From Covid to Bovid to Ovid: A Case of Disseminated Cryptococcus Neoformans

Case Report: Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus, with C. neoformans and C. gattii being the most common species to cause human disease. Immunocompromised individuals are predisposed to infections with C. neoformans, which has known predilection to CNS and pulmonary lymph nodes. We present a unique case of disseminated cryptococcosis in the setting of end-stage renal disease (ESRD), cirrhosis, tumor necrosis factor inhibitor use and steroid use for COVID19. Method(s): A single-patient case report was conducted after IRB approval. Case Presentation: A 55-year-old woman with uncontrolled diabetes, lupus, rheumatoid arthritis on adalimumab, hepatitis C status post boceprevir, cirrhosis, former IV drug use, and ESRD on hemodialysis via bovine arterial-venous fistula graft presented with worsening dyspnea, cough, and altered mental status. Three months prior, patient was admitted to an outside hospital for COVID19, complicated by pulmonary embolism status post anticoagulation therapy. Patient was treated with an unknown steroid regimen, which was continued by a second outside facility when symptoms failed to improve. Patient then presented to our facility 24 hours after discharge due to continued symptoms. On admission, patient was noted to have altered mentation and hypoxia with pulmonary edema on chest x-ray and was urgently hemodialyzed. Further work-up was obtained due to non-resolving symptoms, including blood and sputum cultures, cocci serology and QuantiFERON gold. CT chest revealed bilateral consolidations. Patient was started on antibiotics for presumed hospital-acquired pneumonia. During the hospital stay, preliminarily blood cultures grew yeast and patient was started on Micafungin. However, Micafungin was changed to Liposomal Amphotericin B as ovoid structures seen on gram stain could not confirm nor rule out cryptococcus. Subsequent bronchial wash and bronchoalveolar lavage cultures, as well as final blood cultures resulted Cryptococcus neoformans. Serum cryptococcus antigen returned reactive, titer 1:512. Antibiotics were discontinued and Isavuconazonium was started with Liposomal Amphotericin B. Due to recurrent headaches, lumbar puncture was obtained and revealed lymphocytic pleocytosis without cryptococcal antigenicity. Patient completed 14 days of Liposomal Amphotericin B and Isavuconazole with continuation of Isavuconazole upon discharge. Conclusion(s): Disseminated cryptococcosis in non-HIV patients is rare in the modern HIV era. Clinicians should be aware and include it in their differential of any patient with multiple risk factors for opportunistic infection. In patients with cirrhosis and ESRD, treatment is limited given altered pharmacokinetics. Studies have shown improved survival with the addition of Isavuconazole in patients with disseminated cryptococcosis with CNS involvement in the setting of chronic liver disease and ESRD.

Transcriptome in Human Mycoses

Mycoses are infectious diseases caused by fungi, which incidence has increased in recent decades due to the increasing number of immunocompromised patients and improved diagnostic tests. As eukaryotes, fungi share many similarities with human cells, making it difficult to design drugs without side effects. Commercially available drugs act on a limited number of targets and have been reported fungal resistance to commonly used antifungal drugs. Therefore, elucidating the pathogenesis of fungal infections, the fungal strategies to overcome the hostile environment of the host, and the action of antifungal drugs is essential for developing new therapeutic approaches and diagnostic tests. Large-scale transcriptional analyses using microarrays and RNA sequencing (RNA-seq), combined with improvements in molecular biology techniques, have improved the study of fungal pathogenicity. Such techniques have provided insights into the infective process by identifying molecular strategies used by the host and pathogen during the course of human mycoses. This chapter will explore the latest discoveries regarding the transcriptome of major human fungal pathogens. Further we will highlight genes essential for host–pathogen interactions, immune response, invasion, infection, antifungal drug response, and resistance. Finally, we will discuss their importance to the discovery of new molecular targets for antifungal drugs. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2014, 2022.

Fungal infection: An unrecognized threat

The fungi are eukaryotes and of great interest to microbiologist. Fungi are heterotrophic organism that require organic compounds for nutrition. According to Hawksworth, only around 100 fungi cause diseases in humans and animals out of around 1.5 million existing in the universe. Fungal pathogenic infection may cause allergies, superficial infection, as well as invasive mycosis in severe cases. Public health can be significantly affected by zoonotic fungi that transmit naturally between animals and humans. Prevention of fungal infection arising out of zoonotes has received insufficient attention as it lacks mass awareness. A number of different fungal infections, their signs and symptoms, preventive measures, and treatment protocol are demonstrated in this chapter. Regarding the treatment of various fungal infections, azoles, fluoropyrimidines, polyenes, and echinocandins are the only four molecular classes of drugs available as on date to target fungal metabolic pathways despite years of drug discovery research. Few other promising molecules like morpholines and allylamines are useful antifungal but with poor efficacy and severe side effects when administered systematically. Development of resistance against most common antifungal drugs further aggravates the situation. Fungal infection like mucormycosis is observed in some parts of the world after a patient gets infected with COVID-19 as there is impairment in the immunity system. There is an urgent need to control this fungal infection as it poses serious threat silently. We can limit the spread of fungal infection by protecting susceptible population from being exposed. More efforts are needed from a global health perspective to aware the people regarding neglected fungal infection and its problem so that socioeconomic consequences and mortality can be better explained. An integrated platform of prevention and control strategies for the spread of fungal infection is the need of the hour. © 2023 Elsevier Inc. All rights reserved.

