Comparison of two commercial tests (Immy vs. Dynamiker) for cryptococcal capsular antigen

Abstract INTRODUCTION Lateral flow assay is an advanced method useful in the early diagnosis of cryptococcal meningitis. We aimed to compare two commercial tests for cryptococcal capsular antigen in the sera of asymptomatic patients with human immunodeficiency virus in Barranquilla, Colombia. METHODS Thawed (n=162) previously collected serums (2016-2019) were processed using IMMY and Dynamiker cryptococcal antigen lateral flow assay. RESULTS Compared to IMMY's results, Dynamiker's sensitivity, specificity, positive predictive value, negative predictive value, and kappa index were 100%, 89.9%, 48.3%, 100.0%, and 0.61, respectively. CONCLUSIONS The Dynamiker test had excellent sensitivity, acceptable specificity, and a low detection threshold for cryptococcal antigen in the tested samples.

Production of a latex agglutination reagent for the rapid diagnosis of cryptococcal meningitis / Producción de un reactivo de látex para el diagnóstico rápido de criptococosismeníngea

Abstract Cryptococcosis is a fungal disease affecting more than one million people per yearworldwide. Its main etiological agents are Cryptococcus neoformans species complex and Cryp-tococcus gattii species complex. Cryptococcal meningitis (CM) is considered an AIDS-definingcondition. Rapid diagnosis by cryptococcal antigen assays, either the latex agglutination test(LA) or the lateral flow assay, is key to decreasing mortality due to cryptococcal disease. Theaim of the study was to develop a latex agglutination reagent (LA-ANLIS) for the rapid and reliable diagnosis of cryptococcosis in Argentina. This reagent will be produced in order to supplythe NMLN (National Mycology Laboratory Network). The evaluation of LA-ANLIS performanceand its comparison with the Cryptococcus Antigen Latex Agglutination Test System (LA-IMMY)(Immuno-Mycologics, Inc., USA) were conducted in 94 samples of cerebrospinal fluid. LA-ANLISand LA-IMMY compared exhibited 100% positive agreement and 97% negative agreement. LA-ANLIS showed 94% sensitivity and 97% specificity with the positive and negative predictivevalues of 94% and 97%, respectively. The LA-ANLIS is a reliable, reproducible and cost-effectivereagent, especially useful in countries where the commercial kit is not generally available andmust be obtained at a high cost. National production of reagents is the best choice for a reliableaccess to the rapid diagnosis of CM in Argentina.

Resumen La criptococosis es una enfermedad fúngica que afecta a más de un millón de personas por año en todo el mundo. Los principales agentes etiológicos pertenecen a los complejos de especies Cryptococcus neoformans y Cryptococcus gattii. La criptococosis meníngea (CM) se considera una enfermedad marcadora de sida. El diagnóstico rápido de esta enfermedad a través de la detección del antígeno de Cryptococcus, ya sea por aglutinación en partículas de látex o por inmunocromatografía, es clave para disminuir la mortalidad. El objetivo del presente estudio fue desarrollar un reactivo de aglutinación en partículas de látex para el diagnóstico rápido y certero de la CM en Argentina. Este reactivo (denominado en adelante LA-ANLIS) será producido para abastecer a la Red Nacional de Laboratorios de Micología. Se evaluó el desempeno del reactivo LA-ANLIS, y se realizó una comparación con el reactivo comercial Immuno-Mycologics, Inc. (en adelante, LA-IMMY) utilizando 94 muestras de líquido cefalorraquídeo. Hubo un 100% de acuerdo positivo y un 97% de acuerdo negativo entre los resultados obtenidos con los reactivos LA-ANLIS y LA-IMMY. El reactivo LA-ANLIS mostró una sensibilidad del 94% y una especificidad del 97%; los valores predictivos positivo y negativo fueron del 94 y del 97%, respectivamente. Se concluye que el LA-ANLIS es un reactivo confiable y rentable, que arroja resultados reproducibles, por lo que es especialmente útil en países donde los reactivos comerciales generalmente no están disponibles o sus costos son elevados. La producción nacional de reactivos es la mejor opción para asegurar el acceso de todos los hospitales al diagnóstico rápido de la CM en Argentina.

