Association between neuroimaging and clinical outcomes in individuals with central nervous system cryptococcosis.

BACKGROUND: The radiological manifestations of central nervous system (CNS) cryptococcosis are diverse and often subtle. There is heterogeneity on how different neuroimaging patterns impact prognosis. This study aims to assess the association between the neuroimaging and clinical outcomes of CNS cryptococcosis. METHODS: All patients with CNS cryptococcosis between July 2017 and April 2023 who underwent brain magnetic resonance imaging (MRI) were included. The primary outcome was mortality during hospitalisation. Secondary outcomes were readmission, ventricular shunting, duration of hospitalisation and time to the first negative cerebrospinal fluid culture. We compared the outcomes for each of the five main radiological findings on the brain MRI scan. RESULTS: We included 46 proven CNS cryptococcosis cases. The two main comorbidity groups were HIV infection (20, 43%) and solid organ transplantation (10, 22%), respectively. Thirty-nine patients exhibited at least one radiological abnormality (85%), with the most common being meningeal enhancement (34, 74%). The mortality rates occurred at 11% (5/46) during hospitalisation. We found no significant disparities in mortality related to distinct radiological patterns. The presence of pseudocysts was significantly associated with the need for readmission (p = .027). The ventricular shunting was significantly associated with the presence of pseudocysts (p = .005) and hydrocephalus (p = .044). CONCLUSION: In this study, there is no association between brain MRI findings and mortality. Larger studies are needed to evaluate this important issue.

[Tomography guided biopsy for the diagnosis of pediatric pulmonary Cryptococcosis]. / Punción Biopsia guiada por tomografía para el diagnóstico de Cryptococcosis pulmonar pediátrica.

Pulmonary cryptococcosis is a lung infection caused by the Cryptococcus yeast. It is rare in pediatrics, especially in immunocompetent children. The diagnosis of pulmonary cryptococcosis can be challenging due to the low specificity of symptoms, low index of suspicion, and limited diagnostic resources. OBJECTIVE: To describe a clinical case of pulmonary cryptococcosis in an immunocompetent adolescent, detailing the diagnostic approach. CLINICAL CASE: A 15-year-old patient, previously healthy, from a rural town, who consulted due to cough and a 1-month rib stitch pain, without fever or associated respiratory difficulty, with two images of condensation in the left lung on the chest x-ray. In the Computed Tomography, the images showed a nodular appearance. Due to suspicion of neoplastic pathology, a Positron Emission Tomography was performed, which showed hypermetabolic nodular lesions. The tomographic characteristics could correspond to fungal or granulomatous involvement. Considering the images and epidemiological risk factors such as rural origin and contact with bird droppings, the possibility of a mycosis was considered. A lung needle biopsy was performed under tomographic guidance. Cryptococcus neoformans was identified in the microbiology laboratory culture. The patient received treatment with itraconazole and fluconazole with good clinical and imaging response after 10 months of therapy and follow-up. CONCLUSION: In immunocompetent patients with a nonspecific clinical presentation, images can guide the diagnosis of pulmonary cryptococcosis, and an etiological search is essential to confirm it. In our case, the CT-guided needle biopsy was of great diagnostic utility.

Rinoscopia como auxiliar no diagnóstico de criptococose felina: Relato de caso / Rhinoscopy as aid in the diagnosis of feline cryptococosis: case report

