Fluconazole levels in serum and cerebrospinal fluid according to daily dosage in patients with cryptococcosis and other fungal infections

ABSTRACT Fluconazole is extensively used for the treatment of candidiasis and cryptococcosis. Among other factors, successful treatment is related to appropriate fluconazole levels in blood and cerebrospinal fluid. In the present study, fluconazole levels were determined in 15 patients, 14 of whom had AIDS and 13 had neurocryptococcosis. The only selection criterion was treatment with fluconazole, which was performed with a generic or similar form of the drug. Fluconazole level was determined by high performance liquid chromatography and the susceptibility profile of Cryptococcus spp. isolated from the patients was assessed by broth microdilution. Blood and cerebrospinal fluid fluconazole levels were found to be related to the fluconazole daily dose, and exceeded the minimum inhibitory concentration of this antifungal for the Cryptococcus spp. isolates. A good correlation was observed between serum and cerebrospinal fluid drug concentration. In conclusion, treatment with non-original fluconazole under usual medical practice conditions results in appropriate blood and cerebrospinal fluid levels of the drug for inhibiting Cryptococcus spp. susceptible to this antifungal drug. The relatively common failures of neurocryptococcosis treatment appear not to be due to insufficient fluconazole levels in the cerebrospinal fluid, especially with the use of daily doses of 400-800 mg.

Fluconazole levels in serum and cerebrospinal fluid according to daily dosage in patients with cryptococcosis and other fungal infections.

Fluconazole is extensively used for the treatment of candidiasis and cryptococcosis. Among other factors, successful treatment is related to appropriate fluconazole levels in blood and cerebrospinal fluid. In the present study, fluconazole levels were determined in 15 patients, 14 of whom had AIDS and 13 had neurocryptococcosis. The only selection criterion was treatment with fluconazole, which was performed with a generic or similar form of the drug. Fluconazole level was determined by high performance liquid chromatography and the susceptibility profile of Cryptococcus spp. isolated from the patients was assessed by broth microdilution. Blood and cerebrospinal fluid fluconazole levels were found to be related to the fluconazole daily dose, and exceeded the minimum inhibitory concentration of this antifungal for the Cryptococcus spp. isolates. A good correlation was observed between serum and cerebrospinal fluid drug concentration. In conclusion, treatment with non-original fluconazole under usual medical practice conditions results in appropriate blood and cerebrospinal fluid levels of the drug for inhibiting Cryptococcus spp. susceptible to this antifungal drug. The relatively common failures of neurocryptococcosis treatment appear not to be due to insufficient fluconazole levels in the cerebrospinal fluid, especially with the use of daily doses of 400-800mg.

Diagnóstico de Cryptococcus neoformans mediante la PCR- RFLP en el líquido cefalorraquídeo (LCR) en pacientes hospitalizados en el sur de Brasil / Cryptococcus neoformans diagnosis using PCR-RFLP on cerebrospinal fluid (CSF) of hospitalized patients in southern Brazil

Introducción: Cryptococcus neoformans es un hongo levaduriforme encapsulado, de distribución mundial, principalmente en regiones tropicales, causando infecciones en individuos inmunocomprometidos, sobre todo en los infectados con el virus de la inmunodeficiencia humana (HIV). La capacidad de infección de este hongo es variable, pudiendo citar la facultativa patogenicidad, cápsula con actividad fagocitaria y producción de melanina como antioxidante. El objetivo de este trabajo fue evaluar el uso de la PCR/ RFLP para la detección e identificación de C. neoformans directamente del líquido cefalorraquídeo (LCR) de pacientes ingresados en un hospital público de la ciudad de Lages, Estado de Santa Catarina, sur de Brasil, comparando el resultado con la tinción específica para el hongo y el crecimiento en medio de cultivo. Métodos: Las muestras fueran directamente teñidas con tinta china para observar la cápsula, bien como después sembladas en medio de cultivo (agar dextrosa Sabouraud y agar de Níger) para crecimiento fúngico; también se hizo la extracción del ADN con fenol-cloroformo. La técnica fue utilizada para amplificación del gen URA5 mediante reacción en cadena de la polimerasa (PCR) y después con las enzimas de restricción HhaI y Sau96I para genotipaje mediante la PCR-RFLP. Resultados: En dos muestras fueran aislados C. neoformans con la tinción china y amplificados en la PCR, en las cuales fueran identificados como var. grubii. Conclusión: El serotipo A var. grubii es lo más aislado en la criptococosis humana, principalmente en pacientes HIV, pero se desconoce la preferencia de este serotipo por este grupo de enfermos. (AU)