Visible DNA microarray and loop-mediated isothermal amplification (LAMP) for the identification of Cryptococcus species recovered from culture medium and cerebrospinal fluid of patients with meningitis

Cryptococcal meningitis affects normal hosts and immunocompromised patients exhibiting high mortality rates. The objective of this study was to design two molecular assays, visible microarray platforms and loop-mediated isothermal amplification (LAMP), to identify Cryptococcus spp. and the species neoformans and gattii from the cerebral spinal fluid (CSF). To identify Cryptococcus and the two species, we designed two microarrays DNA platforms based on the internal transcribed spacer (ITS) region and CAP59 gene and LAMP assays specific for Cryptococcus species. The assays were tested using CSF from patients with cryptococcal meningitis. CSF from patients with cryptococcal meningitis was cultured in Sabouraud culture medium, and the Cryptococcus spp. grown in the culture medium were also tested for LAMP and microarray platforms. The results were compared to DNA sequencing of the same genetic regions. A total of 133 CSF samples were studied. Eleven CSFs were positive for Cryptococcus (9 C. neoformans and 2 C. gattii), 15 were positive for bacteria, and 107 were negative. The CAP59 platform correctly identified 73% of the CSF samples, while the ITS platform identified 45.5%. CAP59 platform correctly identified 100% of the Cryptococcus isolates, and ITS platform identified 70%. The two sets of LAMP primers correctly identified 100% of the Cryptococcus isolates. However, for CSF samples, the amplification occurred only in 55.5% of C. neoformans. The methodologies were reliable in the identification of Cryptococcus species, mainly for isolates from culture medium, and they might be applied as adjunctive tests to identify Cryptococcus species.

Meningitis criptocóccica en pacientes sin infección por VIH: presentación de dos casos y revisión de la literatura / Meningeal cryptococcosis in patients non infected with HIV: presentation of two cases and review of the literature

Resumen La criptococosis es una enfermedad fúngica de distribución global con una mayor incidencia en países en vía de desarrollo, donde constituye una de las principales causas de meningitis, asociado a una alta morbi-mortalidad. Afecta principalmente a pacientes con inmunosupresión (por infección por VIH, tratamiento con glucocorticoides, sometidos a trasplantes, cáncer, etc). Sin embargo, en los últimos años se ha presentado un incremento de casos en inmunocompetentes, siendo tanto o más grave que en inmunocomprometidos. Presentamos dos casos de meningitis criptocóccica. Un varón de 48 años, en quien se descartó una infección por VIH u otra causa de inmunosupresión y una mujer de 67 años con antecedentes de cirrosis hepática. Debe considerarse Cryptococcus spp. como posible agente causal de meningitis, tanto en pacientes inmunocomprometidos como inmunocompetentes.

Cryptococcosis is a fungal disease of global distribution with a higher incidence in developing countries, where it represents one of the main causes of meningitis, associated with high morbidity and mortality. It mainly occurs in patients with immunosuppression (due to HIV infection, glucocorticoid treatment, transplants, cancer, etc.). However, in recent years there has been an increase in cases in immunocompetent, which is as serious or more severe than in immunocompromised. We report two cases of cryptococcal meningitis. A 48-year-old male with no pathological history, in whom HIV infection or another cause of immunosuppression was ruled out, and a 67-year-old woman with a previous diagnosis of liver cirrhosis. The above mentioned highlights the importance of always considering Cryptococcus spp. as possible causative agent of meningitis, in both immunocompromised and immunocompetent patients.

Diagnostic and therapeutic strategies in cryptococcosis: impact on outcome

Cryptococcosis diagnosis has been recently improved by the use of rapid cryptococcal antigen testing with lateral flow assays, which have proved sensitive and specific. Using "test and treat" screening strategies for cryptococcal disease with these tests has been showed effective in reducing cryptococcal meningitis (CM) in HIV-infected patients. Recommended induction, consolidation, and maintenance therapeutic strategy for CM is widely unavailable and/or expensive in low and middle-income settings. New therapeutic strategies, mostly using reduced duration, have recently shown acceptable outcome or are currently tested. Diagnostic and therapeutic guidelines for cryptococcal disease in limited resources countries are undergoing a paradigmatic shift.

