Current Epidemiology and Clinical Features of Cryptococcus Infection in Patients Without Human Immunodeficiency Virus: A Multicenter Study in 46 Hospitals in Australia and New Zealand.

BACKGROUND: Patients without human immunodeficiency virus (HIV) are increasingly recognized as being at risk for cryptococcosis. Knowledge of characteristics of cryptococcosis in these patients remains incomplete. METHODS: We conducted a retrospective study of cryptococcosis in 46 Australian and New Zealand hospitals to compare its frequency in patients with and without HIV and describe its characteristics in patients without HIV. Patients with cryptococcosis between January 2015 and December 2019 were included. RESULTS: Of 475 patients with cryptococcosis, 90% were without HIV (426 of 475) with marked predominance in both Cryptococcus neoformans (88.7%) and Cryptococcus gattii cases (94.3%). Most patients without HIV (60.8%) had a known immunocompromising condition: cancer (n = 91), organ transplantation (n = 81), or other immunocompromising condition (n = 97). Cryptococcosis presented as incidental imaging findings in 16.4% of patients (70 of 426). The serum cryptococcal antigen test was positive in 85.1% of tested patients (319 of 375); high titers independently predicted risk of central nervous system involvement. Lumbar puncture was performed in 167 patients to screen for asymptomatic meningitis, with a positivity rate of 13.2% where meningitis could have been predicted by a high serum cryptococcal antigen titer and/or fungemia in 95% of evaluable cases. One-year all-cause mortality was 20.9% in patients without HIV and 21.7% in patients with HIV (P = .89). CONCLUSIONS: Ninety percent of cryptococcosis cases occurred in patients without HIV (89% and 94% for C. neoformans and C. gattii, respectively). Emerging patient risk groups were evident. A high level of awareness is warranted to diagnose cryptococcosis in patients without HIV.

Transbronchial lung biopsy (TBLB) in diagnosing pulmonary alveolar proteinosis (PAP): forgotten role in Australia?

Transbronchial lung biopsy (TBLB) is uncommonly performed in non-malignant conditions because of its low sensitivity and small tissue samples. It is not routinely performed in Australia to investigate idiopathic pulmonary fibrosis, although it can be a useful adjunct in obtaining tissue diagnosis in selected conditions in interstitial lung disease (ILD). A 52-year-old non-smoker received a living unrelated renal transplant in January 2014 but developed insidious onset of dyspnea on exertion 1 year later. Computed tomography of the thorax showed bilateral persistent ground glass opacifications with a characteristic crazy paving pattern, although P neumocystis jirovecii pneumonia was more concerning. He was treated as P neumocystis jirovecii pneumonia but his initial bronchoscopy failed to confirm either diagnoses. He then went on to TBLB that showed the presence of periodic acid-Schiff staining material. We conclude that TBLB is a useful adjunct to obtain histological diagnosis of ILD in carefully selected patients with appropriate radiological indications.