Cryptococcus tetragattii Meningitis Associated with Travel, Taiwan.

Meningitis caused by Cryptococcus tetragattii fungus is rare and has been found in specific geographic regions. We report a case of meningitis caused by C. tetragattii (molecular type VGIV) in an immunocompetent patient in Taiwan. The patient had traveled to Egypt and was positive for granulocyte-macrophage colony-stimulating factor autoantibody.

[Undistinguishable Cryptococcus-related granulomatous lesion from carcinoma in the tail of the pancreas: a case report].

Abdominal computed tomography revealed a 19×13mm delayed enhancing mass and dilation of the distal pancreatic duct in the head of the pancreas. Magnetic resonance cholangiopancreatography showed pancreatic duct stenosis in the tail of the pancreas. Endoscopic retrograde pancreatography revealed an abrupt interruption of the main pancreatic duct at the tail of the pancreas. We could not assess the distal side of the pancreatic stenosis due to the large extent of obstruction. The pancreatic head mass was diagnosed as adenocarcinoma using endoscopic ultrasound-fine needle aspiration biopsy. However, we could not determine whether the pancreatic duct stenosis in the tail of the pancreas was malignant. Nevertheless, we performed a total pancreatectomy with splenectomy. Histological examination showed poorly differentiated adenocarcinoma in the pancreatic head mass but the pancreatic duct stenosis in the tail of the pancreas was diagnosed as pancreatic granuloma caused by Cryptococcus. Fungal infections may reportedly promote the development of pancreatic cancer, as further suggested by this case of cryptococcal infection.

Modification of Hinge/Transmembrane and Signal Transduction Domains Improves the Expression and Signaling Threshold of GXMR-CAR Specific to Cryptococcus spp.

Chimeric antigen receptors (CARs) redirect T cells to recognize a specific target. CAR components play a pivotal role in antigen specificity, structure stability, expression on cell surface, and induction of cellular activation, which together determine the success of CAR T-cell therapy. CAR products targeting B-cell lymphoma encouraged the development of new CAR applications beyond cancer. For example, our group developed a CAR to specifically target glucuronoxylomannan (GXM) in the capsule of Cryptococcus species, called GXMR-CAR or GXMR-IgG4-28ζ. Cryptococcus are fungi that cause the life-threatening disease cryptococcosis, and GXMR-IgG4-28ζ redirected T cells to target yeast and titan cell forms of Cryptococcus spp. Here, we replaced the IgG4-hinge and CD28-transmembrane domains from GXMR-CAR with a CD8α molecule as the hinge/transmembrane and used CD28 or 4-1BB molecules as co-stimulatory domains, creating GXMR-8-28ζ and GXMR-8-BBζ, respectively. Jurkat cells expressing GXMR-CAR containing CD8α as the hinge/transmembrane improved the CAR expression and induced a tonic signaling. GXMR-8-28ζ and GXMR-8-BBζ induced high levels of IL-2 and up-regulation of CD69 expression in the presence of reference strains of C. neoformans and C. gattii. Moreover, GXMR-8-28ζ and GXMR-8-BBζ showed increased strength in response to incubation with clinical isolates of Cryptococcuss spp., and 4-1BB co-stimulatory domain triggered a more pronounced cellular activation. Dasatinib, a tyrosine kinase inhibitor, attenuated the GXMR-CAR signaling cascade's engagement in the presence or absence of its ligand. This study optimized novel second-generation GXMR-CARs containing the CD8-hinge/transmembrane domain that improved CAR expression, antigen recognition, and signal strength in T-cell activation.

Infections of Cryptococcus species induce degeneration of dopaminergic neurons and accumulation of α-Synuclein in Caenorhabditis elegans.

Cryptococcosis in the central nervous system (CNS) can present with motor declines described as Parkinsonism. Although several lines of evidence indicate that dopaminergic (DA) neuron degeneration and α-synuclein accumulation contribute to the hallmark of Parkinsonism and Parkinson's disease (PD), little is known about cryptococcal infections associated with neuronal degeneration. In this study, the effects of Cryptococcus neoformans and C. gattii infections on dopaminergic neuron degeneration, α-synuclein accumulation, and lifespan in Caenorhabditis elegans were investigated. The results showed that cryptococcal infections significantly (P<0.05) induced DA neuron degeneration similar to a selective cathecholamine neurotoxin 6-hydroxydopamine (6-OHDA) in C. elegans (BZ555 strain) when compared to mock infected controls. Cryptococcal infections also significantly (P< 0.05) induced α-synuclein aggregation in C. elegans (NL5901 strain). Moreover, lifespan of the infected worms was significantly decreased (P<0.0001). In conclusion, DA neurodegeneration and α-synuclein accumulation are associated with lifespan reduction during cryptococcal infection in C elegans.