Apport du Crag-Test serum dans le diagnostic de la cryptococcose neuroméningée en milieu rural. A propos de deux observations

Introduction : La cryptococcose neuro-méningée est la plus commune des affections mortelles du Système Nerveux Central chez les patients immuno-déprimés en Afrique Subsaharienne. Il s'agit alors d'une véritable urgence diagnostique et thérapeutique, d'où la mise en œuvre des tests diagnostiques rapides et efficace. Le Crag-Test serum (Antigénémie cryptococcique) pourrait alors se révéler utile sur ces terrains particuliers en milieu rural africain. Observation : Nous rapportons deux cas de cryptococcose neuro-méningée chez deux patientes âgées respectivement de 48 et 38 ans au regard du terrain d'immuno-dépression acquis, la présence de levure encapsulée à l'examen du liquide cérébro-spinal à l'encre de Chine dans un cas et la positivité du Crag-test serum dans les deux cas. La présence d'emblée de facteurs de mauvais pronostic expliquaient l'issue fatale. Conclusion : Compte tenu de la gravité potentielle de cette affection, le Crag-test serum devrait être facilement accessible et disponible pour un diagnostic rapide et une prise en charge précoce et efficace afin de limiter la morbi-mortalité

Criptococoma cerebral e pulmonar em paciente imunocompetente: relato de caso / Cerebral and Pulmonary Cryptococcoma in an Immunocompetent Pacient: Case Report

Neurocriptococose é uma infecção fúngica do sistema nervoso central e sua principal apresentação clínica é a meningoencefalite. Lesões sólidas com aspecto tumoral, denominadas criptococoma, podem manifestar-se principalmente em imunodeprimidos. É relatado caso de paciente jovem, imunocompetente, com lesão tumoral frontal direita com grande efeito de massa e lesão menor em lobo occipital esquerdo, assim como lesão tumoral em pulmão direito. A paciente e seus cuidadores concordaram e autorizaram a publicação do caso. Foi feita revisão da literatura quanto à epidemiologia, tratamento e prognóstico. A paciente foi tratada comanfotericina B lipossomal e submetida à ressecção cirúrgica das lesões cerebrais e pulmonar, em tempos distintos, com bom desfecho clínico. A criptococose é infecção comum que pode acometer indivíduos tanto imunocomprometidos quanto imunocompetentes. Embora a meningoencefalite seja a forma mais comum de acometimento do SNC, existem outras formas mais raras como criptococoma cerebral. Há evidência de que a abordagem cirúrgica das lesões expansivas é benéfica e recomendada.

Neurocryptococcosis is a fungal infection of the central nervous system and its major clinical manifestation is meningoencephalitis. Solid tumor-like lesions, referred as cryptococcoma, usually occurs in immunocompromised patients. This paper reports a young immunocompetent female with a tumor-like lesion on the right frontal region and another one on the left occipital lobe, as well as a tumor lesion on her right lung. The patient and her caregivers have agreed and authorized the publishing of the case. Literature review wasmade regarding the epidemiology, treatment and prognosis. The patient was treated with anfotericine B and underwent surgical resection of the brain and lung lesions, at different times, with good clinical outcome. C. neoformans is a common fungal infection that can affect both immunocompetent and immunocompromised individuals. Although meningoencephalitis is themost common presentation of CNS involvement, there are other rarer forms such as cerebral cryptococcoma. There is evidence that the surgical treatment of mass lesions is beneficial and recommended.

Lateral flow asaay for cryptococcal antigen: animportant advance to improve thhe continuum of hiv care and reduce cryptococcal meningitis-related mottality / Ensaio de Fluxo Lateral para antígeno criptocócico: um importante avanço para melhorar o continuum de cuidados com HIV e reduzir a mortalidade relacionada à meningite criptocóccica

