CRYPTOCOCCAL INFECTIONS IN PATIENTS WITH AIDS Stephen J. Gluckman, M.D. Botswana-UPENN Partnership

Microbiology Encapsulated yeast 4 serotypes A (C. neoformans v grubii) B and C ( C. gatti) D (C. neoformans v neoformans) All types can cause human disease Life cycle Asexual: yeast that reproduce by budding Human infections Sexual: only seen in the laboratory

Ecology and Epidemiology World wide C. neoformans associated with bird droppings C. gatti not associated with birds, associated with eucalyptus trees Generally an infection of immunocompromised but can cause clinical disease in healthy persons Decreased Cell-mediated immunity AIDS – CD 4 usually < 100 Prolonged corticosteroids Organ transplant

Ecology and Epidemiology 15-30% of AIDS patients in Sub-Saharan Africa* Much less common in children No person to person transmission *Powderly, WG Clin Infect Dis 1993

Clinical Presentations Pulmonary Asymptomatic nodule Symptomatic: not distinguishable from other causes History, PE, routine laboratory testing does not produce features peculiarly suggestive of cryptococcal infection Diagnosis Staining of biopsy specimen Culture of sputum and/or blood Serum cryptococcal antigen (CRAG) All patients with pulmonary disease need a CSF examination to r/o sub clinical meningitis

Silver Stain

Clinical Presentations Cutaneous Disseminated disease Looks similar to molluscum contageosum Diagnosis: Unroofing a lesion and making a smear and culture Serum CRAG All patients with cutaneous disease need a CSF examination to r/o sub clinical meningitis

Clinical Presentations Cryptococcal Meningitis Typical Subacute onset of fever and headache Photophobia and/or meningeal signs in only 25% Less typical Seizures Confusion Progressive dementia Visual or hearing impairment FUO Diagnosis CSF Serum CRAG: > 99% sensitive in AIDS patients

Cryptococcal Meningitis In 2003 there were 193 (+) CSF cultures for cryptococcus from PMH * Leucocytes No leucocytes in 31% Only 1-10 leucocytes in 23% 7% had > 250 leucocytes 30% of these had predominately PMN’s 95% (+) India Ink 1% (-) cryptococcal antigen Literature Sensitivity: 93-100% Specificity: 93-98 % *Bisson et al

India Ink

Prognosis for Cryptococcal Meningitis Prior to 1950 it was uniformly fatal Amphotericin B introduced and mortality fell to the 30-40% range In 1970’s 5-FC was released Not for monotherapy Decreased relapse rate when used with Amphotericin B Mortality with current regimens: 10% Predictors of death Altered mental status CSF CRAG > 1024 CSF cell count < 20 Changes in serum CRAG titer do not correlate with clinical outcome. So no need to follow

Summary of Diagnostic Options Culture White mucoid colonies within 48hours Blood cultures often (+) in immunosuppressed patients 2/3rds with meningitis Tissue Silver or mucicarmine stain India Ink for CSF Cryptococcal antigen Serum and CSF are 99% sensitive in AIDS patients Serum is less sensitive in normal hosts

Cryptococcal Meningitis Treatment Antifungal agents Induction Consolidation Maintenance Pressure management

Treatment* *Modified IDSA Guidelines Immunosuppressed (pulmonary, cutaneous, or meningitis) Induction Amphotericin B 0.7-1 mg/kg/day plus 5-flucytosine 100mg/kg/day x 2 weeks then Consolidation Fluconazole 400 mg/day x 6-10 weeks then Suppression Fluconazole 200 mg/day x ?

Cryptococcal Meningitis Treatment One More Thing Anti-fungal: induction, consolidation, maintenance Pressure management Elevated pressure 75% > 200 25% > 350 Repeated lumbar punctures Increased pressure: daily until normal x several days Normal pressure: recheck at 2 weeks prior to switching to fluconazole Lumbar drain VP shunt: if still elevated at 1 month No role for acetazolamide, mannitol Steroids: ?

Treatment Other options Fluconazole induction 5 FC monotherapy Increased mortality Not IDSA first choice 5 FC monotherapy Not an option because of resistance 5-FC plus Fluconazole Increased long term toxicity but an option Caspofungin No efficacy Voriconazole Good in vitro activity but little clinical experience

Summary Cryptococcal infections are common in patients with AIDS In patients with AIDS cryptococcal infections are seen in patients with the lowest CD 4 (+) cell counts Prolonged therapy and secondary prophylaxis is necessary For meningitis both anti-fungal therapy and aggressive pressure management are required