1. Meet the new kid on the block Cryptococcus gattii Karen H. Bartlett, PhD Associate Professor kbartlet@interchange.ubc.ca School of Environmental Health University of British Columbia University of British Columbia

2. The story as it unfolds … In 2001, veterinary lab first to notice  cases of cryptococcosis in pets on Vancouver Island In 2001, veterinary lab first to notice  cases of cryptococcosis in pets on Vancouver Island About the same time, medical microbiologist also finds  human cases … About the same time, medical microbiologist also finds  human cases …

3. What is cryptococcosis? Cryptococcus is an encapsulated yeast and opportunistic primary pathogen. Cryptococcus is an encapsulated yeast and opportunistic primary pathogen. Cryptococcosis is the infection …may involve lungs, CNS, or other organ systems. Cryptococcosis is the infection …may involve lungs, CNS, or other organ systems. Almost exclusively a disease of immunocompromised hosts. Almost exclusively a disease of immunocompromised hosts. It’s the fourth most common cause of life threatening infections in persons with AIDS. It’s the fourth most common cause of life threatening infections in persons with AIDS.

4. Typical cryptococcosis … Encapsulated yeast, can identify from microscope “Normally” associated with pigeons, world wide distribution

5. However!  cases on Vancouver Island were NOT in immunocompromised humans or animals  cases on Vancouver Island were NOT in immunocompromised humans or animals Cryptococcus isolates cultured from human cases were looked at again and subjected to serotyping Cryptococcus isolates cultured from human cases were looked at again and subjected to serotyping Surprise! The Cryptococcus from these British Columbia cases were serogroup B. Surprise! The Cryptococcus from these British Columbia cases were serogroup B.

6. Cryptococcus neoformans There are 4 serogroups of Cryptococcus neoformans that are pathogenic to mammals There are 4 serogroups of Cryptococcus neoformans that are pathogenic to mammals A and D are found world wide A and D are found world wide B and C are only supposed to be found in tropical or subtropical countries B and C are only supposed to be found in tropical or subtropical countries BUT … none of the new cases reported travel histories. BUT … none of the new cases reported travel histories.

7. VarietySerotypeMolecular type C. neoformans var. grubii AVN I VN II C. neoformans var. neoformans D VN IV Neoformans hybridAD VN III Cryptococcus gattiiBCBC VG I VG II VG III VG IV Relationship of pathogenic cryptococci

8. Outbreak … Annual incidence of all cryptococcosis (including AIDS associated) ~ 3-5/10 6 Annual incidence of all cryptococcosis (including AIDS associated) ~ 3-5/10 6 As of July 2001: As of July 2001: Humans (n=38) Pets (n=34) Porpoises (n=2) Incidence on Vancouver Island ~ 20/10 6 Incidence on Vancouver Island ~ 20/10 6

10. Outbreak …continues Annual incidence of all cryptococcosis (including AIDS associated) ~ 3-5/10 6 Annual incidence of all cryptococcosis (including AIDS associated) ~ 3-5/10 6 As of December 2008: As of December 2008: Humans (n=239) Pets (estimate = 3 – 4 times diagnosed human cases) Incidence on Vancouver Island ~ 24/10 6 Incidence on Vancouver Island ~ 24/10 6 Case fatality ratio 8.7 % (19 deaths) Case fatality ratio 8.7 % (19 deaths)

14. Objective: Identify Cryptococcus gattii

15. Objective: Identify Cryptococcus gattii Microscopic 1000x India ink or calcofluor white Capsule Budding yeast with narrow base

16. Objective: Identify Cryptococcus gattii Cryptococcal antigen latex agglutination - Very sensitive – 10 ng /mL biologic fluid - Positive serum test (1:4) probable infection - Positive test ≥ 1:8 active infection - Can be used to monitor effectiveness of tx - Serum (pretreat with pronase) -CSF (no pretreatment) Does not differentiate between C. gattii and C. neoformans

