Fatal disseminaeed cryptococcosis with renal involvement in an HIV-infected patient / Criptococose disseminada fatal com envolvimento renal em paciente infectado pelo HIV

SUMMARYIntroduction: We present a fatal case of disseminated cryptococcosis in a young man whose diagnosis of HIV infection was made at the time of admission to the emergency room.Case report: The patient was a twenty-three-year-old man, with a history of daily fever during one month associated with diarrhea, weight loss, headache, vomiting and generalized seizures. He also had a history of diabetes mellitus, alcoholism and drug addiction. Upon physical examination the patient was pale, disoriented and had periods of agitation. White blood cells count was 3,440/mm3 (5% lymphocytes), hemoglobin was 10g/dL, platelets were 83,000/ mm3. Creatinine was 0.7 mg/dL; urea 19 mg/dL; Na, K, and liver enzymes were within normal limits. Lactic dehydrogenase was 494 IU/L. Cerebrospinal fluid (CSF) analysis revealed 10 white blood cells/mm3 (58% neutrophils, 31% lymphocytes, 11% monocytes) and 2 red blood cells/mm3. India ink test revealed six Cryptococcusyeasts/mm3. CSF glucose was 122 mg/dL and protein was 36 mg/ dL. VDRL test was negative and anti-HIV test was positive. Intravenous hydration, insulin, phenytoin, fluconazole, pyrimethamine, sulfadiazine, folinic acid, and amphotericin B were started. The patient did not improve and became obtunded and hypotensive. He was intubated and put on mechanical respiration. He received vasoactive drugs and died less than 24 hours after admission. A postmortem examination was performed and revealed disseminated cryptococcosis, with severe involvement of the kidneys.Conclusion:Cryptococcosis, as a rule, is a systemic disease that affects mostly immunocompromised individuals, especially patients with AIDS. When diagnosed late in its course it has a very high mortality.

RESUMOIntrodução: Apresentamos um caso fatal de criptococose disseminada em homem jovem cujo diagnóstico de HIV foi feito no momento da admissão na emergência.Relato de caso: O paciente, de 23 anos, sexo masculino, tinha história de febre diária de um mês de duração, associada à diarreia, perda de peso, cefaleia, vômitos e convulsões generalizadas. Tinha ainda história de diabetes mellitus, alcoolismo e drogadição. Ao exame físico havia palidez, desorientação e períodos de agitação. Os exames laboratoriais mostraram 3.440 leucócitos/mm3(5% linfócitos), hemoglobina de 10 g/dL, 83,000 plaquetas/mm3, creatinina de 0,7mg/dL, ureia de 19 mg/dL, Na, K e enzimas hepáticas dentro dos limites da normalidade. A lactato desidrogenase era 494 UI/L. Análise do líquor revelou 10 leucócitos/mm3 (58% neutrófilos, 31% linfócitos, 11% monócitos) e 2 hemácias/mm3, glicose de 122 mg/dL e proteína de 36 mg/dL. A análise com tinta da Índia revelou seis blastoconídeos de Cryptococcus/mm³. O VDRL foi negativo e o anti-HIV positivo. Foi iniciado tratamento com hidratação venosa, insulina, fenitoína, fluconazol, pirimetamina, sulfadiazina, ácido folínico e anfotericina B. O paciente não apresentou melhora e evoluiu com obnubilação e hipotensão, sendo intubado e iniciada ventilação mecânica. Foram administradas drogas vasoativas, e o paciente evoluiu a óbito menos de 24h após a admissão. A autópsia revelou criptococose disseminada, com grave envolvimento renal.Conclusão:A criptococose é via-de-regra, doença sistêmica que afeta principalmente indivíduos imunocomprometidos, especialmente com AIDS, e quando diagnosticada tardiamente apresenta alta mortalidade.