Introduction: Cryptococcus neoformans is an encapsulated yeast with worldwide circulation, predominantly in tropical regions, causing infections in immunocompromised individuals, particularly those infected with human immunodeficiency virus (HIV). The virulence of this fungus is variable, and it should be mentioned the facultative pathogenicity, capsule with anti-phagocytic activity, and antioxidant melanin production. The aim of this study was to evaluate the use of polymerase chain reaction (PCR)/ restriction fragment length polymorphism (RFLP) for detection and identification of C. neoformans directly from the cerebrospinal fluid (CSF) of patients admitted to a public hospital with suspected meningitis and/or meningoencephalitis in the city of Lages, Santa Catarina, southern Brazil. Results were compared using Chinese ink and growth media. Methods: The samples were submitted to direct examination with Chinese ink for capsule observation, then to growth on culture media (Sabouraud Agar and Niger), with subsequent DNA extraction with phenol-chloroform. PCR was the technique used for amplification of URA5 gene, and then restriction enzymes HhaI and Sau96I were used for genotyping by PCR-RFLP. Results: In two samples, C. neoformans were isolated by Chinese ink and amplified by PCR. They were identified as serotype var. grubii. Conclusion: C. neoformans var. grubii is the most commonly isolated in human cryptococcosis, mainly in HIV patients. However, the preference of this serotype for this group of patients is unknown. (AU)

Evaluation of a Cryptococcal antigen Lateral Flow Assay in serum and cerebrospinal fluid for rapid diagnosis of cryptococcosis in Colombia.

A Lateral Flow Assay to detect cryptococcal antigen (CrAg® LFA) in serum and cerebrospinal fluid for the rapid diagnosis of cryptococcosis was evaluated. A retrospective validation was performed. Sensitivity and specificity of the CrAg® LFA was 100%. High concordance (kappa index=1.0) between Cryptococcal Antigen Latex Agglutination System (CALAS®) and CrAg® LFA was observed. CrAg® LFA showed higher analytical sensitivity for detecting low concentrations of cryptococcal antigen.

Fungal colonization of the brain: anatomopathological aspects of neurological cryptococcosis.

Brain infection by the fungus Cryptococcus neoformans results in an estimated 500,000 human deaths per annum. Colonization of the central nervous system (CNS) by C. neoformans causes different clinical syndromes that involve interaction of a number of fungal components with distinct brain cells. In this manuscript, our literature review confirmed the notion that the Cryptococcus field is expanding rapidly, but also suggested that studies on neuropathogenesis still represent a small fraction of basic research activity in the field. We therefore discussed anatomical and physiological aspects of the brain during infection by C. neoformans, in addition to mechanisms by which brain resident cells interact with the fungus. This review suggests that multiple efforts are necessary to improve the knowledge on how C. neoformans affects brain cells, in order to enable the generation of new therapeutic tools in a near future.

Meningoencefalitis causada por Cryptococcus neoformans: presentación de un caso / Meningoencephalitis due to Cryptococcus neoformans: a case report

Introducción: La meningitis/meningoencefalitis por Cryptococcus neoformans, pese a su poca incidencia, es la más frecuente de las infecciones por hongos del sistema nervioso central y presenta una prevalencia cada vez mayor, lo queobliga a tenerla en consideración siempre, especialmente en enfermos inmunosuprimidos.Caso clínico: Se presenta una paciente mestiza de 23 años de edad, que después de realizársele un legrado con fines de interrumpir el embarazo presentó un cuadro neurológico grave. Basados en la clínica, el examen físico y los complementarios realizados, se le diagnosticó una meningoencefalitis por Cryptococcus neoformans.Conclusiones: Se destaca la importancia de los estudios para confirmar el diagnóstico. Especialmente los cultivos del líquido cefalorraquídeo en medios de Sabouraud y tinción con tinta china que evidenciaron en esta paciente la presencia del Cryptococcus neoformans. Con la terapéutica con anfotericina B liposomal y fluconazol se consiguió una evolución favorable(AU)

