Cryptococcosis Bhanthumkomol P.

Outline Background Mycology Taxonomy Identification Ecology Epidemiology Pathogenicity Host response Pathogenesis Clinical manifestation Laboratory diagnosis Management Prognosis Prevention

Mycology Two mating types form conjugation Budding yeast Haploid In vitro Specific, nutrient-poor media Environment Human Asexual Stage Sexual Stage Two mating types form conjugation Budding yeast Haploid Filaments Convert to yeast form Yeast form Basidiospores formed by meiosis Basidia on end

Taxonomy C. neoforman C. neoforman var. neoformans 2 varieties 5 Capsular serotypes C. neoforman var. neoformans capsular serotypes A D AD C. neoforman var. gattii capsular serotypes B C Taxonomy

Identification Culture routine laboratory agar  72 hr can grow in hemoculture white to cream, opaque colony on agar mucoid if prolonged incubation (Polysaccharide capsule formation)

Identification Direct test Serotype identification India ink Rapid urease test Laccase activity Serotype identification Commercial Antibody Glycine assimilation as carbon source DNA analysis Only C. neoformans

Ecology var. neoformans A D AD var. gattii B C pigeons parrots canaries oaks firs eucalyptus maples

Epidemiology Clinical report of Cryptococcus isolation from human without evidence of Cryptococcosis COPD  Endobronchial colonization

Infected ? Access 1. Risk factors 2. Disease evidence Epidemiology

Risk factors Epidemiology HIV Lymphoproliferative disorder : CLL Sarcoidosis Corticosteroid Hyper IgM, IgE syndrome Monoclonal Ab : infiximab SLE DM CD4 T cell lymphopenia Transplant Kidney Liver Peritoneal dialysis Cirrhosis Epidemiology

Epidemiology Serotype A : AIDS All worldwide B : Brazil and other Tropical & subtropical area (Australia, Southeast Asia, Hawaii, Southern California) C : same as B but rare D : Denmark, Germany, Italy, France, Switzerland, USA Epidemiology

Epidemiology Transmission Inhalation “Intensive bird exposure area” Needlestick injury Organ transplant Epidemiology

Pathogenicity Capsule Thicker capsule More virulence !! Antiphagocytosis Decrease complements Intracellular local toxicity Antibody unresponsiveness Interfere Ag presentation Negative charge around yeast Enhance HIV replication Dysregulate cytokine secretion Brain edema Create selectin & TNF-R loss Thicker capsule More virulence !! Pathogenicity

Pathogenicity Melanin Antioxidant  tolerate oxidative stress Antiphagocytosis Decrease T cell response Cell wall change Protection from Temp. and Antifungals Pathogenicity

Ability to growth at body Temp 37 Only C. neoformans May associated with calcineurin Pathogenicity

Host response CMI Intracellular killing opsonization High rate Low Incidence Cryptococcosis High rate Cryptococcal Infection (DH, Ab +ve) CMI Granuloma formation LΦ (CD4,CD8) inhibit growth by direct contact Intracellular killing Activated MΦ  primary effector cell IFN-γ GM-CSF Phagocytes: MΦ, PMN, Microglial cell, NK cell Complement mediated Antibody mediated opsonization

Pathogenesis 3 2 1 Inhalation Stim. Th1 response alveoli Contact alv. MΦ 3 2 1 Im.supp.host Effective Im.Response Dormant Small lung or LN complex dissemination Crypto totally Eliminated Clinical Cryptococcosis Reactivation Pathogenesis

Clinical Manifestation Lung [Normal Host] Chronic endobronchial colonization Prior Chronic lung disease No immunosuppression No evidence of active lung parenchymal disease Serum Crypto Ag Negative Negative CSF and urine C/S May have lung nodule Asymptommatic 1 in 3 of cases Presented with Abn CXR Acute Symptommatic Fever, productive cough Chest pain, wt loss Clinical Manifestation

CXR finding Infiltration : either lobar or interstitial Hilar adenopathy Cavity Pleural effusion Mass/ nodule

Serum crypto antigen In pulmonary crypto Negative  Limited lung disease Positive  Extrapulmonary source include LP for CSF fungus C/S in High risk Pt for dissemination

Early asymptommatic CNS In pulmonary crypto Normal CSF profile only positive fungus c/s

Lung [Immunocompromised Host] Constitutional symptom May presented with CNS infection ARDS Common CXR Alv & Inst. Infiltration DDX: PCP Coinfection must be worked up CMV, PCP, Atypical mycobacteria, Nocardia Clinical Manifestation

CNS 4 forms Meningitis: Acute, Subacute, Chronic Cryptococcoma Spinal cord granuloma Chronic dementia (Hydrocephalus)

Cryptococcal Meningitis Finding Patient with AIDS without AIDS Duration of symptoms Usually <2wk Usually >2wk Positive india ink for CSF ~70% ~50% CSF antigen titer > 1:1024 Common Rare Serum antigen positive 93-99% 50% CSF antigen positive 91-99% >90% CSF WBC <20/mm3 69-97% 3% Extraneural involvement Opening pressure >200mm 62-65% 65%

IRIS Develop 1-2 mo after HAART Correlate with significant drop of HIV-VL Manifestation : worsening symptom Acute meningitis : increase Headache Lymphadenitis : - peripheral - Hilar - Mediastinal

IRIS LAB Increase inflammatory cell in CSF Increase ICP  increase headache But negative CSF & LN aspirate C/S Smear may positive !! Not recommended IRIS

Clinical Manifestation CNS of Var gattii Invade brain parenchyma > var neoformans Cryptococcoma & hydrocephalus May response poorly to Rx Immuno- Competent host !! Clinical Manifestation