Invasive fungal infections in COVID-19 patients from Pakistan

Objective: The objective of this study is to report the frequency and clinical characteristic of IFI in COVID-19 patients. Method(s): This observational study was conducted in Karachi, Pakistan from March 2020-April 2021. Patients with COVID-19 associated aspergillosis (CAPA) were diagnosed using ECMM/ISHAM criteria modified to include tracheal aspirate culture and/or Galactomannan Index (GMI) >4.5 in the possible CAPA category. COVID-19 associated candidemia (CAC) was defined by isolation of Candida species from blood cultures. COVID-19 associated mucormycosis (CAM) was defined as updated EORTC/MSG criteria with inclusion of COVID-19 as host factor. Pneumocystis jirovecii pneumonia (PJP) was defined by consistent clinical and radiological features and PCR positivity. Result(s): During the study period a total of 123 (3.3%) IFI in 3506 hospitalized COVID-19 patients were identified. This included 78 (2.2%) CAPA patients (42 probable;36 possible), 29 (0.8%) CAC (5 C. auris;24 non-C. auris), 10 (0.3%) CAM (7 pulmonary;3 rhinocerebral), 3 (0.08%) PJP and three (0.08%) cases of rare invasive fungal infections (2 C. neoformans;1 Trichosporon asahii). Outcome data was available on 117/123 patients. Of these 117 patients, 78 expired (66.7%). These include 52/74 (70%) CAPA patients, 17/27 (63%) CAC patients, 7/10 (70%) CAM patients and 2/3 (67%) PJP patients. Conclusion(s): We report a rate of 3.3% IFI amongst hospitalized COVID-19 patients at our center. We consider this rate to be an underestimate due to less bronchoscopic procedures and inclusion of only candidemia cases. We also report higher mortality rate with IFI in our patients than global data probably due to delayed diagnosis, co-infections and limited therapeutic options.

Cryptococcus neoformans, a global threat to human health.

BACKGROUND: Emerging fungal pathogens pose important threats to global public health. The World Health Organization has responded to the rising threat of traditionally neglected fungal infections by developing a Fungal Priority Pathogens List (FPPL). Taking the highest-ranked fungal pathogen in the FPPL, Cryptococcus neoformans, as a paradigm, we review progress made over the past two decades on its global burden, its clinical manifestation and management of cryptococcal infection, and its antifungal resistance. The purpose of this review is to drive research efforts to improve future diagnoses, therapies, and interventions associated with fungal infections. METHODS: We first reviewed trends in the global burden of HIV-associated cryptococcal infection, mainly based on a series of systematic studies. We next conducted scoping reviews in accordance with the guidelines described in the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews using PubMed and ScienceDirect with the keyword Cryptococcus neoformans to identify case reports of cryptococcal infections published since 2000. We then reviewed recent updates on the diagnosis and antifungal treatment of cryptococcal infections. Finally, we summarized knowledge regarding the resistance and tolerance of C. neoformans to approved antifungal drugs. RESULTS: There has been a general reduction in the estimated global burden of HIV-associated cryptococcal meningitis since 2009, probably due to improvements in highly active antiretroviral therapies. However, cryptococcal meningitis still accounts for 19% of AIDS-related deaths annually. The incidences of CM in Europe and North America and the Latin America region have increased by approximately two-fold since 2009, while other regions showed either reduced or stable numbers of cases. Unfortunately, diagnostic and treatment options for cryptococcal infections are limited, and emerging antifungal resistance exacerbates the public health burden. CONCLUSION: The rising threat of C. neoformans is compounded by accumulating evidence for its ability to infect immunocompetent individuals and the emergence of antifungal-resistant variants. Emphasis should be placed on further understanding the mechanisms of pathogenicity and of antifungal resistance and tolerance. The development of novel management strategies through the identification of new drug targets and the discovery and optimization of new and existing diagnostics and therapeutics are key to reducing the health burden.