Introduction: The meningitis/meningo–encephalitis caused by Cryptococcus neoformans is the more frequent clinicalpresentation of infection by fungus in the central nervous system, with a progressive increment of prevalence in the last years and actually is necessary to think always about this possibility and especially in patients with immunodeficiency.Case report: Female, 23 years old, who presented a serious neurological disease a few days after a provoked abort. By the clinic symptoms, physical examination and the results of tests realized, she was diagnosed as a patient with meningitis/meningo–encephalitis by Cryptococcus neoformans.Conclusions: Studies such as cultivation of cerebrospinal fluid in Sabouraud and Indian ink staining of cerebrospinal fluidshowed the Cryptococcus Neoformans and corroborated the diagnosis. The treatment was completed with liposomalamphotericin B and fluconazole; the evolution was favorable and the patient was asymptomatic after antifungal therapy(AU)

Central nervous system immune reconstitution inflammatory syndrome in AIDS: experience of a Mexican neurological centre.

BACKGROUND: Highly active antiretroviral therapy (HAART) restores the inflammatory immune response in AIDS patients and it may unmask previous subclinical infections or paradoxically exacerbate symptoms of opportunistic infections. Up to 25% of patients receiving HAART develop immune reconstitution inflammatory syndrome (IRIS). We describe six patients with IRIS central nervous system (CNSIRIS) manifestations emphasizing the relevance of CSF cultures and neuroimaging in early diagnosis and management. METHODS: Patients with CNSIRIS were identified among hospitalized HIV-infected patients that started HAART from January 2002 through December 2007 at a referral neurological center in Mexico. RESULTS: One-hundred and forty-two HIV-infected patients with neurological signs were hospitalized, 64 of which had received HAART, and six (9.3%) developed CNSIRIS. Five patients were male. Two cases of tuberculosis, two of cryptococcosis, one of brain toxoplasmosis, and one possible PML case were found. IRIS onset occurred within 12 weeks of HAART in five patients. Anti-infective therapy was continued. In one case, HAART was temporarily suspended. In long-term follow-up the clinical condition improved in all patients. CONCLUSIONS: CNSIRIS associated to opportunistic infections appeared in 9% of patients receiving HAART. Interestingly, no cases of malignancy or neoplasm IRIS-related were found. Frequent clinical assessment and neuroimaging studies supported diagnosis and treatment. Risk factors were similar to those found in other series.

Líquido cefalorraquídeo en pacientes con criptococosis asociada al SIDA / CSF in patients with AIDS associated cryptococcosis

Se analizaron retrospectivamente los líquidos céfalorraquídeos (LCR) de 44 pacientes con criptococosis asociada al SIDA, internados en la Sala XI del Hospital Muñiz, entre enero de 2000 y diciembre de 2004. Se tuvieron en cuenta en cada caso las características físico-químicas, citológicas y micológicas de los LCR obtenidos por punción lumbar al momento de la admisión. La microscopia con tinta china fue positiva en 38 (90.5%) de 42 pacientes con ese dato disponible. Los 6 pacientes restantes se diagnosticaron por cultivos y/o determinación de antígeno de Cryptococcus neoformans. En el examen físico, 29 (69%) de 42 muestras disponibles, presentaron aspecto límpido y las 13 restantes fueron hemorrágicas (n=3), opalescentes (n=6), xantocrómicas (n=3) o turbias (n=1). Del análisis químico, se obtuvo para la proteinorraquia una mediana de 0,7 g/L (rango 0,1-3,5), de 38 mg/dL (rango 12-75) para la glucorraquia y de 127 meq/L (rango 130-143) para la clorurorraquia. La determinación del antígeno capsular, disponible para 7 muestras de LCR y sangre, mostró una mediana de 1/1.000, con valores más elevados en sangre. Las características del LCR de los pacientes examinados con criptococosis asociada al SIDA no revelaron, al menos en los parámetros evaluados, alteraciones diferentes a las mencionadas en la literatura.