Clinical Manifestation Skin Marker of dissemination > direct inoculation Need biopsy of Dx because of variety of skin manifestation Common : papule, MP with ulcerated center DDX : mollucum, Acne vulgaris, SCC/BCC Clinical Manifestation

Clinical Manifestation Prostate Most case  Asymtommatic Sanctury site for antifungal Rx before HAART Dx : C/S from urine or seminal fluid Require prolonged Rx Clinical Manifestation

Clinical Manifestation EYE Secondary to CNS = occular palsies & papilledema Small white retinal exudate w/o retinitis Severe immunocompromised host 1. occur simultaneously with HIV & CMV 2. Extensive retinal & vitritis - Blindness from optic neuritis - Blindness from increase ICP Clinical Manifestation

Lab Dx 1. Microscopic exam. India ink : CSF 50% positive in Non-AIDS 80% positive in AIDS Biopsy and cytology staining Alcian blue Fontana-masson H&E Gomori

India ink Positive when CSF yeast > 10000 CFU/ml Negative when CSF yeast < 1000 CFU/ml Still positive during and after Treatment Not a marker for treatment failure !!

Laboratory Diagnosis 2. cultures Growth in both Bacterial & Fungus media Isolate : - biochemical & DNA-based - Rapid urease test - Staib’s birdseed, DOPA, Caffeic acid media  melanin Laboratory Diagnosis

Laboratory Diagnosis 3. serology Detection of Cryptococcal polysaccharide Ag Latex agglutination EIA False positive less likely if titer > 1:4 False negative in : Early asymptomatic meningitis Chronic indolent meningitis >90% sensitivity and specificity Laboratory Diagnosis

Laboratory Diagnosis Remark in Serology Screening Crypto Ag in high incidence area in High risk : febrile AIDS patient with headache CSF and Serum Crypto Ag not cross BBB Titer > 1:1024  therapeutic failure Laboratory Diagnosis

Remark in Serum Crypto Ag Serum Crypto Ag  Screening HIV with headache If negative Crypto meningitis not likely ! Not use in : Follow up, Evaluate Rx response and relapse rate False +ve : RF +ve Pt, Trichosporon False –ve : Thin capsule, Prozone phenomenon Laboratory Diagnosis

Laboratory Diagnosis Radiology CXR CT finding MRI Normal Hydrocephalus Gyral enhancement Single or multiple nodule that may or may not enhanced MRI Laboratory Diagnosis

Laboratory Diagnosis MRI More sensitive than CT Numerous, clustered foci of hyperintensity in T2W Non-enhancing on postcontrast T1W in Basal gg & midbrain Laboratory Diagnosis

Remark in imaging No pathognomonic sign In AIDS must DDx Lymphoma Toxoplasmosis Nocardia Follow-up scan may see increased lesion from increased inflammatory response  NOT MARKER OF Rx FAILURE

Management Cryptococal meningitis Amphotericin B 0.7 mg/kg/day Liposomal form 4 mg/kg/day : toxicity decreased Flucytosine : no monotherapy  resistance Fluconazole : fungistatic in suppresive phase Itraconazole : inferior to fluco, alternative

Management Meningitis in HIV 3 Phases 1. Initial phase : Ampho + flucytosine 2 wk 2. Maintainance phase : Fluco 400-800 mg/d for 8-10 wk 3. Chronic suppressive phase : Fluco 200 mg/d decrease relapse rate 50-60%  5% Management

Management Meningitis in Non-HIV 6-8 wk of Amphotericin B  Renal toxicity Amphotericin B 0.5-1.0 MKD for 2wk then LP for CSF C/S if +ve continue Ampho longer and change to Fluconazole 400 mg/d for 8-10 wk May consider Fluconazole 6-12mo Management

Other site not meningitis Disseminated disease : Rx as meningitis Lung in healthy: Fluco 200-400 mg/d for 3-6 mo Cryptococcoma : Fluco for longer period, rarely need surgical intervention (<3cm) Chronic endobronchial colonization  No treatment !! Management

Remark in Treatment relapse Defined by 1. New clinical Sign & Symptom 2. Repeat positive C/S Positive india ink or Crypto Ag not precise indication for Relapse !!

Other treatment modality Care of increase ICP Repeated LP or shunt Detect hydrocephalus in the F/U period Control of HIV Immunomodulation G-CSF GM-CSF IFN-γ Management

Sign and symptom of Inc ICP Management of ICP HIV Pt with headache Sign and symptom of Inc ICP Sign of Inc ICP CN VI palsy Papilledema Symptom of Inc ICP Consciousness alteration Severe headache Visual or hearing loss Indication for brain imaging Duration > 2wk Focal neurological deficit Papilledema, CN VI palsy No contraindication for LP Coma VA drop / Hearing loss Obstructive Hydrocephalus LP open pr ≥40 cm LP 1-2/d Release CSF til Close pr < 20 cm Or Close pr < 50% Open pr At least 10-20 ml CSF Neurosurgical Consultation Open pr still > 20 cm in 7 days Indication of Emergency CSF drainage

Prognosis Most important prognosis is  Ability to control host underlying disease Two major prognostic finding Burden of yeasts at presentation - strongly positive india ink - high titer ≥ 1:1024 - CSF inflammatory cell < 20 cell/ųL Level of sensorium at presentation Lucid < Stuporous < coma

Prevention Fluconazole prophylaxis in AIDS CD4<100 : risk drug resistance Active immunization with vaccine in high risk : GXM-tetanus toxoid conjugate vaccine, no human trial Protective serotherapy by specific monoclonal Ab : repeat injection Avoid high risk environment