SUMMARYAIDS-related cryptococcal meningitis continues to cause a substantial burden of death in low and middle income countries. The diagnostic use for detection of cryptococcal capsular polysaccharide antigen (CrAg) in serum and cerebrospinal fluid by latex agglutination test (CrAg-latex) or enzyme-linked immunoassay (EIA) has been available for over decades. Better diagnostics in asymptomatic and symptomatic phases of cryptococcosis are key components to reduce mortality. Recently, the cryptococcal antigen lateral flow assay (CrAg LFA) was included in the armamentarium for diagnosis. Unlike the other tests, the CrAg LFA is a dipstick immunochromatographic assay, in a format similar to the home pregnancy test, and requires little or no lab infrastructure. This test meets all of the World Health Organization ASSURED criteria (Affordable, Sensitive, Specific, User friendly, Rapid/robust, Equipment-free, and Delivered). CrAg LFA in serum, plasma, whole blood, or cerebrospinal fluid is useful for the diagnosis of disease caused by Cryptococcusspecies. The CrAg LFA has better analytical sensitivity for C. gattii than CrAg-latex or EIA. Prevention of cryptococcal disease is new application of CrAg LFA via screening of blood for subclinical infection in asymptomatic HIV-infected persons with CD4 counts < 100 cells/mL who are not receiving effective antiretroviral therapy. CrAg screening of leftover plasma specimens after CD4 testing can identify persons with asymptomatic infection who urgently require pre-emptive fluconazole, who will otherwise progress to symptomatic infection and/or die.

RESUMOA meningite criptocócica continua causando um substancial índice de óbitos em pacientes infectados por HIV em países de baixa e média renda. Ferramentas diagnósticas para detecção do antígeno capsular polissacarídico criptocócico (CrAg) em soro e líquor tais como o teste de aglutinação de látex (latex-CrAg) ou o imunoensaio (EIE) têm sido utilizadas por muitos anos. Técnicas diagnósticas mais aprimoradas seriam cruciais nas fases assintomática e sintomática da criptococose para reduzir a mortalidade. Recentemente, o ensaio de fluxo lateral para detecção do antígeno criptocócico (LFA CrAg) foi incluído no arsenal diagnóstico. Contrariamente aos outros testes, LFA CrAg é um ensaio imunocromatográfico em formato similar ao teste de gravidez, e requer pouca ou nenhuma infraestrutura laboratorial. Este teste preenche os critérios ASSURED (Affordable, Sensitive,Specific, User friendly,Rapid/ robust,Equipment-free,Delivered) da Organização Mundial da Saúde e pode ser utilizado em soro, plasma, sangue total ou líquor para o diagnóstico da criptococose. LFA CrAg tem melhor sensibilidade analítica para o C. gattii que o teste de látex-CrAg ou EIE. A prevenção da doença criptocócica constituiria uma nova aplicação do LFA CrAg, mediante a triagem de amostras de sangue para a identificação de infecção sub-clínica em pacientes infectados pelo HIV que não apresentam sintomas, possuem contagem de CD4 < 100 células/mL e não recebem terapia antirretroviral eficaz. A triagem de CrgA em amostras de plasma remanescente da contagem de CD4 pode identificar pacientes com infecção assintomática que precisam urgentemente de tratamento preemptivo com fluconazol, evitando assim a progressão para doença sintomática e/ou óbito.

Molecular diagnosis of cryptococcal meningitis in cerebrospinal fluid: comparison of primer sets for Cryptococcus neoformans and Cryptococcus gattii species complex

Aim: This study evaluated the use of polymerase chain reaction for cryptococcal meningitis diagnosis in clinical samples. Materials and methods: The sensitivity and specificity of the methodology were evaluated using eight Cryptococcus neoformans/C. gattii species complex reference strains and 165 cere- brospinal fluid samples from patients with neurological diseases divided into two groups: 96 patients with cryptococcal meningitis and AIDS; and 69 patients with other neurological opportunistic diseases (CRL/AIDS). Two primer sets were tested (CN4-CN5 and the multiplex CNa70S-CNa70A/CNb49S-CNb-49A that amplify a specific product for C. neoformans and another for C. gattii). Results: CN4-CN5 primer set was positive in all Cryptococcus standard strains and in 94.8% in DNA samples from cryptococcal meningitis and AIDS group. With the multiplex, no 448-bp product of C. gattii was observed in the clinical samples of either group. The 695 bp products of C. neoformans were observed only in 64.6% of the cryptococcal meningitis and AIDS group. This primer set was negative for two standard strains. The specificity based on the negative samples from the CTL/AIDS group was 98.5% in both primer sets. Conclusions: These data suggest that the CN4/CN5 primer set was highly sensitive for the identification of C. neoformans/C. gattii species complex in cerebrospinal fluid samples from patients with clinical suspicion of cryptococcal meningitis. .