17. Objective: Identify Cryptococcus gattii Culture techniques: Primary plating as normal – Cryptococcus grows well on Sabouraud Dextrose Agar Colonies visible at 48 – 72 hr Optimal growth 30 – 35 o C (slower ≥ 37) Cream coloured, glistening or matte

18. Objective: Identify Cryptococcus gattii Add primary isolation media Bird Seed Agar or Caffeic Acid Agar (C. gattii = dark chocolate brown) (C. neoformans = milk chocolate brown)

19. Objective: Identify Cryptococcus gattii Confirmation agar: Canavanine-glycine-bromthymol blue (CGB) (C. gattii = grows & turns medium blue 24 h – 5 days) (C. neoformans = no growth, medium yellow or green)

20. Objective: Identify Cryptococcus gattii Physiological tests: C. neoformans and C. gattii are indistinguishable: Germ tube test negative Hydrolysis of urea positive (rapid test available) Growth on cycloheximide media negative Carbohydrate assimilation tests Caffeic Acid disk (rapid test available)

21. 1 kb marker (Gibco-BRL) R634 R794 F2596 F2932 F3179 F3197 99MR10 1 kb marker (Gibco-BRL) F2863 F2866 F3016 1 kb marker (Gibco-BRL) E113 ENV123 ENV124 ENV125 ENV129 ENV130 ENV131 ENV133 ENV152 ENV153 1 kb marker (Gibco-BRL) WM148 VNI Standard WM626 VNII Standard WM628 VNIII Standard WM629 VNIV Standard 1 kb marker (Gibco-BRL) WM179 VGI Standard WM178 VGII Standard WM161 VGIII Standard WM779 VGIV Standard 1 kb marker (Gibco-BRL) URA5-RFLP unique genotypes clinicalenvironmental Source: S. Kidd

22. URA5 - orotidine monophosphate pyrophosphorylase CAP59 - capsular associated protein GPD1- glyceraldehyde-3-phosphate dehydrogenase LAC1- laccase PLB1- phospholipase SOD1- superoxide dismutase IGS1- rRNA intergenic spacer C. gattii MLST genotyping scheme

23. Genotyping Cryptococcus at BCCDC Source: M. Morshed

24. Susceptibility testing Cryptococcus - Break points not established for crypto. - E-test used by many laboratories -Micro-broth dilution media not standardized (added glucose ±, shaking ±) - Fluconazole ± Ampho B for uncomplicated pulmonary 3 – 12 months

25. MIC µg/mL fluconzaole GenotypeRangeGeo MeanMIC 50 MIC 90 VG IIa2 – 85.588 VG IIb4 – 3212.516 VG I & III0.5 – 163.0416 All0.5 – 327.3816 Susceptibility testing C. gattii Source: Dr. Shawn Lockhart Centers for Disease Control and Prevention

26. MIC µg/mL Amphotericin B GenotypeRangeGeo MeanMIC 50 MIC 90 VG IIa0.125 – 0.250.19 VG IIb0.06 – 0.250.160.190.25 VG I & III0.05 – 0.190.100.1250.19 All0.05 – 0.250.160.19 Susceptibility testing C. gattii Source: Dr. Shawn Lockhart Centers for Disease Control and Prevention

27. Rates and demographics 1999 -2007 Incidence Incidence 236 cases 236 cases Mean 24.2 cases per year Mean 24.2 cases per year 25.1/million population Vancouver Island 25.1/million population Vancouver Island Demographics Mean age – 59 years Age range 2 – 92 y  4 pediatric cases  70 – 79 y highest incidence Male 56% Source: BC CDC 2008

28. Mortality 19 deaths (case fatality ratio of 8.7%) 19 deaths (case fatality ratio of 8.7%)  Underlying cause of death in 9; contributing cause in 10 Mean age at death: 67.6 (range 26 – 91y) Mean age at death: 67.6 (range 26 – 91y)  Cases who died were older than those who did not Median time from diagnosis to death: 54 days (range 5 – 577 d) Median time from diagnosis to death: 54 days (range 5 – 577 d) 12 (63.2%) had underlying medical conditions 12 (63.2%) had underlying medical conditions  6 cancer  3 COPD  2 liver disease  1 HIV, lung transplant, congestive heart failure, congenital heart malformation Cases who died were more likely to present with CNS disease Cases who died were more likely to present with CNS disease Source: Galanis 2008

