentrations of 5-Flucytosine, amphotericin B, fluconazole, itriconazole, voriconazole against the isolate were <4 μg/mL, <0.5 μg/mL, 4 μg/mL, ≤0.25 μg/mL, 0.125 μg/mL respectively. The patient was initially treated with intravenous amphotericin B and flucytosine. After anti-Cryptococcus treatment for two months, the patient clinically improved, and the lesions were reduced on a follow-up CT scan. The patient made a full functional recovery after treatment for six months. Cryptococcosis has hidden onset, atypical clinical symptoms and lack of specificity. Blood stream is the main channel for Cryptococcus to spread and involve many organs of the whole body, including skin, bone and so on. Therefore, early use of blood culture to monitor blood flow dissemination, actively removing the primary focus and cutting off the infection route in time and carrying out effective anti-Cryptococcus treatment are conducive to the patient's early recovery.

Diminished CD40L expression on T-cells in a case of disseminated cryptococcosis

X-linked hyperimmunoglobulin M (HIGM) syndrome may increase the susceptibility of patients to disseminated cryptococcal infections primarily due to CD40L deficiency that causes defective cross talk between T- and B-cells, thus preventing class switching. In HIGM syndrome, serum IgM levels are elevated with severe reduction in serum immunoglobulin G (IgG) and IgA levels. In addition, the expression of CD40L (CD154) on in vitro-activated T-cells is severely reduced or absent. Here, we describe a rare, and perhaps, the first reported case in India of a 3-year-old male child with X-linked HIGM immunodeficiency syndrome who developed disseminated Cryptococcosis. Evaluation of the serum IgG profile of the patient revealed increased serum IgM levels with reduced IgG and IgA levels. Both the frequency and the function of T-cells, primarily CD40L on activated T-cells, showed weak expression suggestive of HIGM syndrome.

Clinical characteristics and prognosis of disseminated cryptococcosis in children / 中华实用儿科临床杂志

Objective To analyze the clinical characteristics and prognosis of disseminated cryptococcosis in children.Methods The data of disseminated cryptococcosis inpatients were reviewed retrospectively at Beijing Children's Hospital,Capital Medical University,from January 2002 to September 2014.The demographic data,clinical manifestations,laboratory findings,imaging,antifungal treatments and outcomes of all the patients were analyzed.Results Overall 25 children with disseminated cryptococcosis were enrolled including 17 boys(68.0％).The average age was 7 years old.Four cases (16.0％) had underlying conditions,among them 1 case had human immunodeficiency virus(HIV)-positive.The median time to diagnosis was 32 (23-47) days,44.0％ of the patients (11 cases) were misdiagnosed,and 8 cases misdiagnosed as tuberculosis.All patients had fever.Other common clinical manifestations included cough (16 cases),headache (10 cases),vomiting (10 cases),altered mental status (6 cases) and stomachache (6 cases).Respiratory system involvement was seen in all cases,central nervous system was involved in 18 cases,other organ involvement included lymph nodes,spleen,liver,kidney,skin,skeleton and costicartilage.Amphotericin B (AmB) + Fluconazole (Flu) ± 5-flucytosine (5-FC) was the most common therapy (15 cases),Flu ± 5-FC for 6 cases,AmB ± 5-FC for 2 cases,Voricanazole (VOR) for 1 case.Sixteen cases (66.7％) got recovery/improved on discharge,8 cases (33.3％) rejected to the advise and discharged with treatment failure,and the HIV-infected patient transferred to a special hospital.Fifteen patients (60.0％) were followed up,and 13 cases (87.0％) showed recovery,but 2 died in the long-term prognosis.Conclusions Disseminated cryptococcosis in children is more common in school-age boys.Most patients are without underlying conditions.Disseminated cryptococcosis can cause multiple organ damage.Patients with prolonged fever,cough,headache,with or without underlying diseases,can be suspected as disseminated cryptococcosis.Blood and cerebrospinal fluid culture for fungus,cryptococcal antigen should be performed for early diagnosis and treatment.

Fatal cryptococcosis involving multiple sites in an immunocompetent child.

Disseminated cryptococcosis is less common in immunocompetent individuals. Herein, we report a fatal case of cryptococcosis in apparently immunocompetent child with multiple site involvement. The yeast isolated from cerebrospinal fl uid, blood, endotracheal, gastric and lymph node aspirate was identifi ed by molecular method as Cryptococcus neoformans var. grubii.

Vertebro-cerebral cryptococcosis mimicking tuberculosis: A diagnostic dilemma in countries with high burden of tuberculosis.