Metagenomic next-generation sequencing assists in the diagnosis of Cryptococcus pneumonia: Case series and literature review.

Background: Pulmonary cryptococcosis (PC) was once thought to occur only in patients with immune deficiencies, such as tested positive for the Human Immunodeficiency Virus (HIV). However, in recent years, it has been discovered that more than half of the patients with PC in our nation are individuals with normal immune function. As more and more PC cases are recorded, our diagnosis and treatment approaches, as well as our understanding of PC, are gradually improving. In reality, most PC patients still have a high incidence of misdiagnosis on their initial visit. It is primarily linked to the diverse clinical manifestations, atypical imaging findings, and inaccurate diagnostic approaches. Methods: The research was conducted from 2019 to 2020. We performed traditional microbiological testing and mNGS on sample from patients with fever of Pulmonary nodules or lung infections. Furthermore, we collected patients' baseline information, clinical features, laboratory and imaging examination results, diagnosis, treatment and outcome. In the end, we confirmed three cases of PC using biopsy and mNGS. Conclusion: Our data demonstrates that mNGS can be utilized as an auxiliary method for PC diagnosis. Early mNGS aids in the identification of pathogens, enabling early diagnosis and treatment, as well as a reduction in the rate of misdiagnosis and illness progression.

Taxonomy of Pathogenic Yeasts Candida, Cryptococcus, Malassezia, and Trichosporon.

This review describes the changes in yeast species names in the previous decade. Several yeast species have been reclassified to accommodate the "One fungus=One name" (1F=1N) principle of the Code. As the names of medically important yeasts have also been reviewed and revised, details of the genera Candida, Cryptococcus, Malassezia, and Trichosporon are described in Section 3, along with the history of name changes. Since the phylogenetic positions of Candida species in several clades have not been clarified, revision of this species has not been completed. Among the species that remain unrevised despite their importance in the medical field, we propose the transfer of six Candida species to be reclassified in the Nakaseomyces clade, including Nakaseomyces glabratus and Nakaseomyces nivalensis.

PAMPs and Host Immune Response in Cryptococcal Infection.

Cryptococcus spp. are yeast-type opportunistic fungal pathogens with thick polysaccharide capsules that infect the lungs via airborne routes and frequently cause fatal meningoencephalitis. The cellular immune mechanism plays a central role in controlling cryptococcal infection and is critically regulated by Th1-Th2 immune balance. Pathogens that have invaded the host are recognized by innate immune cells, and appropriate immune responses are initiated. Pathogen-associated molecular patterns (PAMPs) are recognized by macrophages and dendritic cells via pattern recognition receptors (PRRs), which trigger the inflammatory responses as the first line of host defense. Some PRRs, such as Toll-like receptors (TLRs), NOD-like receptors (NLRs), and C-type lectin receptors (CLRs), are involved in the recognition of cryptococcal components, such as glucuronoxylomannan (GXM), mannoproteins (MPs), and nucleic acids. However, some cryptococcal cell components suppress the host immune response. This review will highlight the cryptococcal components involved in host immune responses. Future research is expected to promote the understanding of the mechanism of host immune response to Cryptococcus, which will lead to the development of new vaccines and therapies for cryptococcal infection.

Espectro de coinfecciones pulmonares fúngicas oportunistas en COVID-19: lo que el radiólogo debe saber / Spectrum of opportunistic fungal lung co-infections in COVID-19: What the radiologist needs to know

Las coinfecciones pulmonares fúngicas asociadas a la COVID-19 pueden ocurrir en pacientes gravemente enfermos o con comorbilidades subyacentes e inmunosupresión. Las infecciones fúngicas invasivas más comunes son causadas por aspergilosis, mucormicosis, y las debidas a Pneumocystis, criptococo y cándida. Los radiólogos integran las características clínicas de la enfermedad con el enfoque basado en patrones de TAC y desempeñan un papel crucial en la identificación de estas coinfecciones en la COVID-19 para ayudar a los médicos a realizar un diagnóstico seguro, iniciar el tratamiento y prevenir complicaciones.(AU)