Criptococose é uma micose sistêmica não contagiosa que acomete, principalmente, felinos. O agente etiológico é uma levedura do gênero Cryptococcus sp., e a sua transmissão ocorre por via aerógena, com a inalação dos esporos que se alojam, principalmente, na cavidade nasal e pulmão. A forma nasal é a mais comum em felinos e as suas manifestações clínicas incluem edema nasofacial, eritema e secreção nasal. O diagnóstico pode ser realizado por meio de cultivo micológico, citologia, histologia e reação em cadeia polimerase. Neste artigo, é apresentado o relato de caso de um felino diagnosticado com criptococose, no qual o diagnóstico de triagem foi realizado por meio de rinoscopia. No atendimento inicial, o animal apresentava hiporexia, reflexo de deglutição constante, engasgos, odor acentuado em região nasal e crepitações pulmonares com evolução de três meses. O diagnóstico foi realizado com o emprego de rinoscopia, que identificou massa interna na região da mucosa nasofaríngea, com posterior biópsia e exame anatomopatológico. Após a confirmação diagnóstica, o paciente foi medicado com itraconazol 10 mg/kg SID, por 5 meses, e teve a resolução de todos os sinais clínicos apresentados. A criptococose deve ser considerada como diagnóstico, diferencial de alterações do sistema respiratório em felinos e a rinoscopia pode ser um recurso diagnóstico importante para auxiliar na conclusão e reconhecimento da enfermidade.(AU)

Cryptococcosis is a non-contagious systemic mycosis that primarily affects felines. Its etiological agent is a yeast of the genus Cryptococcus sp., and its transmission occurs through the air, by inhalation of spores that primarily lodge in the nasal cavity and lungs. The nasal form is the most common in felines and clinical manifestations include nasofacial edema, erythema and nasal discharge. Diagnosis can be made by means of mycological culture, cytology, histology and polymerase chain reaction. This article presents a case of a feline diagnosed with cryptococcosis, in which the screening diagnosis was performed by means of rhinoscopy. In the initial care, the animal presented hyporexia, constant swallowing reflex, choking, accentuated odor in the nasal region and pulmonary crackles with evolution of three months. The diagnosis was made using rhinoscopy, which identified an internal mass in the nasopharyngeal mucosa, and subsequent biopsy and anatomopathological examination. After diagnostic confirmation, the patient was medicated with itraconazole 10 mg/kg SID for 5 months and had resolution of all clinical signs presented. Cryptococcosis should be considered as a differential diagnosis of alterations in the respiratory system in cats and rhinoscopy can be an important diagnostic tool to assist in the conclusion and recognition of this disease.(AU)

[Vertebral cryptococosis. Case report and literature review]. / Criptococosis vertebral. Comunicación de un caso y revisión bibliográfica.

Cryptococcosis is an infectious disease caused by a ubiquitous encapsulated yeast called Cryptococcus neoformans, it is usually associated with immunosuppressed patients. Osteomyelitis occurs in 5-10%, the spine involvement is one of the most reported. The purpose of this work is to present a case of isolated vertebral cryptococcosis and detail the results of a literature review. The treatment protocol is not yet established but it is recommended to start with aggressive intravenous therapy and continue with a suppressive treatment orally during a variable time. Surgical indication is considered in lesions that affect the spinal stability, deformity or neurological compromise and for local infectious control.

Criptococosis vertebral: comunicación de un caso y revisión bibliográfica / Vertebral cryptococosis: case report and literature review

Resumen La criptococosis es una micosis sistémica producida por un hongo levaduriforme encapsulado denominado Cryptococcus neoformans. Es una enfermedad universal, que ocurre con mayor frecuencia en pacientes inmunocomprometidos, manifestándose principalmente como una enfermedad diseminada con compromiso meníngeo o pulmonar. Sin embargo, la osteomielitis ocurre solo en 5-10% de los casos, siendo el compromiso vertebral el más frecuente. Presentamos un caso de criptococosis vertebral aislada y una búsqueda bibliográfica sobre el tema. Se recomienda realizar una terapia antifúngica de inducción intravenosa y continuar con una fase de consolidación, vía oral, de duración variable. La indicación quirúrgica se considera en lesiones que comprometen la estabilidad vertebral y aquellas que presentan un compromiso neurológico, producen deformidad y para reducir el inóculo infeccioso.