29. Case-Control study 1999 – 2001 (n = 30) Risk factorsMatched OR95% CI Corticosteroids8.111.74, 37.80 Chronic lung disease3.211.08, 9.52 Recurrent pneumonia2.711.05, 6.98 Cancer2.030.63, 6.81 Current or past smoker1.180.44, 3.20 Diabetes0.650.17, 2.50 Asthma0.450.12, 1.66 Outdoor building repair4.001.00, 16.00 Woods within mile of house1.700.17, 2.02 Camping1.230.23, 2.91 Gardening1.150.47, 2.79 Branch clean-up0.290.10, 0.76 Cutting/chopping wood0.170.04, 0.76 Pruning0.280.09, 0.88 Source: MacDougall & Fyfe 2008

30. Population-based risk factors 1999 – 2007 (n = 218) Risk FactorPrevalence in C. gattii cases Prevalence in BC population P-value Age ≥ 50 years72.4%31.3%< 0.001 Male55.8%49.6%0.198 Current smoker41.9%17.8%< 0.001 Invasive cancer24.7%3.6%< 0.001 HIV Infection3.7%0.2%< 0.001 COPD4.1%8.0%0.09 Asthma3.4%7.8%0.54 Corticosteroids27.0%unknown Source: Galanis 2008

31. Environmental & host risk factors (canine) Source: Duncan 2006

32. Environmental & host risk factors (feline) Source: Duncan 2006

33. Airborne Cryptococcus by month

34. BC Host tree species

35. Tree swab by geographic location Tree LocationDistance from Victoria (km) Swabs examined Swabs positive % positive Campbell RiverN 2452000% CourtenayN 200220136% ParksvilleN 12539112632% NanaimoN 10030731% CowichanN 50168148% Gulf IslandsE 2011771% Victoria353123% Distance from Parksville (km) Port AlberniW 40571119% West CoastW 1404500 MainlandE 90 - 10023100

36. Cryptococcus in soil by geographic location LocationDistance from Victoria (km) nCFU/gram soil GM GSD Range Campbell RiverN 2456000 CourtenayN 2001391.55.2 0 – 4365 ParksvilleN 1251274.712.1 0 – 29512 NanaimoN 1001361.33.1 0 – 708 CowichanN 50962.613.2 0 – 36308 Gulf IslandsE 201041.65.4 0 – 181970 Victoria1671.23.0 0 – 2042 Distance from Parksville (km) Port AlberniW 40482.35.0 0 – 537 MainlandE 90-100124000

37. Mobility of Cryptococcus Air Air Wood/sawdust Wood/sawdust Soil Soil Shoes Shoes Car tires/wheel wells Car tires/wheel wells Water Water

38. Mobility on car wheel wells

39. Environmental sampling: Mainland and beyond

40. Source: S. Mak 2010

41. Conclusions: Cryptococcus gattii is endemic on the east coast of Vancouver Island Cryptococcus gattii is endemic on the east coast of Vancouver Island Cultured from a wide range of native tree species Cultured from a wide range of native tree species Not homogeneous in the environment (hot spots) Not homogeneous in the environment (hot spots)

42. Conclusions: Human cases preceded by animal cases, veterinarians most likely to see sentinel cases Human cases preceded by animal cases, veterinarians most likely to see sentinel cases C. gattii mis-identified as C. neoformans if additional laboratory tests not performed C. gattii mis-identified as C. neoformans if additional laboratory tests not performed Multiple C. gattii genotypes in Cascadia Multiple C. gattii genotypes in Cascadia