Contribución al estudio de la criptococosis infantil en Cuba / Contribution to the study of infant cryptococosis in Cuba

Introducción: a partir de 1998 en el laboratorio de micología del Instituto Pedro Kourí se observó un incremento del número de aislamientos de Cryptococcus obtenidos de niños seronegativos al VIH con meningoencefalitis. Los reportes de criptococosis infantil a nivel mundial son infrecuentes y generalmente se encuentran asociados al sida. Objetivo: estudiar la criptococosis infantil en Cuba a través de la evaluación integral de 7 casos. Métodos: se realizó un estudio retrospectivo integral, se revisaron las historias clínicas de 7 pacientes pediátricos afectados por criptococosis menigoencefálica y se caracterizaron los aislamientos obtenidos (uno de cada paciente). A estos se les determinó la especie, variedad, serotipo, patogenicidad en un modelo murino y susceptibilidad a la anfotericina B. Resultados: la edad media de los niños fue de 5,8 años, con ligero predominio del sexo femenino (4:3). Los síntomas más frecuentes resultaron la cefalea, fotofobia, fiebre y los vómitos. En 6 pacientes el estudio citoquímico del líquido cefalorraquídeo y el examen imaginológico de cráneo evidenciaron anomalías. El diagnóstico microbiológico se realizó mediante examen directo y cultivo. Todos los aislamientos correspondieron con Cryptococcus neoformans serotipo A y la anfotericina B mostró una concentración mínima inhibitoria menor o igual que 0,125 mg/mL. El 85,7 porciento mostró actividad fenoloxidasa y elevada letalidad en los animales infectados (71,4-100 porciento). Conclusiones: el pronóstico de la meningoencefalitis por Cryptococcus está estrechamente ligado a un diagnóstico precoz. Esta realidad hace que deba tenerse siempre presente, por lo que los datos aportados bien pudieran servir de alerta a los médicos de asistencia

Introduction: since 1998, an increasing number of Cryptococcus isolates obtained from HIV-negative children with meningoencephalitis was observed in the mycology laboratory at Pedro Kourí Institute. The global reports of child cryptococcosis are rare and usually associated with AIDS. Objectives: to study child cryptococosis in Cuba through the comprehensive evaluation of 7 cases. Methods: the clinical histories of seven pediatric patients with cryptococcal meningoencephalitis were examined and the obtained isolates (one per patient) were characterized. The species, variety, serotype, pathogenicity in a mouse model and amphotericin B susceptibility of the isolates were determined. Results: average age of the children was 5.8 years, with a slight female predominance (4:3). The most common symptoms were headache, photophobia, fever and vomiting. The cytochemical study of cerebral spinal fluid and skull imaging test showed abnormalities in 6 patients. The microbiological diagnosis was made through direct examination and culture. All the isolates were from Cryptococcus neoformans serotype A and amphotericin B showed a minimum inhibitory concentration £ 0.125 mg/mL. In the group, 85.7 percent showed phenoloxidase activity and high lethality rate in infected animals (71.4 to 100 percent). Conclusions: the prognosis of cryptococcal meningoencephalitis is closely linked to early diagnosis, therefore, this should be always kept in mind and the provided data from this study may serve as warning to attending physicians

Fatores prognósticos na meningite criptocócica em hospital de referência para doenças infecciosas / Prognostic factors of cryptococcal meningitis in a referrence hospital for infectious diseases / Factores pronósticos en la meningitis criptocócica en un hospital de referencia para enfermedades infecciosas