Cryptococcosis is an infectious disease caused by a ubiquitous encapsulated yeast called Cryptococcus neoformans, it is usually associated with immunosuppressed patients. Osteomyelitis occurs in 5-10%, the spine involvement is one of the most reported. The purpose of this work is to present a case of isolated vertebral cryptococcosis and detail the results of a literature review. The treatment protocol is not yet established but it is recommended to start with aggressive intravenous therapy and continue with a suppressive treatment orally during a variable time. Surgical indication is considered in lesions that affect the spinal stability, deformity or neurological compromise and for local infectious control.

Endemic pulmonary fungal diseases in immunocompetent patients: an emphasis on thoracic imaging.

INTRODUCTION: Systemic endemic mycoses are prevalent in specific geographical areas of the world and are responsible for high rates of morbidity and mortality in these populations, and in immigrants and travelers returning from endemic regions. The most common fungal infections that can affect the lungs of immunocompetent patients include histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis, sporotrichosis, aspergillosis, and cryptococcosis. Diagnosis and management of these diseases remain challenging, especially in non-endemic areas due to the lack of experience. Therefore, recognition of the various radiologic manifestations of pulmonary fungal infections associated with patients' clinical and epidemiologic history is imperative for narrowing the differential diagnosis. Areas covered: This review discusses the clinical and radiological findings of the main endemic fungal diseases affecting the lungs in immunocompetent patients. Specific topics discussed are their etiology, epidemiology, pathogenesis, clinical manifestations, methods of diagnosis, pathology and main imaging findings, especially in computed tomography. Expert commentary: Imaging plays an important role in the diagnosis and management of pulmonary fungal infection and may reveal useful signs. Although definitive diagnosis cannot be made based on imaging features alone, the use of a combination of epidemiologic, clinical and imaging findings may permit the formulation of an adequate differential diagnosis.

Cryptococcoma mimicking a brain tumor in an immunocompetent patient: case report of an extremely rare presentation

ABSTRACT CONTEXT: Central nervous system (CNS) infectious diseases have high prevalence in developing countries and their proper diagnosis and treatment are very important for public health planning. Cryptococcus neoformans is a fungus that may cause several CNS manifestations, especially in immunocompromised patients. Cryptococcal meningitis is the most common type of involvement. Mass-effect lesions are uncommon: they are described as cryptococcomas and their prevalence is even lower among immunocompetent patients. The aim here was to report an extremely rare case of cryptococcoma causing a mass effect and mimicking a brain tumor in an immunocompetent patient. The literature on CNS cryptococcal infections was reviewed with emphasis on cryptococcomas. Clinical, surgical and radiological data on a female patient with this rare presentation of cryptococcoma mimicking a brain tumor are described. Case Report: A 54-year-old female patient presented to the emergency department with a rapid-onset progressive history of confusion and completely dependency for basic activities. Neuroimaging showed a left occipital lesion and neurosurgical treatment was proposed. From histopathological evaluation, a diagnosis of cryptococcoma was established. She received clinical support with antifungals, but despite optimal clinical treatment, her condition evolved to death. CONCLUSIONS: Cryptococcal infections have several forms of presentation and, in immunocompetent patients, their manifestation may be even more different. Cryptococcoma is an extremely rare presentation in which proper surgical and clinical treatment should be instituted as quickly as possible, but even so, there is a high mortality rate.

Cryptococcoma mimicking a brain tumor in an immunocompetent patient: case report of an extremely rare presentation.