Abordagem cirúrgica de lesão granulomatosa criptocócica cerebral (criptococoma) em paciente imunocompetente / Surgical Approach to an Immunocompetent Patient's Cerebral Granulomatosis (cryptococcoma)

Acriptococose é a principalmicosequeatingeosistemanervosocentral, sendode distribuição mundial, mais prevalente em países em desenvolvimento. Atualmente, são descritas duas subespécies: Cryptococcus neoformans neoformans, associado à imunossupressão, e Cryptococcus neoformans gattii, em pacientes imunocompetentes. A criptococose do sistema nervoso central parenquimatosa em sua forma granulomatosa, ou criptococoma, é extremamente rara, sendo mais frequente a forma meningítica ou meningoencefalítica. Relatamos o caso de um paciente de 35 anos, não portador da síndrome de imunodeficiência adquirida e imunocompetente, com manifestações clínicas iniciais de cefaleia crônica, hemiparesia progressiva, confusão mental aguda e primeiro episódio de crise convulsiva tônico-clônica generalizada. Hipóteses diagnósticas préoperatórias de neoplasia maligna ou abscesso cerebral. Realizado procedimento cirúrgico, remoção completa da lesão maior, diminuindo o efeito de massa. A lesão foi diagnosticada, através de exame anatomopatológico, como criptococoma, o que torna o caso extremamente raro pelo tamanho da lesão e por ser o paciente imunocompetente. Houve melhora completa do déficit neurológico. O paciente encontra-se em seguimento clínico e tratamento medicamentoso com anfotericina-B.

Cryptococcosis is the main mycosis affecting the central nervous system, with worldwide distribution and higher prevalence in developing countries. Currently, two subspecies are described: Cryptococcus neoformans neoformans (associated with immunosuppression) and Cryptococcus neoformans gattii (in immunocompetent patients). Cryptococcosis of the central nervous system as a parenchymal granuloma or cryptococcoma is extremely rare, contrasting to themuchmore frequentmeningitic form. We report a 35 year-old immunocompetent patient with chronic headache, progressive hemiparesis, acute confusion and first episode of tonic-clonic seizures. Preoperative diagnostic hypotheses were malignancy or abscess. A large mass (5.5 cm) was surgically removed from the right parietal lobe relieving the mass effect. This was later diagnosed by pathological examination as cryptococcoma, an extremely rare case in view of lesion size and its occurrence in an immunocompetent subject. The patient evolved with complete resolution of the neurological deficit and is on amphotericin-B treatment.

Cryptococcosis in Colombian children and literature review

Cryptococcosis is reported in adults and is often acquired immune deficiency syndrome (AIDS)-associated; however, its frequency in children is low. Based on the National Survey on Cryptococcosis conducted in Colombia, an epidemiological and clinical analysis was performed on cases of the disease observed in children less than 16 years old between 1993-2010. We found 41 affected children (2.6% prevalence) from the 1,578 surveys received. The country mean annual incidence rate was 0.017 cases/100,000 children under 16 years, while in Norte de Santander the incidence rate was 0.122 cases/100,000 (p < 0.0001). The average age of infected children was 8.4 and 58.5% were male. In 46.3% of cases, a risk factor was not identified, while 24.4% had AIDS. The most frequent clinical manifestations were headache (78.1%), fever (68.8%), nausea and vomiting (65.6%), confusion (50%) and meningeal signs (37.5%). Meningitis was the most frequent clinical presentation (87.8%). Amphotericin B was given to 93.5% of patients as an initial treatment. Positive microbiological identification was accomplished by India ink (94.7%), latex in cerebrospinal fluid (100%) and culture (89.5%). Out of 34 isolates studied, Cryptococcus neoformans var. grubii (VNI 85.3%, VNII 8.8%) was isolated in 94.1% of cases and Cryptococcus gattii (VGII) was isolated in 5.9% of cases. These data are complemented by a literature review, which overall suggests that cryptococcosis in children is an unusual event worldwide.