CRYPTIC CRYPTO: PULMONARY CRYPTOCOCCOSIS IN AN IMMUNOCOMPETENT HOST

SESSION TITLE: Uncommon Presentations and Complications of Chest Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Cryptococcus is a ubiquitous fungus in the environment. Infections can occur in humans when Cryptococcus is aerosolized and inhaled. Severity of clinical presentation varies from asymptomatic pulmonary colonization to disseminated life-threatening infection such as meningitis. These infections usually occur with deficiencies in T-cell-mediated immunity, including those with HIV/AIDS and immunosuppression due to transplantation. Herein we present a case of isolated pulmonary cryptococcosis in an immunocompetent host. CASE PRESENTATION: The patient is a 36-year-old never-smoker male with history of recurrent left spontaneous pneumothorax status post VATS blebectomy, negative for alpha-1 antitrypsin deficiency and cystic fibrosis. A year later, he presented with fatigue, shortness of breath, and dry cough after a recent trip to Ohio. Viral panel including COVID-19 was negative. A chest x-ray showed a new 4 cm rounded opacity in the right middle lobe (RML). A CT scan of the chest showed 2 mass-like and nodular areas of consolidation with surrounding GGOs within the RML (Figure 1). He underwent navigational bronchoscopy with transbronchial biopsy (TBBx) of RML, BAL, and EBUS with transbronchial needle aspiration (TBNA). Cytology was negative for malignant cells. BAL showed rare yeast. Pathology of the TBBx showed the airway wall with chronic inflammation including granulomatous inflammation, positive for yeast, most consistent with Cryptococcus with positive Grocott methenamine silver (GMS) stain (Figure 2). Culture of the TBNA grew C. neoformans var. grubii. Other cultures were negative. Serum Cryptococcal antigen was positive. HIV test was negative. He started treatment with oral fluconazole with improvement of symptoms. DISCUSSION: Clinical presentation of pulmonary cryptococcosis can include a variety of symptoms in which immune status is critical for determining the course of infection. Infection can vary from asymptomatic infection to severe pneumonia and respiratory failure, and meningitis. Similarly, imaging findings can also vary and be characterized as pulmonary nodules, consolidations, cavitary lesions, and/or a diffuse interstitial pattern. The diagnosis of Cryptococcus is made using histology, fungal cultures, serum cryptococcal antigen, and radiography in the appropriate clinical and radiological context. Treatment recommendations are determinant on immune status of the patient as well as symptoms. Asymptomatic and localized disease in immunocompetent patients can be monitored and mild/moderate disease can be treated with fluconazole. Those with severe or disseminated infection warrant induction therapy with an amphotericin B and flucytosine CONCLUSIONS: Clinical and radiological presentation of cyptococcosis varies depending on immune status. Disease can occur in both immunocompromised and competent hosts. Immune status determines disease course and treatment. Reference #1: Huffnagle GB, Traynor TR, McDonald RA, Olszewski MA, Lindell DM, Herring AC, et al. Leukocyte recruitment during pulmonary Cryptococcus neoformans infection. Immunopharmacology. 2000 Jul 25;48(3):231–6. Reference #2: Kd B, Jw B, Pg P. Pulmonary cryptococcosis. Semin Respir Crit Care Med [Internet]. 2011 Dec [cited 2022 Apr 2];32(6). Available from: https://pubmed.ncbi.nlm.nih.gov/22167400/ Reference #3: Ms S, Rj G, Ra L, Pg P, Jr P, Wg P, et al. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society of America. Clin Infect Dis Off Publ Infect Dis Soc Am [Internet]. 2000 Apr [cited 2022 Apr 1];30(4). Available from: https://pubmed.ncbi.nlm.nih.gov/10770733/ DISCLOSURES: No relevant relationships by Mina Elmiry No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih no disclosure on file for Priyanka Makkar;No relevant relationships by Jonathan Moore