43. Team Crypto once and future … Vancouver Vancouver  BC CDC  Epidemiology  L. MacDougall (ex), S. Mak, E. Galanis,  L. MacDougall (ex), S. Mak, E. Galanis, Colette Gaulin, Min Li  Laboratory  M. Moreshed, Min Lee, L. Hoang, S. Mithani  UBC Sarah Kidd (ex), Yat Chow, Jim KronstadSarah Kidd (ex), Yat Chow, Jim Kronstad

44. Team Crypto once and future … Vancouver Island Vancouver Island Victoria and Health Authorities Victoria and Health Authorities Pam Kibsey, Murray Fyfe Pam Kibsey, Murray Fyfe Centre for Coastal Health Centre for Coastal Health Craig Stephen, Colleen Duncan (ex) Craig Stephen, Colleen Duncan (ex) Animal surveillance Animal surveillance Central Laboratory (ex) Central Laboratory (ex) Canada West Critical Care (Vancouver) Canada West Critical Care (Vancouver)

45. Team Crypto once and future … Cryptococcus gattii working group of the Pacific Northwest Cryptococcus gattii working group of the Pacific Northwest Kieren Marr, Kausik Datta, Rebecca Baer, Edmond Byrnes, Joseph Heitman, Mira Leslie, Shelley Magill Kieren Marr, Kausik Datta, Rebecca Baer, Edmond Byrnes, Joseph Heitman, Mira Leslie, Shelley Magill CDC Cryptococcus group CDC Cryptococcus group Tom Chiller, Shawn Lockhart, Julie Harris, Ron Wohrle Tom Chiller, Shawn Lockhart, Julie Harris, Ron Wohrle

46. Acknowledgements: BC Lung Association BC Lung Association Michael Smith Foundation for Health Research Michael Smith Foundation for Health Research Sampling team members: Sampling team members: Yat Chow, Tracy Kirkham, Molly Chen, Hua Shen, Caroline Chen, Timothy Ma, Fred Rockwell Yat Chow, Tracy Kirkham, Molly Chen, Hua Shen, Caroline Chen, Timothy Ma, Fred Rockwell BC Parks employees, Vancouver Island EHOs BC Parks employees, Vancouver Island EHOs

47. Publications: in press or in preparation … Mak, S, Klinkenberg, B, Bartlett, K, Fyfe, M. (in press) Ecological Niche Modeling of Cryptococcus gattii in British Columbia, Canada. Environmental Health Perspectives 118 (5):653- 658 Mak, S, Klinkenberg, B, Bartlett, K, Fyfe, M. (in press) Ecological Niche Modeling of Cryptococcus gattii in British Columbia, Canada. Environmental Health Perspectives 118 (5):653- 658 Chapter: “The emergence of Cryptococcus gattii infections on Vancouver Island and expansion in the Pacific Northwest.” Karen Bartlett, Edmond Byrnes, Colleen Duncan, Murray Fyfe, Eleni Galanis, Joseph Heitman, Linda Hoang, Sarah Kidd, Laura MacDougall, Sunny Mak, Kieren Marr, Muhammad Morshed, Sarah West, and James Kronstad. In: Cryptococcus: from human pathogen to model yeast. Eds: J. Kwon-Chun and J. Heitman. ASM Press. Expected publication date 2010. Chapter: “The emergence of Cryptococcus gattii infections on Vancouver Island and expansion in the Pacific Northwest.” Karen Bartlett, Edmond Byrnes, Colleen Duncan, Murray Fyfe, Eleni Galanis, Joseph Heitman, Linda Hoang, Sarah Kidd, Laura MacDougall, Sunny Mak, Kieren Marr, Muhammad Morshed, Sarah West, and James Kronstad. In: Cryptococcus: from human pathogen to model yeast. Eds: J. Kwon-Chun and J. Heitman. ASM Press. Expected publication date 2010. Lester, S, Bartlett, K, and others 2010 A review of C. gattii cryptococcosis in the North American Pacific Northwest. Vet Clin Path Lester, S, Bartlett, K, and others 2010 A review of C. gattii cryptococcosis in the North American Pacific Northwest. Vet Clin Path