Nos últimos 20 anos, a doença criptocócica cresceu significativamente e aletalidade, bem como a taxa de recidiva da doença, ainda permanece elevada, a despeito dos avanços no seu entendimento e no desenvolvimento de novas abordagens terapêuticas. O objetivo deste artigo é analisar o perfil clínico-epidemiológico dos pacientes com encefalite. criptocócica no Hospital Couto Maia (HCMaia), propondo-se a avaliar quais condições interferem na evolução desses pacientes e elevam as taxas de letalidade da doença. Trata-se de um estudo retrospectivo com dois componentes: descritivo e analítico. Estudaram-se fatores prognósticos de 50 pacientes com diagnóstico de meningoencefalite criptocócica admitidos no Hospital Couto Maia, Salvador, Bahia, Brasil, entre 2002 e 2008. Os resultados indicamque 70por cento dos pacientes eram masculinos; 90por cento tinham sorologia conhecida para HIV, sendo positiva em 52por cento; 46por cento apresentavam sintomas entre 14 e 30 dias. Observou-se menor celularidade liquórica e maior percentagem de líquor com citoquímica normal nos pacientes HIV positivos. A letalidade foi de 22por cento. O comprometimento do nível de consciência foi associado a maior letalidade. Maior frequência de óbito foi encontrada entre os HIV positivos e naqueles que não realizaram punção lombar como método terapêutico da hipertensão intracraniana. Concluiu-se que pacientes HIV positivos podem apresentar característicasclínicas e liquóricas não encontradas habitualmente na meningoencefalite criptocócica. Rebaixamento do nível de consciência foi o único preditor independente de letalidade na população estudada.

During the last 20 years, the cryptococcal disease increased significantly but the mortality and the rate of disease recurrence still remains high despite advances in their understanding and the development of new therapeutic approaches. The objective of this document is to analyze the clinical and epidemiological profile of patients with encephalitis cryptococcal in the Couto Maia Hospital (HCMaia), in order to evaluate what are the circumstances that affect the evolution of these patients and increase the fatality rates of the disease. This is a retrospective study, with two components: descriptive and analytical. Prognostic factors were studied with 50 patients diagnosed with cryptococcal meningoencephalitis,admitted in the Couto Maia Hospital, in Salvador, Bahia, Brazil, between 2002 and 2008. The results indicate that 70percent of patients were male, 90percent have serology indicating HIV and positive in 52percent of the cases and 46percent presenting symptoms between 14 and 30 days. There was less cellularity CSF and CSF with largest percentage cytochemistry normal in HIV-positive patients. The mortality rate was 22percent. The commitment level of consciousness was associated with increased mortality. Major frequency of death was found among HIV positive and those who did not made lumbar puncture as a treatment of intracranial hypertension. It can be concluded that HIV-positive patients may present clinical and cerebrospinal fluid characteristics not usually found in cryptococcal meningoencephalitis. Decreased level of consciousness was the onlyindependent predictor of mortality in this population.

En los últimos 20 años, la enfermedad por Cryptococcus, y su letalidad, creció significativamente, y la tasa de recaida de la misma aún permanece elevada, a pesar de los logros en su comprensión y en el desarrollo de nuevos enfoques terapéuticas. El objetivo de este estudio es analizar el perfil clínico- epidemiológico de los pacientes con encefalitis criptocócica en el Hospital Couto Maia (HCMaia), proponiendo evaluar las condiciones que interfieren en la evolución de esos pacientes, así como la elevación de la tasa de letalidad de la enfermedad. Se trata de un estudio retrospectivo, con dos componentes: descriptivos y analítico. Se estudiaron los factores pronósticos de 50 pacientes con diagnóstico demeningoencefalitis criptocócica, ingresados, entre 2002 y 2008, en el Hospital Couto Maia, Salvador, Bahia, Brasil. Los resultados indican que 70por ciento de los pacientes eran masculinos; 90por ciento tenían serología conocida para el VIH, siendo, en el 52por cientoositiva; 46por ciento presentaban síntomas entre 14 y 30 días. Se observó menor celularidad licuórica y un mayor porcentaje de lícuor con citoquímica normal en los pacientes VIH positivos. La letalidad fue de 22por ciento. El comprometimiento del nivel de conciencia fue asociado a la mayor letalidad. Se detectó mayor frecuencia de óbito entre los VIH positivos y en aquellos que no han realizado la punción lumbar como método terapéutico de la hipertensión intracraneal. Se concluyeque los pacientes con VIH positivos pueden presentar características clínicas y licuóricas no encontradas habitualmente en la meningoencefalitis criptocócica. En la población estudiada, la disminución del nivel consciencia, fue el único predictor independiente de la letalidad.

Cryptococcal liver abscess in HIV-negative individual.