Fungal lung co-infections associated with COVID-19 may occur in severely ill patients or those with underlying co-morbidities, and immunosuppression. The most common invasive fungal infections are caused by aspergillosis, mucormycosis, pneumocystis, cryptococcus, and candida. Radiologists integrate the clinical disease features with the CT pattern-based approach and play a crucial role in identifying these co-infections in COVID-19 to assist clinicians to make a confident diagnosis, initiate treatment and prevent complications.(AU)

Clinical performance of the IMMY cryptococcal antigen lateral flow assay in dogs and cats.

BACKGROUND: Cryptococcal lateral flow antigen assays (CLFAs) have been assessed in comparison to the latex cryptococcal antigen agglutination test but their clinical performance is unknown. OBJECTIVE: Determine clinical performance of IMMY CLFA (Immuno-Mycologics Inc, Oklahoma) using patients with and without cryptococcosis as the reference standard. ANIMALS: One-hundred ninety-seven serum samples from client-owned dogs and cats. METHODS: Review of medical records of a referral population of dogs and cats that had CLFA performed between 2012 and 2020. Animals were classified as cryptococcosis positive (Cr+) or negative (Cr-) based on clinical information. Clinical diagnosis was used to calculate positive and negative percent agreement of the CLFA. RESULTS: Twelve specimens (4 canine, 8 feline) were obtained from Cr+ animals and had positive CLFA results. One-hundred eighty-five specimens (139 canine, 46 feline) were collected from Cr- animals. Negative CLFA results were recorded in 129 canine and 44 feline Cr- samples. Positive CLFA results were noted for 10 canine and 2 feline Cr- samples. Positive percent agreement of CLFA was 100% (confidence interval [CI], 39.8%-100% dogs; 63.1%-100% cats). Negative percent agreements were 92.8% (CI, 87.2%-96.5%) for dogs and 95.7% (CI, 85.2%-99.5%) for cats. CONCLUSIONS AND CLINICAL IMPORTANCE: A negative IMMY CLFA result enables reliable exclusion of cryptococcal infection in dogs and cats. By contrast, a positive result must be interpreted cautiously and further testing should be performed to verify a diagnosis of cryptococcosis.

Clinical utility of cryptococcal antigen detection in transthoracic needle aspirate by lateral flow assay for diagnosing non-HIV pulmonary cryptococcosis: A multicenter retrospective study.

Lateral flow immunoassay (LFA) detection of cryptococcal capsular polysaccharide antigen (CrAg) is reported to be the most rapid and convenient laboratory method for diagnosing cryptococcosis. Its clinical diagnostic use, however, is not well studied. We retrospectively analyzed the data from 97 patients with suspected pulmonary cryptococcosis (PC) at 2 tertiary care centers. CrAg in both serum and lung aspirate specimens were examined by LFA. We divided the patients who were diagnosed with PC into group I, patients positive for CrAg in both the serum and lung aspirate, and group II, patients positive for CrAg in the lung aspirate but not in the serum. We analyzed the differences in imaging distribution, morphological characteristics, and concomitant signs between the 2 groups. Of all 97 patients, 47 were diagnosed with PC. Lung aspirates were positive for CrAg in 46/47 patients with PC (sensitivity 97.9%, specificity 100%, positive predictive value = 100%, negative predictive value = 98%). There were no false positive results in the noncryptococcosis patients, revealing a diagnostic accuracy of 99%. Serum CrAg tests were positive in 36/47 patients with PC (sensitivity 76.6%, specificity 100%, accuracy 88.7%, positive predictive value = 100%, negative predictive value = 82%). Chest imaging data showed a statistically significant greater number of single lesions in group II than in group I (P < .05). More lesions accompanied by halo signs were showed in group I (P < .01), whereas more accompanied by pleural stretch signs were found in group II (P < .01). The LFA-positive rate of CrAg in lung aspirate samples was higher than that of the serum samples, especially in patients with single pulmonary lesion or in those accompanied by pleural stretch. The direct measurement of CrAg in lung aspirate is a rapid, useful alternative diagnostic method for PC confirmation.