Cerebrospinal fluids (CSF) of 44 patients with cryptococcosis associated with Acquired Immunodeficiency Syndrome (AIDS), treated in the Ward XI of the Muñiz Hospital from January 2000 to December 2004, were retrospectively analyzed. The physical, chemical, cytological and mycological characteristics of CSF obtained by lumbar puncture at the moment of admission were taken into account in each case. India ink microscopy was positive in 38 (90.5%) out of 42 patients and the remainning 6 patients were diagnos- ed by cultures and/or determination of capsular antigen of Cryptococcus neoformans. At physical examination, 29 (69%) out of 42 samples showed a limpid aspect and the remaining 13 were hemorrhagic (n=3), opalescent (n=6), xanthochromic (n=3) or turbid (n=1). Chemically, the median of proteinorraquia was 0.7 g/L (range 0.1-3.5 g/L), 38 g/L (range 12-75 g/L) for glycorrhachia and 127 meq/L (range 130-143 mEq/L) for clorurorrachia. The capsular antigen of Cryptococcus neoformans, available for 7 CSF and blood samples, showed a median of 1/1.000 in both, with higher values in blood than in CSF. The CSF of patients with AIDS associated cryptococcosis evaluated in the present study did not reveal important differences, at least in the evaluated parameters, with respect to those cited in the literature.

Cryptococcus neoformans shows a remarkable genotypic diversity in Brazil.

The genotypic diversity of Brazilian Cryptococcus neoformans strains was analyzed. The majority of the samples were alphaA (65%), followed by alphaB (17.5%), alphaD (9%), alphaAaD hybrids (5%), and alphaC (3.5%). A considerable genotypic diversity occurred within C. neoformans var. grubii, and a new amplified fragment length polymorphism genotype, 1B, was recognized.

The spectrum of computerized tomography (CT) findings in central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii in immunocompetent children.

Cranial CT scans of eleven immunocompetent children with central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii were retrospectively reviewed. These children had an average age of 8.8 years and positive culture for C. n. var. gattii in cerebrospinal fluid. The most common signs and symptoms were headache, fever, nuchal rigidity, nausea and vomiting. No normal cranial CT was detected in any patient. Hypodense nodules were observed in all patients. The remaining scan abnormalities were as follows: nine had diffuse atrophy, six had hydrocephalus, and five had hydrocephalus coexistent with diffuse atrophy.

[Hemichorea-hemiballism associated to cryptococcal granuloma in a patient with AIDS: case report]. / Hemicoréia-hemibalismo associado a granuloma criptocócico em paciente com SIDA: relato de caso.

Movement disorders are not common in acquired immunodeficiency syndrome. Hemichorea-hemiballism (HC-HB) is the most common of them all, and it is usually related to oportunistic toxoplasmosis of the basal ganglia. We present a 28-year-old man, HIV positive with HC-HB caused by a right subthalamic granuloma, which did not respond to treatment for toxoplasmosis. Cryptoccococic antigen was positive in the cerebrospinal fluid and antifungic therapy led to clinical and radiologic improvement, thus the diagnosis of a granulomatous lesion by Cryptococcus neoformans was established. Current literature on HC-HB and its relationship with AIDS is subsequently reviewed.

[The clinical laboratory characteristics of 104 cases of cryptococcal meningoencephalitis]. / Características clínicas laboratoriais de 104 casos de meningoencefalite criptocócica.

With the purpose of describing the clinical and laboratory characteristics of cryptococcus meningoencephalitis, we reviewed the records of 104 patients admitted with this diagnosis at Couto Maia Hospital, reference for patients with infectious diseases in Salvador-BA Northeastern Brazil, from 1972 to 1996. The patients' age varied from 8 months to 79 years. Sixty-four (61.5%) patients were male. The duration of the disease varied from 2 to 150 days, average 27.7 days. The most common signs and symptoms were headache (92.7%), fever (84.4%) and neck stiffness (83.2%). The cell number in cerebrospinal fluid was greater than 4/mm > or = in 95.8% of the patients with lymphocyte predominance in 86.3% of the cases. The lethality rate was 42.7%.

Aspectos clínicos y microbiológicos en un paciente inmunocompetente con criptococosis del sistema nervioso central / Clinical and microbiological aspects in an immunocompetent patient with cryptococcosis of the central nervous system

Se realizó la presentación de un caso con criptococosis con localización en el sistema nervioso central en un paciente joven e inmunocompetente, atendido en el Instituto Superior de Medicina Militar "Dr. Luis Díaz Soto". Dicho paciente presentó inicialmente un cuadro de meningoencefalitis aguda, la que posteriormente evolucionó a una encefalitis crónica con secuelas cerebrales. Se demostró la causa micótica del proceso mediante estudio microbiológico del líquido cefalorraquídeo en el que se diagnosticó la presencia de Cryptococcus neoformans como agente causal. No se comprobaron otras localizaciones del hongo en el paciente. Se describieron y actualizaron aspectos clínicos y microbiológicos de la enfermedad(AU)