INCIDENCE, CLINICAL CHARACTERISTICS, AND OUTCOMES OF PATIENTS WITH COVID-19 AND FUNGAL COINFECTION

SESSION TITLE: COVID-19: Other Considerations in Management SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: To evaluate the incidence of fungal co-infections clinical characteristics, and outcomes in patients with COVID-19. METHODS: We conducted a retrospective chart review of electronic medical records of 2,639 adult patients admitted for COVID -19 to our health system from April 1, 2020 to December 31, 2021. Demographic data, comorbidities, length of hospital stay, laboratory results including fungal diagnostics, COVID therapeutics and antifungals, need for ICU admission, mechanical ventilation and in-hospital mortality were collected. RESULTS: A total of 45 of 2,639 (1.7%) COVID-19+ patients had a positive fungal test or culture of fungal pathogen and subsequently received antifungal treatment. Of these 25 (55.6%) cases of Aspergillus species were the most prominent, followed by Candida species at 12 (26.7%). Of note, there was one case each of Cryptococcus and Histoplasma (2.2%). COVID-19+ patients with fungal co-infection who survived (18;40%) were significantly younger compared to COVID-19+ patients with fungal co-infection who died (27;60%, p=0.014). Majority of COVID-19+ patients with fungal co-infection were white with average length of hospitalization of 24 days. Those patients who survived had a significantly longer length of hospitalization compared to COVID-19+ patients who died (survived 31 ± 21.5 compared to 19.6 ± 10.4 days, p<0.05). Majority of COVID-19+ patients received steroids, and remdesivir therapy for COVID-19. Antifungal treatment consisted of either voriconazole or micafungin as predominate fungal pathogens were either Aspergillus or Candida spp. CONCLUSIONS: Pulmonary aspergillosis followed by invasive candidiasis were the most common fungal co-infections in COVID-19 patients treated at our institution. In-hospital mortality from all fungal co-infections was 60%. Patients that survived were younger and hospitalized longer compared to those who expired. Need for mechanical ventilation, ICU admission and COVID therapeutics were not significantly different between the survived and expired group of COVID-19 patients with fungal co-infections. CLINICAL IMPLICATIONS: The increased risk and incidence of COVID-19 and fungal co-infection has been noted in a handful of studies with invasive aspergillosis being the most commonly reported fungal co-infection. There have been very few reports of other fungal co-infections including invasive candidiasis, mucormycosis, histoplasmosis, and cryptococcosis. Minimal incidence data has been reported on co-infection with other opportunistic fungal pathogens such as Histoplasma spp., Pneumocystis jirovecci, or Cryptococcus neoformans. This study supports previous findings of increase risk of Aspergillosis, but also show incidence of Histoplasmosis and Crytpococcal fungal infections. These fungal infections may be under reported in COVID-19 and may warrant further research. DISCLOSURES: No relevant relationships by Christopher Destache No relevant relationships by Rutendo Jokomo-Nyakabau No relevant relationships by Dorothy Kenny No relevant relationships by Paul Millner No relevant relationships by Anny Nguyen No relevant relationships by Mohammad Selim No relevant relationships by Richard Swaney No relevant relationships by Manasa Velagapudi

Neuromeningeal cryptococcosis in a patient not infected with human immunodeficiency virus and without known risk factors: A case report.

We report a 24-year-old female patient not infected with human immunodeficiency virus (HIV) and without other risk factors of immunosuppression, presenting with neuromeningeal cryptococcosis. Cerebrospinal fluid (CSF) analysis revealed the presence of Cryptococcus neoformans. The evolution was unfavorable and the patient died even after appropriate antifungal treatment.

Delayed HIV diagnosis of patients due to the COVID-19 pandemic

Introduction: The AIDS disease epidemic is still a global problem. To date, finding the connection between HIV and SARSCoV-2 infection is very significant. Case Report: A 51-year-old woman was admitted to the Neurology Department due to neurological symptoms lasting for 1.5 months. Imaging examinations of the CNS, chest CT and cerebrospinal fluid examination revealed significant abnormalities. Tests for HIV and SARS-CoV-2 were both positive. Klebsiella pneumoniae ESBL+ was detected in rectal swab as well as findings of Candida antigens and antibodies of Cryptococcus neoformans mycosis in serum. Due to these results, appropriate treatment was implemented but with with a time delay which resulted in the death of the patient. Conclusions: HIV infection may be associated with an increased risk of severe SARS-CoV-2 infection causing an increase in mortality rate during the COVID-19 pandemic. Confirmation and early detection of HIV infection permits early and accurate diagnosis and faster treatment decisions.

A Case of Pulmonary Cryptococcosis After Severe COVID-19 Pneumonia T. Roesch

Introduction / Case Presentation:46yo female with a history of CKD, atrial flutter, bioprosthetic valve with mitral ring, and recent COVID-19 pneumonia who presented to the emergency department (ED) with shortness of breath, fevers, and fatigue. Three months prior, she had been diagnosed with severe COVID-19 pneumonia, for which she received dexamethasone, remdesivir, tocilizumab, anakinra, and IVIG. She was discharged to a nursing facility with a prolonged steroid taper, ending 1 month prior to admission.In the ED, the patient had a chest x-ray that demonstrated bibasilar atelectasis and opacification, and a CT chest revealed right lower lobe consolidation and surrounding ground glass opacities. A respiratory pathogen PCR swab was negative. Sputum culture was negative for bacterial and fungal growth. Blood cultures did not grow any organisms. Given recent immunosuppression and imaging findings, a serum Cryptococcal antigen was drawn, which was positive with a titer of 1:128. A transthoracic needle biopsy of the patient's right lower lung was then performed. The specimen did not grow any bacteria or fungi and AFB stain on the tissue was negative. Pathology demonstrated a collection of histiocytes, neutrophils, and necrotic debris. PAS, GMS, and mucicarmine stains were positive for fungal organisms consistent with Cryptococcus species. Discussion: Cryptococcosis is a fungal infection due predominately to one of two encapsulated yeasts, Cryptococcus neoformans or Cryptococcus gattii. C. neoformans is found in soil worldwide, and infection typically begins with spore inhalation. Clinically significant disease is seen mostly in immunocompromised patients.Corticosteroids and interleukin inhibitors, such as anakinra (IL-1) and tocilizumab (IL-6), are used in the treatment of COVID-19. These medications have been associated with increased risk for opportunistic infections, including invasive fungal infections. The diagnosis of pulmonary cryptococcosis may be challenging, as symptoms are often nonspecific and may radiographically resemble bacterial pneumonia, malignancy, or other infections. Serum cryptococcal antigen detection tests may be helpful in establishing the diagnosis, as well as histopathology showing narrow-based budding yeast. Conclusion: Patients with prior COVID-19 infection commonly return to healthcare settings with sequelae of their previous coronavirus infection. In our case, it was the prior treatment of COVID-19, which included immunomodulating therapy, that lead to a secondary pulmonary cryptococcal infection. When evaluating pulmonary processes that evolve after an acute infection with COVID-19, it is important to keep a broad differential, including uncommon and/or opportunistic infectious etiologies, particularly when a patient has received prolonged courses of steroids and tocilizumab.