Opportunistic fungal infections in immunocompromised patients are usually caused by candida, aspergillus, cryptococcus or zygomycetes. Rarely, fungal infections may occur in immunocompetent indivivals and are usually caused by cryptococcus or aspergillus. When infected by cryptococcus, the usual sites of infection include respiratory tract, central nervous system, or skin. Uncommon sites are liver, spleen, prostate, and bone marrow. When it involves liver, it can present with micro-abscesses, cholangitis, or hepatitis. Here we report a case of cryptococcal infection of liver in a HIV-negative patient presenting with micro-abscesses.

Complicaciones temibles en un paciente con VIH/SIDA criptococosis, tuberculosis miliar, meningoencefalitis / Fearsome Complications in a Patient with HIV/AIDS: Cryptococcosis, Miliary Tuberculosis, Meningoencephalitis

Los criptococos son un grupo de hongos que se encuentran en el suelo donde hay aves, fundamentalmente palomas. De las diversas especies de criptococo, solamente resulta patógeno para el hombre Cryptoccocus neoformans. La manifestación más frecuente de esta infección es la meningoencefalitis, que afecta principalmente a pacientes inmuno comprometidos. La tuberculosis miliar representa una entidad poco frecuente dentro de las formas de presentación extrapulmonar de la tuberculosis, en pacientes inmunocompetentes. Sin embargo, en los pacientes infectados por el virus de la inmunodeficiencia humana, esta cifra oscila alrededor de 10%. Se presenta un reporte de caso, donde el paciente cursó con esta forma de Tuberculosis. Caso Clínico: Paciente masculino de 53 años, con cuadro de evacuaciones diarreicas crónicas intermitentes, fiebre diaria, vómitos postprandiales 4 a 5 veces al día, de 3 meses de evolución, cefalea intensa de 10 días, concomitantemente presentó una convulsión tónico clónica hace una semana. Además tos crónica con expectoración blanquecina y hemoptisis. Al examen físico se observó microadenopatías cervicales bilaterales, hipoventilación pulmonar bilateral, desviación de la lengua y comisura labial hacia lado derecho, disminución de fuerza en ambos miembros inferiores y superior derecho. Se realiza prueba para la detección de VIH, la cual resulta positiva, con conteo de 10 células CD4, punción lumbar en donde se obtiene líquido cefalorraquídeo ligeramente turbio, tinta china y antígena para criptococo positivo. Paciente es diagnosticado con VIH y SIDA, criptococosis del sistema nervioso central, tuberculosis miliar por rayos X, y meningoencefalitis. Se inicia cobertura antibiótica y antifímica a la cual el paciente respondió favorablemente...

Líquido cefalorraquídeo en pacientes con criptococosis asociada al SIDA / CSF in patients with AIDS associated cryptococcosis

Se analizaron retrospectivamente los líquidos céfalorraquídeos (LCR) de 44 pacientes con criptococosis asociada al SIDA, internados en la Sala XI del Hospital Muñiz, entre enero de 2000 y diciembre de 2004. Se tuvieron en cuenta en cada caso las características físico-químicas, citológicas y micológicas de los LCR obtenidos por punción lumbar al momento de la admisión. La microscopia con tinta china fue positiva en 38 (90.5%) de 42 pacientes con ese dato disponible. Los 6 pacientes restantes se diagnosticaron por cultivos y/o determinación de antígeno de Cryptococcus neoformans. En el examen físico, 29 (69%) de 42 muestras disponibles, presentaron aspecto límpido y las 13 restantes fueron hemorrágicas (n=3), opalescentes (n=6), xantocrómicas (n=3) o turbias (n=1). Del análisis químico, se obtuvo para la proteinorraquia una mediana de 0,7 g/L (rango 0,1-3,5), de 38 mg/dL (rango 12-75) para la glucorraquia y de 127 meq/L (rango 130-143) para la clorurorraquia. La determinación del antígeno capsular, disponible para 7 muestras de LCR y sangre, mostró una mediana de 1/1.000, con valores más elevados en sangre. Las características del LCR de los pacientes examinados con criptococosis asociada al SIDA no revelaron, al menos en los parámetros evaluados, alteraciones diferentes a las mencionadas en la literatura.