Cerebrospinal fluid profiles in acquired immunodeficiency syndrome with and without neurocryptococcosis

A criptococose e uma das infeccoes fungicas mais comuns do sistema nervoso central (SNC) em pacientes com Sindrome da Imunodeficiencia Adquirida (SIDA), sendo meningoencefalite ou meningite manifestacoes frequentemente observadas. Apesar disso, poucos sao os estudos sistematicos sobre a composicao do liquido cefalo-raquidiano (LCR) de pacientes com SIDA e neurocriptococose. No presente estudo, foram analisadas amostras de LCR de 114 pacientes soropositivos para HIV, com queixa clinica sugestiva de envolvimento do SNC, sendo 32 com neurocriptococose (Grupo 1) e 82 sem doenca neurologica identificada (Grupo 2). Considerando os resultados citologicos e bioquimicos, dois perfis liquoricos foram observados...

Cerebrospinal fluid profiles in acquired immunodeficiency syndrome with and without neurocryptococcosis.

Cryptococcosis is one of the most common fungal infections of the central nervous system (CNS) in AIDS patients and meningoencephalitis or meningitis is a frequently observed manifestation. However, systematic studies of cerebrospinal fluid (CSF) composition from AIDS patients with CNS cryptococcosis have been few. CSF samples from 114 HIV seropositive patients whose clinical complaint suggested CNS involvement, were analyzed; 32 samples from patients diagnosed as having neurocryptococcosis (Group 1) and 82 samples from patients with no identified neurological disfunction (Group 2). Based on cytological and biochemical results, two distinct profiles were observed: Normal (Group 1 = 31%, Group 2 = 39%); Abnormal (Group 1 = 69%, Group 2 = 61%). Lymphocytes were the most frequent cells in both groups. Our CSF cytological and biochemical findings showed that in AIDS patients liquoric abnormalities are quite frequent, non-specific and difficult to interpret. In these circumstances a systematic search to identify the etiologic agent using microbiological and/or immunological assays must be routinely performed.

Modified India ink preparation for Cryptococcus neoformans in cerebrospinal fluid specimens.

A novel modified India ink technique for the diagnosis of Cryptococcus neoformans in cerebrospinal fluid specimens is described. It employs 2% chromium mercury and India ink. This technique allows a clear identification of some external and internal structures of the organism. Three layers from the outer capsule that have previously been discerned only by electron microscopy are distinguished.

Estudo comparativo do LCR de pacientes com neurocriptococose sem AIDS e com AIDS

Ate a decada de 80, antes do surgimento da AIDS, a criptococose era relativamente rara. Verificou-se que esta doenca afeta muito frequentemente os pacientes com AIDS e pode ser a primeira manifestacao desta sindrome. O objetivo deste trabalho e o de comparar o resultado dos exames das amostras de LCR inicial na meningencefalite por criptococo entre pacientes com e sem AIDS. Este trabalho e baseado no estudo de 41 pacientes com neurocriptococose sem AIDS e de 23 pacientes com neurocriptococose e AIDS. Este estudo permitiu verificar que a reacao inflamatoria, no sistema nervoso, quando presente, foi de menor intensidade nos pacientes com AIDS; a reacao inflamatoria esteve presente em todos os pacientes sem AIDS e ausente em 21,7 por cento dos pacientes com AIDS...

Neurocriptococose por Cryptococcus neoformans näo capsulado / Neurocryptococcosis due to non capsulated Cryptococcus neoformans

Os autores registram um caso de neurocriptococose em paciente HIV-positivo, por Cryptococcus neofarmans acapsulado ou deficiente em cápsula. O quadro neurológico era de meningoencefalite subaguda, compatível ao diagnóstico de neurotuberculose, pelo exame do líquido cefalorraqueano (LCR). Estruturas leveduriformes foram encontradas no interior de macrófagos, ao exame citomorfológico do LCR. Cultivo do sedimento do LCR revelou a presença de Cryptococcus neoformans näo capsulado (identificaçäo bioquímica). A inoculaçäo da amostra em camundongo, por via intraperitoneal, permitiu a produçäo de cápsula que desaparecia em cultivos. Foi estudada a micromorfologia do fungo à microscopia eletrônica de varredura. A evoluçäo foi favorável com o emprego da anfotericina B associada a 5-fluoreocitosina. Näo foi caracterizada a variedade de Criptococcus neoformans agente do processo