The global burden of HIV-associated cryptococcal infection in adults in 2020: a modelling analysis.

BACKGROUND: Cryptococcal meningitis is the most common cause of meningitis in adults living with HIV in sub-Saharan Africa. The estimates of national, regional, and global burden of cryptococcal meningitis are essential to guide prevention strategies and determine needs for diagnostic tests and treatments. We present a 2020 estimate of the global burden of HIV-associated cryptococcal infection (antigenaemia), cryptococcal meningitis, and cryptococcal-associated deaths. METHODS: We defined advanced HIV disease as adults with a CD4 count of less than 200 cells/µL, as this group is at highest risk for cryptococcosis. We used UNAIDS estimates (2019-20) and population-based HIV impact assessment surveys (2016-18) to estimate the number of adults with CD4 counts of less than 200 cells/µL at risk for cryptococcosis, by country and region. Secondly, we summarised cryptococcal antigenaemia prevalence in those with a CD4 count of less than 200 cells/µL by reviewing published literature. Thereafter, we calculated the number of cryptococcal antigen (CrAg)-positive people in each country and region by multiplying the number with advanced HIV disease at risk for cryptococcal infection by the cryptococcal antigenaemia prevalence of the respective country or region. We estimated progression from cryptococcal antigenaemia to meningitis or death based on estimates from the published literature. FINDINGS: We estimated that there were 4·3 million (IQR 3·0-4·8) adults with HIV and CD4 counts of less than 200 cells/µL globally in 2020. We calculated a mean global cryptococcal antigenaemia prevalence of 4·4% (95% CI 1·6-7·4) among HIV-positive people with CD4 counts of less than 200 cells/µL, corresponding to 179 000 cases (IQR 133 000-219 000) of cryptococcal antigenaemia globally in 2020. Annually, we estimated that there are 152 000 cases (111 000-185 000) of cryptococcal meningitis, resulting in 112 000 cryptococcal-related deaths (79 000-134 000). Globally, cryptococcal disease accounts for 19% (13-24) of AIDS-related mortality. INTERPRETATION: Despite a reduction in the estimated absolute global burden of HIV-associated cryptococcal meningitis compared with 2014, likely to be due to antiretroviral therapy expansion, cryptococcal disease still accounts for 19% of AIDS-related deaths, similar to 2014 estimates. To end cryptococcal meningitis deaths by 2030, cryptococcal diagnostics, meningitis treatments, and implementation of preventive screening are urgently needed. FUNDING: None.

Investigation of CryptoPS LFA-positive sera in patients at risk of cryptococcosis.

Cryptococcal antigen (CrAg) is a capsule polysaccharide antigen that can be detected in the fluids of patients with cryptococcal infections. Cryptococcal Antigen Latex Agglutination System (CALAS), enzyme-linked immunosorbent assays (EIA), and lateral flow assay (LFA) are the main methods available. Two main commercial LFA kits are available: CryptoPS (Biosynex, Illkirch Graffenstaden, France) and CrAg LFA (IMMY, Inc. USA). In our lab, we prospectively used CryptoPS as a screening tool in serum for confirmed positive results with CALAS. We investigated the rigor of the CryptoPS test in serum in a multicentric evaluation over 3 years. To improve the specificity of CryptoPS in serum, we additionally implemented and evaluated a pretreatment protocol before CryptoPS testing. A total of 43 serum samples collected from 43 patients were investigated. We found that the CryptoPS assay is hampered by a high rate of false-positive results in serum with a high rate of CryptoPS-positive but CrAg LFA-negative and CALAS-negative sera in patients with no proof of Cryptococcus infection (n = 29). Using a simple pretreatment procedure (5 min incubation at 100°C and centrifugation) we were able to reverse false-positive results, suggesting that there could be interferent material present in the serum. Pretreatment also impacted the CryptoPS results (negative result) in two patients with the cryptococcal disease, one with isolated antigenemia and one with cryptococcal meningitis. Comparing the titers obtained with CALAS and CrAg LFA, we noticed that the titer obtained with CrAg LFA was almost 10-fold higher than those with CALAS. This study showed that Biosynex CryptoPS in serum could give false-positive results even in the absence of cryptococcal disease. These could be reduced by applying an easy pretreatment procedure to the serum before testing, with little but existing impact on the sensitivity.