Intrathecal inflammatory responses in the absence of SARS-CoV-2 nucleic acid in the CSF of COVID-19 hospitalized patients

Objective: Evaluate SARS-CoV-2 RNA and inflammatory cytokines and chemokines in the CSF of patients with acute COVID-19 and neurologic symptoms, and to compare these to controls and patients with known neurotropic pathogens. Background: Neurologic symptoms have been described in 30-60% of hospitalized patients with Coronavirus Disease 2019 (COVID-19). However, little is known about CSF profiles in these patients. Design/Methods: CSF from twenty-seven consecutive patients with COVID-19 and neurological symptoms was assayed for SARS-CoV-2 RNA using quantitative reverse transcription PCR (RT-qPCR) and unbiased metagenomic sequencing. Assays for blood brain barrier (BBB) breakdown (CSF:serum albumin ratio (Q-Alb)), and proinflammatory cytokines and chemokines (IL-6, IL-8, IL-15, IL-16, monocyte chemoattractant protein -1 (MCP-1) and monocyte inhibitory protein - 1β (MIP-1β)) were performed in 23 patients and compared to CSF from patients with HIV-1 (16 virally suppressed, 5 unsuppressed), West Nile virus (WNV) (n=4) and 16 healthy controls (HC). Results: Median CSF cell count for COVID-19 patients was 1 white blood cell/μL;two patients were infected with a second pathogen (Neisseria, Cryptococcus neoformans). No CSF samples had detectable SARS-CoV-2 RNA by either detection method. In patients with COVID-19 only, CSF IL-6, IL-8, IL-15, and MIP-1β levels were higher than HC and suppressed HIV (corrected-p < 0.05). MCP-1 and MIP-1β levels were higher, while IL-6, IL-8, IL-15 were similar in COVID-19 compared to WNV patients. Q-Alb correlated with all proinflammatory markers, with IL-6, IL-8, and MIP-1β (r≥0.6, p<0.01) demonstrating the strongest associations. Conclusions: Lack of SARS-CoV-2 RNA in CSF is consistent with pre-existing literature. Evidence of intrathecal proinflammatory markers in a subset of COVID-19 patients with BBB breakdown despite minimal CSF pleocytosis is atypical for neurotropic pathogens.

HISTOPLASMOSE DISSEMINADA: ACHADOS MORFOLÓGICOS EM SANGUE PERIFÉRICO, RELATO DE UM CASO

Objetivo: Relatar os achados morfológicos de infecção disseminada por Histoplasma capsulatum encontrados em sangue periférico de paciente imunossuprimido. Relato: Paciente do sexo masculino, 51 anos, transplantado renal há 20 anos, doador vivo aparentado. Dá entrada em um Pronto Socorro da cidade de São Paulo relatando febre não aferida e calafrios há uma semana, associado a quadro de tosse e prurido. Exame para detecção do novo coronavírus há três dias, negativo. Por se tratar de paciente transplantado renal é internado em isolamento e evoluiu com sepse e IRA (Injúria Renal Aguda), secundárias a possível processo infeccioso e com hipercalemia, acidose metabólica e úlceras duodenais hemorrágicas. Os exames laboratoriais mostraram: PCR = 37 mg/dL, Creatinina = 4,16 mg/dL, Leucócitos = 3.150/mm3, Neutrófilos = 2.390/mm3. TC de tórax demonstra consolidação localizada em LSD e LMD com formato de árvore em brotamento. Foi descartada a hipótese de pneumonia bacteriana e levantada a suspeita de infecção fúngica ou por micobactéria pulmonar. Evoluiu com piora do estado geral, impossibilitando a realização de broncoscopia para biopsia e/ou lavado. Os testes sorológicos foram negativos para: antígeno de Cryptococcus neoformans, IgM e IgG para Mycoplasma pneumoniae, anticorpos totais para Paracoccidioidomicose e Histoplasmose, mas positivos para antígeno de Aspergillus. Ao longo da evolução, a análise morfológica da série branca do hemograma demonstrou a presença de inclusões citoplasmáticas em neutrófilos compatíveis com possível fungo encapsulado, provavelmente Histoplasma. As mesmas formas foram observadas em raros monócitos e livres em meio às plaquetas. Apesar da imediata instituição do tratamento, o paciente teve evolução desfavorável. Conclusão: A histoplasmose se mostrou uma doença com capacidade de disseminação até em paciente com níveis baixos de imunossupressão, como neste caso relatado, após 20 anos de transplante. A análise morfológica ganhou papel de destaque no diagnóstico, geralmente realizado por outras metodologias específicas, nesse caso impossibilitadas pelas condições clínicas do paciente. Foi o hemograma o primeiro exame que conseguiu apresentar dados conclusivos da infecção por histoplasma, podendo auxiliar a equipe médica a tomar condutas direcionadas para o tratamento. O resultado positivo de Aspergillus do paciente sofreu provável reação cruzada com Histoplasma devido a limitações técnicas do método. O papel do morfologista se mostrou crucial nesse caso, demonstrando a importância de manter equipes bem treinadas e preparadas para atuar em casos raros e difíceis. Sendo assim, esse trabalho traz imagens de achados que poderão auxiliar outros morfologistas na identificação do patógeno em suas rotinas.