We report a case of a 30-year-old immunocompetent man with disseminated cryptococcosis who was initially treated with antitubercular therapy due to clinical and radiological diagnosis of vertebro-cerebral tuberculosis. The diagnosis of Cryptococcus infection was made due to incidental isolation of this fungus from blood culture with negative cerebrospinal fluid culture results. Though disseminated cryptococcosis with central nervous system, skeletal, and skin involvement is an uncommon manifestation of Cryptococcus neoformans infection, a high clinical suspicion and early initiation of therapy is needed to recognise and treat such patients efficiently.

Criptococcosis diseminada y síndrome de reconstitución inmune: presentación de un caso

La criptococosis es una enfermedad oportunista definitoria de sida con bajo incidencia en población pediátrica y de elevada mórbida-mortalidad. Presentamos el caso de un adolescente con diagnóstico reciente de sida con criptococosis diseminada como parte de un síndrome de reconstitución a la séptima semana de inicio de terapia antirretroviral, quien recibió manejo de forma exitosa con anfotericina B en monoterapia y sin complicaciones a un año de seguimiento.

Cryptococcosis is an AIDS-defining opportunistic disease with low incidence in the pediatric population associated with high morbidity and mortality. We report the case of a teenager newly diagnosed with AIDS with disseminated cryptococcosis as part of an immune reconstitution syndrome in the seventh week of initiation of antiretroviral therapy, who received mono therapy with amphotericin B without complications to a year follow up

A Case of Disseminated Crytococcosis in a Patient with Systemic Lupus Erythematosus / 대한류마티스학회지

Disseminated cryptococcosis mainly occurs in immunocompromised patients. It enters the body through the respiratory tract and spreads to the lungs, skin, liver and lymphoid organs. Among cryptococcosis, cryptococcal meningitis is a relatively frequent manifestation and causes serious morbidity and mortality. It needs urgent diagnosis and initiation of effective antifungal therapy. It is difficult to differentiate cryptococcal meningitis from neuropsychiatric lupus due to similar clinical symptoms, laboratory and cerebrospinal fluid findings. We report a case of disseminated cyrptococcosis in a patient with systemic lupus erythematosus being managed with mycophenolate mofetil, prednisolone and hydroxychloroquine.

Criptococose disseminada em lúpus eritematoso sistêmico juvenil / Disseminated cryptococcosis in juvenile systemic erythematosus lupus

O lúpus eritematoso sistêmico (LES) é uma doença inflamatória multissistêmica, na qual as infecções são responsáveis por altos índices de morbimortalidade. Os usos de corticóide e imunossupressores contribuem para o aumento das infecções. Embora as bactérias sejam os agentes mais comuns, grande variedade de patógenos tem sido relatada. Este artigo descreve um caso de LES em um menino de 15 anos com criptococose disseminada (sistema nervoso central, pulmão e rim) e encefalite tuberculosa presumível. A coexistência de infecção por Cryptococcus e LES é descrita na literatura, mas a associação desta com encefalite tuberculosa é incomum. O risco potencial de infecções em pacientes lúpicos imunossuprimidos deve alertar o médico a adotar estratégias diagnósticas e terapêuticas precoces visando ao espectro ampliado de possíveis patógenos.

Systemic lupus erythematosus (SLE) is a multisystem inflammatory disease, in which infection is responsible for high rates of mortality. The use of corticosteroids and immunosuppressive therapy contributes to this high incidence of infections. Although bacteria are the most common agents, a wide variety of pathogens has been reported. This article reports a case of SLE in a 15 years-old boy with disseminated criptococosis (central nervous system, lungs and kidneys) and presumptive tuberculous encephalitis. The coexistence of infection by Cryptococcus and SLE is described in the literature, but the combination of this with tuberculous encephalitis is uncommon. The potential risk of infection in immunosuppressed SLE patients should alert the physician to adopt early diagnostic and therapeutic strategies aiming at an extended spectrum of pathogens.

Cutaneous Cryptococcosis Clinically Mimicking Necrotizing Fasciitis

Secondary cutaneous cryptococcosis may occur earlier than other manifestations of disseminated cryptococcosis. A 68-year-old woman presented with multiple ulcerative lesions on the right calf of 2 weeks duration. She had been treated with antibiotics, but the lesions spread rapidly. The initial clinical impression was necrotizing fasciitis, but routine KOH mounting from the ulcerative lesions showed numerous budding yeast cells with peripheral clear zones and further investigations including a skin biopsy, tissue cultures and India ink preparations allowed a rapid and definitive diagnosis of cutaneous cryptococcosis. Studies for other evidence of infection elsewhere revealed an asymptomatic pulmonary lesion. We report a case of secondary cutaneous cryptococcosis clinically mimicking necrotizing fasciitis that occured before other manifestations of disseminated cryptococcosis.