48. Datta, K. Bartlett, K, Baer, R, Byrnes, E, Galanis, E, Heitman, J, Hoang, L, Leslie, M, MacDougall, L, Magill, S, Morshed, M, Marr, K. 2009. Cryptococcus gattii: an Emerging Pathogenic Fungus in the Pacific Northwest. Emerging Infectious Diseases 15(8): 1185-1191. Datta, K. Bartlett, K, Baer, R, Byrnes, E, Galanis, E, Heitman, J, Hoang, L, Leslie, M, MacDougall, L, Magill, S, Morshed, M, Marr, K. 2009. Cryptococcus gattii: an Emerging Pathogenic Fungus in the Pacific Northwest. Emerging Infectious Diseases 15(8): 1185-1191. Datta, K., Bartlett, KH, Marr, KA. 2009. Cryptococcus gattii emergence in Western North America: Exploitation of a novel ecological niche. Interdisciplinary Perspectives on Infectious Diseases v. 2009, Article ID 176532, 8 pages. doi:10.1155/2009/176532. Datta, K., Bartlett, KH, Marr, KA. 2009. Cryptococcus gattii emergence in Western North America: Exploitation of a novel ecological niche. Interdisciplinary Perspectives on Infectious Diseases v. 2009, Article ID 176532, 8 pages. doi:10.1155/2009/176532. Galanis, E, Hoang, L, Kibsey, P, Morshed, M, Phillips, P. 2009. Clinical presentation, diagnosis and managment of Cryptococcus gattii cases: Lessons learned from British Columbia. Can J Infect Dis Med Microbiol 20(1): 23-28. Galanis, E, Hoang, L, Kibsey, P, Morshed, M, Phillips, P. 2009. Clinical presentation, diagnosis and managment of Cryptococcus gattii cases: Lessons learned from British Columbia. Can J Infect Dis Med Microbiol 20(1): 23-28. Fyfe, M, MacDougall, L, Romney, M, Starr, M, Pearce M, Mak, S, Mithani, S, Kibsey, P. 2008. Cryptococcus gattii infections on Vancouver Island, British Columbia, Canada: Emergence of a tropical fungus in a temperate environment. CCDR 34(6): 1 – 12. Fyfe, M, MacDougall, L, Romney, M, Starr, M, Pearce M, Mak, S, Mithani, S, Kibsey, P. 2008. Cryptococcus gattii infections on Vancouver Island, British Columbia, Canada: Emergence of a tropical fungus in a temperate environment. CCDR 34(6): 1 – 12. Chambers, C, MacDougall, L, Li, M, Galanis, E. 2008. Using tourism data to define specific risk areas for Cryptococcus gattii on Vancouver Isalnd, Canada. Emerg Infecg Dis 14(11): 1781 – 3. Chambers, C, MacDougall, L, Li, M, Galanis, E. 2008. Using tourism data to define specific risk areas for Cryptococcus gattii on Vancouver Isalnd, Canada. Emerg Infecg Dis 14(11): 1781 – 3. Bartlett, KH, Kidd, SE, Kronstad, J. 2008. The emergence of Cryptococcus gattii in British Columbia and the Pacific Northwest. Current Infectious Disease Reports, 10(1): 58-65. Bartlett, KH, Kidd, SE, Kronstad, J. 2008. The emergence of Cryptococcus gattii in British Columbia and the Pacific Northwest. Current Infectious Disease Reports, 10(1): 58-65. Nicol, A-M, Hurrell, C, McDowall, W, Bartlett, K, Elmieh, N. 2008. Communicating the risks of a new, emerging pathogen: the case of Cryptococcus gattii. Journal of Risk Analysis 28(2): 373-386 Nicol, A-M, Hurrell, C, McDowall, W, Bartlett, K, Elmieh, N. 2008. Communicating the risks of a new, emerging pathogen: the case of Cryptococcus gattii. Journal of Risk Analysis 28(2): 373-386 doi:10.1111/j.1539-6924.2008.01024.x. Bartlett, KH,, Kronstad, J. 2007. The emergence of Cryptococcus gattii in British Columbia and the Pacific Northwest. Current Fungal Infection Reports, 1:108 - 115 Bartlett, KH, Kidd, SE, Kronstad, J. 2007. The emergence of Cryptococcus gattii in British Columbia and the Pacific Northwest. Current Fungal Infection Reports, 1:108 - 115 Upton, A, Fraser, JA, Kidd, SE, Bretz, C, Heitman, J, Bartlett, KH, Raverty, S. Marr, KA. 2007. First Contemporary Case of Human Infection with Cryptococcus gattii in Puget Sound: Evidence for Spread of the Vancouver Island Outbreak. Journal of Clinical Microbiology, 45(9):3086-8. Upton, A, Fraser, JA, Kidd, SE, Bretz, C, Heitman, J, Bartlett, KH, Raverty, S. Marr, KA. 2007. First Contemporary Case of Human Infection with Cryptococcus gattii in Puget Sound: Evidence for Spread of the Vancouver Island Outbreak. Journal of Clinical Microbiology, 45(9):3086-8. Kidd, SE, Chow, Y, Mak, S, Bach, PJ, Chen, H, Hingston, AO, Kronstad, JW, and. 2007 Characterization of Environmental Sources of Cryptococcus gattii in British Columbia, Canada, and the Pacific Northwest. Applied and Environmental Microbiology, 73 (5):1433 – 1443. Kidd, SE, Chow, Y, Mak, S, Bach, PJ, Chen, H, Hingston, AO, Kronstad, JW, and Bartlett, KH. 2007 Characterization of Environmental Sources of Cryptococcus gattii in British Columbia, Canada, and the Pacific Northwest. Applied and Environmental Microbiology, 73 (5):1433 – 1443.