A case of fungal pneumonia in immunocompetent patient in nonendemic area

Introduction: Cryptococcal pneumonia is predominantly seen in immunosuppressed individuals and rarely in immunocompetent population. We report a case of middle age male with Cryptococcal pneumonia. History: A 45-year-old male farmer by occupation presented with shortness of breath for 2months, cough with sputum for 2 months associated with streaky hemoptysis, fever on and off for 1month, loss of appetite for 1 month, no history of SARS CoV 2, no h/o long term steroid usage and immunosuppression (HIV, malignancy) no significant family history. Presentation: Spo2- 98%RA, Blood pressure and pulse rate were normal. Examination reveaed Decreased breath sounds in left infra scapular area. Rest systemic examination was normal. Diagnosis: HIV, HBsAg were negative, Sputum Gram stain, KOH mount, culture was negative, Sputum CBNAAT was negative. Chest x-ray s/o non homogenous opacity in left mid zone. CT chest s/o Consolidation in superior segment of left lower lobe. Patient underwent FOB in view of hemoptysis. Bronchial washings cytology was negative, CBNAAT was negative, Fungal culture s/o Cryptococcus neoformans sensitive to amphotericin B and Flucytosine. Management: Microbiology based treatment with Amphotericin B and fluconazole. Clinical Implications: Any evidence of a cavitating nodule on CT in a patient presenting with cough & sob, a fungal infection is suspected irrespective of immune status and endemicity.

Characteristics and Outcomes in Hospitalized Patients with Covid-19 Complicated by Fungemia: A Single Center Retrospective Study

Background. Covid19 caused by SARS-CoV2 can lead to significant morbidity and mortality. Fungemia is a rare hospital-associated infection and there are limited data regarding its association with Covid19. We reviewed all cases of fungemia in our Covid19 cohort at Stony Brook University Hospital (SBUH). Methods. We conducted a retrospective medical record review of patients admitted with Covid19 in a 3-month interval. We reviewed positive blood cultures for fungi and recorded co-morbidities, co-infections, length of stay, treatments, and outcomes (survival vs death). There were 60 positive blood cultures for fungi in 25 unique patients (Table 1);in prior years < 30 per year reported at SBUH. Collation of each unique identified fungal species from fungal blood cultures in patients hospitalized with Covid-19 Results. During a 3 month interval at the local peak of the pandemic 1398 patients hospitalized with Covid19 at SBUH, 25 cases of fungemia were detected;C. albicans (CA) n=8,32%, non C albicans species (nCA) n=16,64%, and C. neoformans n=1,4%, 17/25 (68%) also with bacteremia during same hospitalization. In same 3 months there were 264 cases of bacteremia and Covid19 co-infection. Demographics and medical co-morbidities of fungemic patients are in Table 2. Majority were men (76%). No difference between fungaemic (FC) and total cohort (TC) in median age (62 vs 62), DM p=0.31, HTN p=1.0, COPD p=0.12. Within FC, DM was higher in nCA group (58.8%) vs CA group (37%). Mortality was 40% in FC vs 15% in TC, p< 0.001. Within FC mortality was 56% in nCA and 25% in CA group. C. parapsilosis was the most common nCA species isolated with 43% mortality. FC more likely to require ICU and mechanical ventilation (88% vs 15%, p< 0.0001) and had longer median length of stay 42 days vs 22 days. The median time from admission to fungaemia was 21d, from central line placement 19d, Table 3. Of FC 21 (84%) were treated with steroids/Tocilizumab concurrently. Of note, no mortality was recorded in the 4 patients that did not receive steroids/Tocilizumab. PCT and WBC were significantly higher at time of fungemia as compared to admission, Table 3. Relevant patient characteristics and laboratory parameters in patients hospitalized with Covid19 and fungemia Conclusion. Fungemia in hospitalized patients with COVID-19 is associated with higher mortality. We observed higher fatality in non C. albicans infections. Prolonged use of central line catheters and concurrent treatment with steroids/tociluzimab are likely high-risk factors for development of fungemia.