Cerebrospinal fluids (CSF) of 44 patients with cryptococcosis associated with Acquired Immunodeficiency Syndrome (AIDS), treated in the Ward XI of the Muñiz Hospital from January 2000 to December 2004, were retrospectively analyzed. The physical, chemical, cytological and mycological characteristics of CSF obtained by lumbar puncture at the moment of admission were taken into account in each case. India ink microscopy was positive in 38 (90.5%) out of 42 patients and the remainning 6 patients were diagnos- ed by cultures and/or determination of capsular antigen of Cryptococcus neoformans. At physical examination, 29 (69%) out of 42 samples showed a limpid aspect and the remaining 13 were hemorrhagic (n=3), opalescent (n=6), xanthochromic (n=3) or turbid (n=1). Chemically, the median of proteinorraquia was 0.7 g/L (range 0.1-3.5 g/L), 38 g/L (range 12-75 g/L) for glycorrhachia and 127 meq/L (range 130-143 mEq/L) for clorurorrachia. The capsular antigen of Cryptococcus neoformans, available for 7 CSF and blood samples, showed a median of 1/1.000 in both, with higher values in blood than in CSF. The CSF of patients with AIDS associated cryptococcosis evaluated in the present study did not reveal important differences, at least in the evaluated parameters, with respect to those cited in the literature.

Amaurose bilateral por menigoencefalite criptocócica: relato de caso / Bilateral amaurosis due to cryptococcus meningoencephalitis: case report

Meningoencefalite criptocócica é infecção causada por um fungo denominado Cryptococcus neoformans. Duas formas são conhecidas: variação gattii e neoformans. A infecção antes da puberdade é rara. Cerca de metade dos pacientes apresentam algum estado imunossupressivo. O papiledema está presente em um terço dos pacientes por ocasião do diagnóstico. Relatamos um caso de meningoencefalite por criptococose em paciente de oito anos de idade, sem relato de doenças prévias, que evoluiu com amaurose bilateral. O diagnóstico foi confirmado por detecção do C. neoformans, var. gattii. O paciente foi tratado com anfotericina B e dexametasona. Na literatura existem poucos relatos de perda visual permanente após meningite por criptococose. A existência de um protocolo para tratamento de pacientes com papiledema é um fator determinante para evitar a perda visual.

Cryptococcal meningitis is caused by the yeast Cryptococcus neoformans. Two varieties are recognized: var. gattii and var. neoformans. It is usually associated with immunosuppressive states, particularly HIV infection. Cryptococcal infection of the central nervous system is uncommon in immunocompetent children and difficult to diagnose. Ocular complications are common. Optic disc swelling was found in 33 percent. The following report describes a case of meningitis caused by C. neoformans var. gattii in an 8 year-old immunocompetent child who developed optic atrophy. The patient was treated with amphotericin B associated with corticosteroids. Possible therapeutic strategies aimed at reducing visual loss in cryptococcal meningitis have great importance to avoid this important morbidity.

Criptococose palpebral: relato de caso / Palpebral cryptococcosis: case report

Relata-se o caso de uma paciente portadora de síndrome da imunodeficiência adquirida empiricamente tratada com esquema tríplice para tuberculose miliar. Durante a evolução clínica a paciente cursou com lesões comprometendo a pálpebra e conjuntiva tarsal à direita. A hipótese diagnóstica inicial foi de tuberculose ocular com comprometimento conjuntival e palpebral. A biópsia da lesão conjuntival mostrou presença do Criptococcus neoformans. Após o início do tratamento específico com anfotericina B, a paciente apresentou melhora das lesões cutâneas.

Bronchiolitis obliterans organizing pneumonia caused by capsule-deficient cryptococcosis.

A 67-year-old diabetic man presented with progressive multifocal myeloradiculopathy for 6 months, with no pulmonary symptoms. A chest x-ray and CT scan of the lungs revealed bilateral multiple nodular infiltrates in the right upper lobe and the lower lobes bilaterally, mimicking metastases. A thoracoscopic lung biopsy demonstrated bronchiolitis obliterans organizing pneumonia caused by capsule-deficient cryptococcosis.