CONTEXT: Central nervous system (CNS) infectious diseases have high prevalence in developing countries and their proper diagnosis and treatment are very important for public health planning. Cryptococcus neoformans is a fungus that may cause several CNS manifestations, especially in immunocompromised patients. Cryptococcal meningitis is the most common type of involvement. Mass-effect lesions are uncommon: they are described as cryptococcomas and their prevalence is even lower among immunocompetent patients. The aim here was to report an extremely rare case of cryptococcoma causing a mass effect and mimicking a brain tumor in an immunocompetent patient. The literature on CNS cryptococcal infections was reviewed with emphasis on cryptococcomas. Clinical, surgical and radiological data on a female patient with this rare presentation of cryptococcoma mimicking a brain tumor are described. CASE REPORT: A 54-year-old female patient presented to the emergency department with a rapid-onset progressive history of confusion and completely dependency for basic activities. Neuroimaging showed a left occipital lesion and neurosurgical treatment was proposed. From histopathological evaluation, a diagnosis of cryptococcoma was established. She received clinical support with antifungals, but despite optimal clinical treatment, her condition evolved to death. CONCLUSIONS: Cryptococcal infections have several forms of presentation and, in immunocompetent patients, their manifestation may be even more different. Cryptococcoma is an extremely rare presentation in which proper surgical and clinical treatment should be instituted as quickly as possible, but even so, there is a high mortality rate.

Criptococose intestinal em um cão: relato de caso / Intestinal cryptococcosis in a dog: a case report

A criptococose é uma micose sistêmica que em cães frequentemente está envolvida com lesões nos sistemas respiratório e nervoso central. O acometimento do sistema gastrointestinal por este fungo é considerada rara. O objetivo deste estudo é relatar um caso de criptococose intestinal em um cão, macho, da raça Boxer, de quatro anos, com histórico de êmese e diarreia sanguinolenta há cinco dias. Ao exame físico foi constatado dor abdominal e estrutura firme em região mesogástrica. Após realização de exame ultrassonográfico sugestivo de intussuscepção, realizou-se a celiotomia exploratória, e foi visualizada uma lesão nodular de 5 cm na parede do jejuno, retirada por enterectomia. O fragmento intestinal contendo a lesão foi encaminhado para análise histopatológica. Na macroscopia, a massa apresentava aspecto gelatinoso aos cortes, com superfície de corte compacta e tonalidade creme. No exame histopatológico, observou-se acentuada quantidade de estruturas leveduriformes, redondas ou ovoides, circundada por espessa cápsula, e discreto e difuso processo inflamatório mononuclear. A coloração pelo ácido periódico de Schiff (PAS) ajudou a confirmar a infecção pelo fungo do gênero Cryptococcus. Não foi possível dar continuidade ao caso, uma vez que o proprietário não retornou mais ao atendimento. Sugere-se que a porta de entrada da criptococose neste estudo, tenha sido através da ingestão da levedura desidratada, ou pela entrada do agente na extensa ulceração em jejuno, já que o mesmo pode ser encontrado em intestino delgado de cães saudáveis e de cães com enteropatia crônica. Conclui-se que, apesar da criptococose intestinal em cães ser considerada rara, recomenda-se a inclusão nos diagnósticos diferenciais de lesões que acometem os segmentos intestinais sem o envolvimento clínico de demais sistemas.(AU)

Cryptococcosis is a systemic mycosis and is often associated with lesions in the respiratory and central nervous systems in dogs. However, the involvement of the gastrointestinal system in this fungal infection is rare. This study reports a case of intestinal cryptococcosis in a 4-year-old male Boxer dog with a history of emesis and bloody diarrhea for five days. His physical examination revealed abdominal pain and a firm structure in the mesogastric region. After an ultrasound examination suggested intussusception, exploratory celiotomy was performed, and a 5 cm mass was visualized on the wall of the jejunum, which was subsequently removed by an enterectomy and sent for histopathological analysis. Macroscopically, the mass presented a gelatinous aspect, with a compact cut surface and cream shade. On histopathological examination, multiple leveduriform structures, round or ovoid, surrounded by a thick capsule, and discrete, diffuse mononuclear inflammatory processes were observed. Schiffs periodic acid staining confirmed the infection with a fungus of the genus Cryptococcus. It was not possible to continue the investigation because the owner did not return to the service. It is suggested that the entry point of cryptococcosis was through the ingestion of dehydrated yeast or through extensive jejunal ulceration, as it can be found in the small intestine of both healthy dogs and those with chronic enteropathy. Therefore, although intestinal cryptococcosis in dogs is rare, it is recommended to include it as a differential diagnosis for gastrointestinal lesions without the clinical involvement of other systems.(AU)

Cryptococcosis in non-HIV/non-transplant patients: A Brazilian case series.