Puerperal brain cryptococcoma in an HIV-negative woman successfully treated with fluconazole: a case report

Cryptococcus spp. cerebral abscesses are uncommon in immunocompetent subjects. The recommended induction treatment is the administration of amphotericin B plus flucytosine combined with resection for lesions ≥3cm. In this paper, we describe an HIV-negative woman diagnosed with a large cryptococcoma in the immediate postpartum period. The lesion was not resected, and due to amphotericin B intolerance, she received an extended course of fluconazole monotherapy. There was no disease recurrence during the 4 years of follow-up. The abrupt onset of her symptoms following delivery suggests that she developed a postpartum immune reconstitution syndrome. This case also demonstrates that in specific situations fluconazole monotherapy can be attempted in immunocompetent patients with cryptococcoma.

Acelularidad del líquido cefalorraquídeo como factor pronóstico adverso en meningitis criptocóccica / Acellularity of cerebrospinal fluid as adverse prognostic factor in cryptococcal meningitis

Introducción: las enfermedades oportunistas, y dentro de ellas la meningitis criptocóccica en pacientes inmunodeprimidos, constituyen causa mayor de letalidad en países en vías de desarrollo. Objetivo: identificar factores de mal pronóstico como la acelularidad del líquido cefalorraquídeo (LCR) para individualizar medidas terapéuticas encaminadas al logro de una mayor supervivencia y calidad de vida de estos pacientes. Métodos: se estudió la celularidad de todos los LCR de los 170 casos de Bojanala, North West, ingresados en el Hospital Provincial de Rustenburg, South África por meningitis criptocóccica desde mayo de 2001 hasta abril de 2004. Se interrelacionó el número de células blancas del LCR con la letalidad intrahospitalaria, seropositividad al virus de inmunodeficiencia humana (VIH) y nivel de linfocitos T4. Resultados: se detectó una asociación altamente significativa entre acelularidad basal del LCR y riesgo a morir, y significativa con progresión lineal de mayor mortalidad en los casos con descenso evolutivo del número de células blancas en sucesivos LCR. Se constató un alto índice de letalidad (36,5 por ciento)por meningitis criptocóccica. No hubo diferencias significativas entre acelularidad y letalidad en pruebas de comparación de grupos acorde al nivel de linfocitos T4 y a la confirmación o no de la seropositividad al VIH. Conclusiones: tanto la acelularidad basal como la progresión descendente evolutiva del número de células blancas del LCR constituyen herramientas útiles para la predicción del riesgo a morir por meningitis criptocóccica

Introduction: opportunistic diseases, and among them, cryptococcal meningitis in immune-compromised patients, are a major cause of lethality in developing countries Objective: to identify mal prognostic factors such as acellularity of cerebrospinal fluid (CSF) to identify therapeutic measures aimed to achieve improved survival and quality of life of these patients. Methods: cellularity was studied in all CSF of the 170 cases in Bojanala, North West, who were admitted to the Rustenburg Provincial Hospital, South Africa for cryptococcal meningitis from May 2001 to April 2004. The number of CSF white cell with hospital mortality, seropositive human immunodeficiency virus (HIV) and level of T4 lymphocytes were interrelated. Results: a highly significant association was found between baseline CSF acellularity and risk of death, and significant linear progression of increased mortality in patients with developmental decline in the number of white cells in successive CSF. A high fatality rate (36.5 percent) for cryptococcal meningitis was also found. No significant differences was found between acellularity and lethality tests comparing groups according to the level of T4 lymphocytes and the confirmation or otherwise of HIV seropositivity. Conclusions: both basal acellularity and evolutionary downward progression of the number of CSF white cells are useful tools for predicting the risk of death for cryptococcal meningitis

Cryptococcoma of the brain in an immunocompetent man.

Cryptococcosis is a common opportunistic systemic disease in immunocompromised patients. Pulmonary or brain cryptococcosis is the most common clinical presentation. Immunocompetent patients can also be affected, especially in tropical and subtropical zones where the life cycle of the causal agent, Cryptococcus gattii, is completed. We present a previously healthy man with progressive intracranial hypertension and a right paraventricular mass on CT scan and MRI. Cryptococcus gattii yeasts were isolated from the cerebrospinal fluid. A ventriculoperitoneal shunt was placed and the patient was treated with amphotericin B, fluconazole and dexamethasone. The patient died due to severe intracranial hypertension.