A Case of Pulmonary Cryptococcosis with Non-Small Cell Lung Cancer in Idiopathic CD4+ T-Lymphocytopenia

Cryptococcus neoformans commonly causes opportunistic infections in immunocompromised patients, especially in patients with AIDS. CD4+ T-lymphocytopenia in AIDS indicates an increased risk of opportunistic infection and a decline in immunological function. Idiopathic CD4 T-lymphocytopenia (ICL) is characterized by depletions in the CD4+ T-cell subsets, without evidence of HIV infection. Immunodeficiency can exist in the absence of laboratory evidence of HIV infection, and T-cell subsets should be evaluated in patients who present with unusual opportunistic infections. We report a case of pulmonary cryptococcosis and lung cancer in a patient with persistently low CD4+ cell counts, without evidence of HIV infection.

Postmortem pathology of opportunistic infection in a HIV positive patient--a case report.

An autopsy case of HIV positive patient with multiple opportunistic infections is described. We received heart, lungs, spleen and both the kidneys along with pieces of cerebrum for anatomy and histopathological examination. Histology of organs revealed disseminated non-granulomatous necrotizing type of tissue reaction with superadded infection with Cryptococcus neoformans (C. neoformans) in liver and brain. Pneumocysts carini (P. carini) induced pneumonia in lungs, disseminated mycobacterial infection in spleen, lungs, liver and kidneys and acute fibrinous meningitis with superadded infection with C. neoformans in brain. Special stains were carried out to demonstrate different organisms.

Criptococose pulmonar pseudotumoral associada à síndrome de Cushing / Pseudotumoral pulmonary cryptococcosis in association with Cushing's syndrome

Em pacientes com síndrome de Cushing, observa-se freqüência aumentada de infecções oportunistas que possuem uma elevada mortalidade e estão associadas à gravidade do hipercortisolismo. Criptococose pulmonar é uma destas infecções oportunistas e pode mimetizar uma neoplasia pulmonar, tornando o seu diagnóstico difícil. Apresentamos um caso de um paciente do sexo masculino, jovem, com síndrome de Cushing ACTH-dependente e grave hipercortisolismo. O paciente obteve a cura após cirurgia transfenoidal, mas desenvolveu quadro febril. Tomografia computadorizada de tórax mostrou um nódulo pulmonar que não se alterava em radiografias seriadas. A investigação para tuberculose, infecção fúngica e bacteriana foi inconclusiva, tornando a hipótese de neoplasia pulmonar mais provável. O paciente faleceu por sepse urinária. A necropsia, no entanto, demonstrou tratar-se de criptococose pseudotumoral. Pacientes com síndrome de Cushing e infiltrado pulmonar devem ser avaliados quanto à infecção fúngica, como Cryptococcus neoformans.

Pneumocystis carinii pneumonia and its association with other opportunistic infections in AIDS--an autopsy report of five cases.

Pneumocystis carinii pneumonia (PCP) has been reported as one of the opportunistic pathogens in AIDS. The significance of this pathogen in AIDS is well established so that, the diagnosis of PCP in an adult simultaneously establishes the diagnosis of AIDS. This point is well emphasised in the CDC case definition of AIDS. In western literature, the occurrence of PCP in AIDS is widely reported. However, in Indian literature only sporadic case reports have been documented. This study reports 5 cases of PCP encountered amongst 34 AIDS-autopsies studied. PCP alone was present in 2 cases. It is worth noting that it was simultaneously associated with cryptococcosis, tuberculosis and CMV in 3 remaining cases, highlighting the need for extensive investigations even after establishing the diagnosis of PCP in a known full blown AIDS patient.

Disseminated Cryptococcosis in a Patient with Pituitary Cushing's Disease

Disseminated cryptococcosis mainly occurs in patients with cell-mediated immunity disorders. A case of disseminated cryptococcosis, in a patient with pituitary Cushing's disease, is reported. Cultures of blood, cerebrospinal fluid (CSF) and aspirates of a skin lesion all grew Cryptococcus neoformans. Despite antifungal treatment, with amphotericin-B, the patient died within 3 weeks.