Cryptococcosis is a classical systemic opportunistic mycosis, primarily occurring among patients with significant immunologic impairment. However, this disease could also affect patients without any recognized immunologic defects, that is, phenotypically normal patients. The medical records of 29 non-HIV/nontransplant patients with cryptococcal disease during the period 2007-2014 were retrospectively reviewed. The most common site of infection was the central nervous system (n = 25, 86.2%), followed by the pulmonary system (n = 11, 37.9%) and blood (n = 2, 6.8%). Thoracic- and brain-computed tomography demonstrated abnormalities of 81.2% (n = 13) and 62.5% (n = 15), respectively. In sum, 22% (n = 6) of the patients experienced a significant underlying condition. More than one therapeutic regimen was used in 77.8% (n = 21) of the patients. The isolates were identified as being Cryptococcus neoformans species complex (n = 4, 36.4%) and Cryptococcus gattii species complex (n = 7, 63.6%). The overall mortality was 20.7% (n = 6). Herein, we presented the first case series of cryptococcosis in this specific population in São Paulo City, Brazil. The incidence of cryptococcosis in our hospital has not increased in recent years, and 77.8% (n = 21) of cases had no obvious predisposing factor. However, this disease remains associated with high mortality.

[Cavitary pneumonia in an AIDS patient with cryptococcosis]. / Neumonía cavitada por Cryptococcus neoformans en un paciente con sida.

Pulmonary cryptococcosis is an unusual fungal infection that is most often found in AIDS or in organ transplant recipients. Although in immunocompromised patients, cryptococcal infection often causes pulmonary infections, the diagnosis of lung involvement is generally difficult. The presentation of pulmonary cryptoccosis in HIV-infected patients appears to be more acute and severe than in other immunocompromised patients, probably related with the severe immunosuppression. Diffuse infiltrates, mediastinal and hilar lymph nodes enlargement are the most common radiological findings in AIDS-associated pulmonary cryptococcosis. Cavitation is a rare form of and includes only 10% to 15% of all cases. Only a few case reports or studies with small number of patients of pulmonary cryptococcosis have been published over the past two decades. We report a case of an AIDS patient who developed cavitary pneumonia as the only clinical expression of cryptococcosis.

Cryptococcus gattii fungemia: report of a case with lung and brain lesions mimicking radiological features of malignancy.

A 64-year-old apparently immunocompetent white man developed lung and brain lesions of disseminated cryptococcosis. The radiologic features mimicked those of lung cancer metastatic to the central nervous system. C. gattii was recovered from cultures of bronchoalveolar lavage fluid, brain biopsy, and blood. The same fungus was recovered from pulmonary and brain specimens at autopsy. Serum and cerebrospinal fluid cryptococcal antigen tests were diagnostic in our case and should be included in the diagnostic evaluation of unexplained pulmonary and cerebral lesions. A literature search showed few reports of fungemia by this species of Cryptococcus, contrasting to C. neoformans.

Simultaneous chronic pulmonary paracoccidiodomycosis and disseminated cryptococcosis in a non-HIV patient.

An unusual case of chronic pulmonary paracoccidiodomycosis and disseminated cryptococcosis in a non-HIV infected patient is reported in a 72-year-old previously healthy man. A chest radiograph disclosed a bilateral diffused interstitial infiltrate involving middle and lower lung fields. Specimen samples taken from the tracheal tube revealed yeast-like organisms suggestive of Cryptococcus neoformans and Paracoccidiodes brasiliensis. Blood and cerebrospinal fluid culture was positive for C. neoformans and the immunodiffusion test against paracoccidiodin revealed a precipitation band. The patient died 24 days after the admission.