1. Cryptococcosis
Bhanthumkomol P.

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

3. 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

4. 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

5. 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)

6. 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

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

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

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

10. 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

11. 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

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

13. 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

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

15. Ability to growth at body Temp37
Only C. neoformans
May associated with calcineurin
Pathogenicity

16. 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

17. 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

18. 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

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

20. 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

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

22. 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

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

24. 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%

25. 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

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

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

28. 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

29. 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

30. 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

31. 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

32. 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 !!

33. 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

34. 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

35. 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

36. 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

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

38. 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

39. 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

40. 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

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

42. Management Meningitis in Non-HIV
6-8 wk of Amphotericin B  Renal toxicity
Amphotericin B 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

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

44. 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 !!

45. 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

46. 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 ml CSF
Neurosurgical Consultation
Open pr still > 20 cm in 7 days
Indication of Emergency CSF drainage

47. 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

48. 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