Spontaneous cryptococcal peritonitis in cirrhotic patients.

Spontaneous bacterial peritonitis is a common complication in patients with cirrhosis and ascites. However, spontaneous peritonitis caused by Cryptococcus neoformans is uncommon. Delayed diagnosis of cryptococcal peritonitis often results in death. We describe three cases of spontaneous cryptococcal peritonitis in patients with decompensated cirrhosis. One case had associated symptomatic human immunodeficiency virus infection. Clinical awareness of this entity may lead to the early diagnosis and proper treatment.

X-linked Hyper-IgM Syndrome Associated with Cryptosporidium parvum and Cryptococcus neoformans Infections: the First Case with Molecular Diagnosis in Korea

X-linked hyper-IgM syndrome (XHIM) is a rare primary immunodeficiency disorder, caused by mutations of the gene encoding CD40 ligand (CD40L; CD154). We report the clinical manifestations and mutational analysis of the CD40L gene observed in a male patient from a XHIM family. Having hypogammaglobulinemia and elevated IgM, the 3-yr-old boy exhibited the characteristic clinical features of XHIM. The patient suffered from frequent respiratory infections, and chronic enteritis caused by Cryptosporidium parvum. In addition, a lymph node biopsy and a culture from this sample revealed C. neoformans infection. Activated lymphocytes from the patient failed to express CD40L on their surface as assessed by flow cytometry and a missence mutation (W140R) was found at the XHIM hotspot in his CD40L cDNA to confirm the diagnosis. Genetic analysis of the mother and sister showed a heterozygote pattern, indicating carrier status. To our knowledge, this is the first report on the molecular diagnosis of an XHIM patient in Korea.

Cryptococcal prostatitis in a patient with chronic lymphocytic leukemia.

Cryptococcosis is a systemic mycosis usually affecting patients of immunodeficiency i.e. transplants recipients, patients on chemotherapy for neoplastic diseases and in those suffering from human immunodeficiency virus infection. We report a 52-year old male suffering from chronic lymphocytic leukemia (CLL) on chemotherapy who presented with fever and features of prostatism. Cryptococcus neoformans infection (CN) was diagnosed on aspiration of a prostatic nodule. Subsequent investigations revealed a disseminated involvement by cryptococcus. The case represents an unusual presentation of disseminated cryptococcosis.

Changing scenario of cryptococcosis in a tertiary care hospital in north India.

BACKGROUND & OBJECTIVES: With the increase in the number of patients of AIDS, the incidence of cryptococcosis is on the rise in India. It was therefore considered important to evaluate the predisposing factors, laboratory investigations and outcome of patients with cryptococcosis in this changed scenario. METHODS: We assessed 58 patients with cryptococcosis retrospectively over a five year period (January 1995-December 1999) at the Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. RESULTS: The annual incidence of cryptococcosis in PGIMER, Chandigarh has increased about 15 fold from 1970-1982 (pre AIDS era) to 1995-1999 (present series). Of the 47 patients studied for predisposing factors, 36 patients were identified with predisposing factors, HIV infection (57.4%) was the commonest followed by haematologic malignancies (6.3%) and renal transplant (4.2%). Forty one patients were diagnosed by isolation of the organism as well as antigen detection in cerebrospinal fluid/serum, 9 by isolation alone and 8 by antigen detection alone. Quantitative antigen titres were done in 38 patients and a significantly higher (P < 0.01) antigen titre (> 512) was observed in HIV positive patients as compared to HIV negative patients. All isolates tested were of Cryptococcous neoformans var neoformans biotype and no resistance to antifungal agents was noted. Twenty of 41 patients receiving treatment improved. The results were compared with other studies available from India. INTERPRETATION & CONCLUSION: The incidence of cryptococcosis is on the rise in this part of north India and this can be attributed to an increase in AIDS cases.