Cryptococcal meningitis complicated by covid-19

Case Report A 45-year-old man with a history of end-stage renal disease s/p kidney transplant 14 months prior presented with severe headaches, neck pain, nausea, and vomiting for the past week. He takes tacrolimus, mycophenolate mofetil, and prednisone. Exam was notable for fever of 38.1°C, photophobia, and neck pain induced with forward flexion. Noncontrasted CT head found no intracranial processes. Lumbar puncture demonstrated an opening pressure of 45 cm H20 with CSF showing 108 WBCs with 67% neutrophils, normal glucose, and protein elevated to 112 mg/dL. Due to our high suspicion for cryptococcal meningitis, he was started on induction therapy with amphotericin B and flucytosine. CSF and serum cryptococcal antigens later returned positive at 1:320 and 1:2560, respectively. CSF culture also grew Cryptococcus neoformans/gattii complex. He underwent serial lumbar punctures and completed 14 days of induction therapy. He was transitioned to fluconazole consolidation after CSF cultures cleared and opening pressures on lumbar puncture had normalized. After induction, he acutely developed a severe leukopenia to 100 cells/mm3 along with profuse diarrhea. Over the next 1-2 days, he had progressive cough and dyspnea followed by hypotension, tachycardia, and hypoxemia, at which point he was diagnosed with SARS-CoV-2. He had completed his SARS-CoV-2 vaccinations 4 months prior to hospitalization. He was started on broad spectrum antibiotics and dexamethasone, placed on high-flow oxygen, and transferred to the intensive care unit. He was diagnosed with Klebsiella pneumoniae bacteremia. He developed progressive multi-organ failure and suffered a cardiac arrest. After discussion with family, the patient was transitioned to comfort care and passed away. Patients on immunosuppressive therapy are high risk for severe outcomes from both opportunistic infections and common infections that may affect the immunocompetent. It was critical to maintain a broad differential on this patient's presentation, as while cryptococcal meningitis is classically a disease of advanced HIV/AIDS, it may also occur in patients with alternative causes of immunosuppression. These patients often have other features that complicate therapy, such as an inability to reduce immunosuppression to control the disease, or drug interactions between antifungals and their immunosuppressive medications. This patient also suffered other complications from his chronic immunosuppression;a poor response to his initial SARS-CoV-2 vaccination and predisposition to more severe COVID-19 disease. Both leukopenia and diarrhea are common findings in COVID-19, which provoked the Klebsiella pneumoniae bacteremia. This unfortunate case demonstrates the need to always remain vigilant for both opportunistic and routine infections in an immunocompromised patient, especially in the setting of an ongoing viral pandemic.

CRIPTOCOCOSE CUTÂNEA SEM ACOMETIMENTO ENCEFÁLICO EM PACIENTE COM SIDA

A criptococose é uma doença fúngica e oportunista, causada pelo fungo da classe Blastomycetes, da família Cryptococcaceae e apresenta duas espécies patogênicas: C. neoformans e C. gattii. A infecção pode ser adquirida por quaisquer indivíduos saudáveis ou não, mas, as pessoas mais suscetíveis são os portadores de SIDA. A infecção no homem acontece por via respiratória;a levedura atinge os pulmões e, dependendo do estado imunológico do paciente, dissemina-se através por vias hematogênica ou linfática, para o sistema nervoso central, globo ocular e tecido cutâneo. O exame direto com coloração de tinta de nanquim é de fácil execução, rápido e barato permitindo a visualização das estruturas características do Cryptococcus spp, porém, o padrão-ouro para o diagnóstico é a associação do exame histopatológico com a cultura. Anfotericina B, é um medicamento fungicida que em associação a 5-flucitosina, constitui primeira opção de tratamento. Descrição do caso: Paciente feminina, 36 anos, venezuelana, com diagnostico de infecção pelo HIV há aproximadamente 2 anos, porém sem tratamento antirretroviral regular. Foi admitida em agosto de 2021 no Hospital de referência de Roraima por alteração neurológica (afasia, hemiparesia direita e alteração da marcha) com achados sugestivos de leucoencefalopatia multifocal progressiva (LEMP) na ressonância magnética do encéfalo;foi diagnosticada também com COVID-19. Durante a internação, evoluiu com surgimento de lesões elevadas, circunscritas, hipercrômicas em face, pescoço, tronco e membros superiores e lesão ulcerada de bordas elevadas de aproximadamente 5 cm na face medial do tornozelo esquerdo. Realizada biópsia das lesões que demonstraram infiltrado inflamatório linfohistiocitário, com esporos fúngicos de variados tamanhos, com cápsula espessa que se coram pela coloração HE e mais nitidamente pelo Grocott sugestivo de infecção por Cryptococcus neoformans. Análise de líquor realizado em 2 oportunidades teve exames diretos e culturas negativas para estruturas fúngicas;não foi possível realizar teste de aglutinação em Latex para Cryptococcus. Fez uso de Anfotericina B lipossomal e Fluconazol por 2 semanas, evoluindo com boa resposta cutânea, porém sem melhora do quadro neurológico. Comentário: A criptococose cutânea localizada uma condição na qual as lesões estão confinadas à pele, não disseminadas sistemicamente e ao mesmo tempo, não estão associadas a fungemia.