49. MacDougall, L, Kidd, SE, Galanis, E., Mak, S., Leslie, MJ, Cieslak, PR, Kronstad, JW, Morshed, MG, and Bartlett, KH. 2007. Spread of Cryptococcus gattii in British Columbia, Canada, and detection in the Pacific Northwest, USA. Emerging Infectious Diseases 13(1):42-50. Kidd, SE, Bach, PJ, Hingston, AO, Mak, S, Chow, Y, MacDougall, L, Kronstad, JW, Bartlett, KH. 2007. Cryptococcus gattii Dispersal Mechanisms, British Columbia, Canada. Emerging Infectious Diseases 13(1):51-57. Duncan, C, Schwantje, H, Stephen, C, Campbell, J, Bartlett K. 2006. Cryptococcus gattii in wildlife of Vancouver Island, BC, Canada. Journal of Wildlife Diseases 42: 175-178. Duncan, C, Stephen, C, Lester, S, Bartlett, KH. 2005. Sub-clinical infection and asymptomatic carriage of Cryptococcus gattii in dogs and cats during an outbreak of cryptococcosis. Medical Mycology 43: 511- 516. Kidd, SE, Guo, H, Bartlett, KH, Kronstad, JW, Xu, J. 2005. Comparative gene genealogies indicate that two clonal lineages of Cryptococcus gattii in British Columbia resemble strains from other geographical areas. Eucaryotic Cell 4: 1629-1638. Duncan C, Stephen C, Lester S and Bartlett, KH. 2005 Follow-up study of dogs and cats with asymptomatic Cryptococcus gattii infection or nasal colonization. Medical Mycology 43: 663-666. Kidd S, Hagen F, Tscharke M, Huynh M, Bartlett KH, Fyfe, M, MacDougall L, Boekhout T, Kwon-Chung KJ, Meyer W. 2004. A rare genotype of Cryptococcus gattii caused the cryptococcosis outbreak on Vancouver Island (British Columbia, Canada). Proceedings of the National Academy of Sciences 101(49): 17258-17263. Lester S, Kowalewich N, Bartlett KH, Krockenberger MB, Fairfax, TM, Malik R. 2004. Clinicopathologic features of cryptococcosis in dogs, cats, ferrets, and a bird: 38 Cases (January to July 2003). Journal of the American Veterinary Medical Association, 225 (11): 1716-1722.