Meningitis por Cryptococcus neoformans en niños y adolescentes infectados por virus de la inmunodeficiencia humana / Cryptococcus neoformans meningitis in children and adolescentes infected with HIV

Three cases of meningitis due to criptococcus in children infected with HIV are reported. All patients had severe immunodeficiency. The first case occurred before antiretroviral therapy. The second case had poor adherence to treatment. The third case is a teenager with prolonged fever, who did not have a clear source of transmission of HIV and was immunodeficient at the time of diagnosis. Examination of cerebrospinal fluid with India ink dye was essential for making the diagnosis in all three cases. The disease course was adequate in all three patients despite flucytosine not being available.

Se presentan tres casos de meningitis por Cryptococcus sp. en niños infectados con VIH e inmunodeficiencia grave. El primero fue en la época en que no se disponía de TAR. El segundo fue un paciente no adherente al tratamiento. La tercera fue una adolescente en la que se hizo diagnóstico por una enfermedad febril prolongada, donde no fue posible encontrar la fuente de transmisión de VIH y que en el momento del diagnóstico estaba con inmunosupresión grave. En los tres fue fundamental para el diagnóstico rápido la tinción de LCR con tinta china. La evolución de la enfermedad fue adecuada en los tres pacientes aunque no se contó en ninguno de los casos con flucitosina.

Cryptococcal Meningitis in Patients with or without Human Immunodeficiency Virus: Experience in a Tertiary Hospital

PURPOSE: Cryptococcal meningitis is a relatively common opportunistic infection in human immunodeficiency virus (HIV) patients and it can frequently occur in immunocompetent hosts without any apparent underlying disease. Nevertheless, little is known about cyptococcal meningitis in the Korean population. The purpose of this study was to evaluate the clinical features and initial laboratory findings of cryptococcal meningitis in patients with and without HIV at a tertiary care teaching hospital. MATERIALS AND METHODS: We performed a retrospective study at a tertiary care teaching hospital from January 2001 to December 2009. Eleven HIV positive patients and nine HIV negative patients were included. RESULTS: The most common symptoms were headache and fever in cryptococcal meningitis, and diabetic mellitus, end stage renal disease and liver cirrhosis were the main associated conditions in patients without HIV. Patients with HIV showed lower peripheral CD4+ cell counts (median: 9, range: 1-107) and a higher burden of cryptococcus than patients without HIV. There were no statistically significant differences in serum CRP level and other cerebrospinal fluid parameters between patients with HIV and without HIV. The in-hospital mortality was 10%, and recurrence of cyptococcal meningitis was observed in 3 patients with HIV and this occurred within 5 months of the first episode. CONCLUSION: Cryptococcal meningitis is fatal without treatment, therefore, rapid recognition of symptoms such as fever and headache and diagnosis is required to decrease the mortality. Recurrence of meningitis after treatment should carefully be followed up, especially in advanced HIV patients.

Cryptococcus gattii molecular type VGII as agent of meningitis in a healthy child in Rio de Janeiro, Brazil: report of an autochthonous case / Cryptococcus gattii tipo molecular VGII como agente causador de meningoencefalite em criança saudável no Rio de Janeiro, Brasil: relato de um caso autóctone

Cryptococcus gattii causes meningoencephalitis in immunocompetent hosts, occurring endemically in some tropical and subtropical regions. Recently, this fungus was involved in an outbreak in Vancouver Island and British Columbia (Canada). In this temperate region, the VGII type is predominant. The paper describes an autochthonous case of meningoencephalitis by C. gattii VGII in a previously health child in Rio de Janeiro, considered nonendemic region of Brazil. The fungus was identified by biochemical tests and the molecular type was determined by URA5-RFLP. The present report highlights the need for clinical vigilance for primary cryptococcal meningitis in nonendemic areas.

Cryptococcus gattii é causa de meningoencefalite em hospedeiros imunocompetentes, ocorrendo endemicamente em regiões tropicais e subtropicais. Recentemente foi causador de surtos na Ilha de Vancouver e na Columbia Britânica (Canadá). Nesta região de clima temperado, o tipo VGII é predominante. Relatamos um caso de meningoencefalite pelo C.gattii tipo VGII acometendo criança previamente saudável autóctone do Rio de Janeiro, região não endêmica do Brasil. O agente foi identificado por testes bioquímicos e o tipo molecular determinado através de URA5-RFLP. O presente relato enfatiza a necessidade de vigilância clínica para a meningite criptocóccica primária em áreas não endêmicas.