FUNGEMIA POR PAPILIOTREMA (CRYPTOCOCCUS) LAURENTII FUNGEMIA EM PACIENTE BRASILEIRO COM SARS-COV-2

Papiliotrema laurentii (Cryptococcus laurentii), é raramente associado a infecções humanas. Entretanto, nas últimas décadas, o número de infecções por não-C.neoformans aumentou,incluindo P. laurentii e C. albidus. Fungemia por espécies não-neoformans tem sido descritas em pacientes imunocomprometidos (AIDS,doenças linfoproliferativas,corticoesteróides,sarcoidose e TOS). Feminina 54 anos, obesa, diabetes mellitus tipo 2, cardiopata e hipertensa. Admitida com tosse e dispneia, evoluindo com insuficiência respiratória e Sars-Cov-2 por RT-PCR. Transferida para UTI e tratada com o protocolo para COVID-19. Em 4 dias,evoluiu com piora da função renal e hipotensão com indicação de hemodiálise. Apresentou instabilidade hemodinâmica refratária e vasopressores, sendo coletadas amostras de hemocultura, recebendo pipetazobactam 4,5 g 6/6h.Após 10 dias foi identificado P. laurentii, (sequenciamento D1/D2, ITS1 e ITS4). Teste de suscetibilidade in vitro (CLSI M27ED4) para AMB), FLUCO) e VORICO = 0,25, 8 e 0,125 µg, respectivamente.Iniciado AMB 50 mg/dia + FLUCO-800 mg/dia. Amostras deLCR coletadas LCR revelaram redução progressiva de proteína e leucócitos. Hemoculturas foram negativas após 2 semanas e um mês do início da terapia. AMB foi suspenso após 12 dias,com manutenção do FLUCO por 84 dias. Após 78 dias de ventilação mecânica e 107 dias em UTI,paciente foi transferida para enfermaria de reabilitação, recebendo alta em 09/11/2020 com oxigênio via traqueostomia. P. laurentii é raramente associado a infecção humana. A imunossupressão induzida pela COVID-19, associada ao uso de corticoesteróides e dispositivos invasivos pode ser relacionada a infecção por patógenos incomuns, como P. laurentii. Considerando a vulnerabilidade a co-infecções em pacientes com COVID-19, a suspeita precoce e identificação do agente etiológico é fundamental pararedução de mortalidade. Tratamento recomendado para infecções por não-C.neoformans é limitada devido a pouca quantidade de casos e falta de estudos clínicos. Para fungemia por P. laurentii, AMB é usado para diversos casos, com tempo médio de 25 dias. FLUCO também têm sido utilizado em alguns pacientes com fungemia, por 17 dias em média. Poucos dados estão disponíveis para o tratamento de meningite, com alguns casos tratados com sucesso com indução com AMB seguido de manutenção com FLUCO por longo período.

Cryptococcal Protease(s) and the Activation of SARS-CoV-2 Spike (S) Protein.

In this contribution, we report on the possibility that cryptococcal protease(s) could activate the SARS-CoV-2 spike (S) protein. The S protein is documented to have a unique four-amino-acid sequence (underlined, SPRRAR↓S) at the interface between the S1 and S2 sites, that serves as a cleavage site for the human protease, furin. We compared the biochemical efficiency of cryptococcal protease(s) and furin to mediate the proteolytic cleavage of the S1/S2 site in a fluorogenic peptide. We show that cryptococcal protease(s) processes this site in a manner comparable to the efficiency of furin (p > 0.581). We conclude the paper by discussing the impact of these findings in the context of a SARS-CoV-2 disease manifesting while there is an underlying cryptococcal infection.

Fatal case of disseminated cryptococcal infection and meningoencephalitis in the setting of prolonged glucocorticoid use in a Covid-19 positive patient.

Based on the RECOVERY trial, glucocorticoids have become the mainstay of treatment for COVID-19, thus increasing the risk of opportunistic infections. We report a case of disseminated Cryptococcus neoformans with documented meningoencephalitis in a patient with severe COVID-19 in the setting of prolonged glucocorticoid administration with poor outcome likely due to adrenal involvement.