Lateral flow assays are useful to detect the cryptococcal antigen in human fluids. We investigated CryptoPS-positive results and observed that true false-positive results occurred. The false-positive results can be reduced by applying an easy pretreatment procedure.

Pulmonary Co-infection with Cryptococcus Species and Pneumocystis jirovecii in an Old Patient Without a Previous Predisposing Illness.

BACKGROUND: Cryptococcosis and pneumocystosis are opportunistic infections which are more common in immunosuppressed individuals. Herein, we report a rare case of coinfection of pulmonary cryptococcosis (PC) and Pneumocystis jirovecii pneumonia (PJP) in a patient without a previous predisposing illness. Case presentation A 76-year-old man was admitted to our hospital with complaints of cough, expectoration, shortness of breath, and fever. A chest computed tomography (CT) showed multiple nodules with diffuse ground-glass opacities (GGOs) in both lungs. The patient was diagnosed as extrinsic allergic alveolitis (Pigeon breeder's lung). After treatment with corticosteroids, the patient improved with significant absorption of GGOs on chest CT. However, pulmonary nodules gradually enlarged and such lesions could not be explained by EAA. Based on the positivity of serum cryptococcal antigen and pathological examination of lung nodule which confirmed the presence of Cryptococcus spores, PC was diagnosed later and fluconazole was administered. However, repeated chest CT performed about 2 months after antifungal treatment showed significantly increased GGOs in both lungs. The pathological examination of new lung lesions revealed the presence of P. jirovecii. The patient was finally diagnosed having coinfection of PC and PJP and sulfamethoxazole was further prescribed. Thereafter, the patient improved again with significant absorption of GGOs as noted on chest CT. CONCLUSIONS: Concomitant PC and PJP is very rare, especially in a patient without a previous predisposing illness. Additionally, when pulmonary lesions cannot be completely explained by one kind of infectious disease, the possibility of mixed infection should be considered.

Cryptococcal Antigen Screening and Missed Opportunities for Earlier Diagnosis Among People With HIV and Poor Virologic Control in the Bronx, NY.

BACKGROUND: There is no established cryptococcal antigen (CrAg) screening guideline for people with HIV who are antiretroviral therapy experienced but have poor virologic control. We assessed factors associated with CrAg screening and describe missed opportunities for earlier testing. SETTING: Ambulatory clinics affiliated with Montefiore Medical Center, Bronx, NY. METHODS: This was a retrospective chart review of CrAg screening among asymptomatic people with HIV with absolute CD4 counts 200 cells/mm 3 and HIV viral loads (VLs) > 200 copies/mL receiving HIV care from 2015 to 2020. We used Cox proportional hazards regression to identify predictors of screening, including longitudinal CD4 count and HIV VL as time-varying covariables. Among cases of diagnosed cryptococcosis, we assessed for opportunities for earlier diagnosis. RESULTS: Screening CrAg was performed in 2.9% of 2201 individuals meeting the inclusion criteria. Compared with those not screened, those who were screened had a shorter duration of HIV infection (0.09 vs. 5.1 years; P = 0.001) and lower absolute CD4 counts (12 vs. 24 cells/mm 3 ; P < 0.0001). In a multivariable model stratified by median HIV duration, CD4 < 100 [hazard ratio (HR), 7.07; 95% confidence interval (CI): 2.43 to 20.6], VL > 10,000 (HR, 15.0; 95% CI: 4.16 to 54.0), and a shorter duration of HIV infection (HR, 0.60; 95% CI: 0.42 to 0.86) were associated with screening for those with HIV < 5 years. Among those diagnosed with cryptococcosis (n = 14), 6 individuals had an ambulatory visit in the preceding 6 months but did not undergo screening. CONCLUSION: CrAg screening was infrequently performed in this at-risk population. Those with a longer duration of HIV infection were less likely to undergo CrAg screening, highlighting potential missed opportunities for earlier diagnosis.

Diagnostic Accuracy of Point of Care Cryptococcal Antigen Lateral Flow Assay in Fingerprick Whole Blood and Urine Samples for the Detection of Asymptomatic Cryptococcal Disease in Patients with Advanced HIV Disease.

Cryptococcal disease (CD) is a leading cause of mortality among individuals with advanced HIV disease (AHD). Screening with serum cryptococcal antigen (sCrAg) lateral flow assay (LFA) enables early detection of subclinical disease but requires venipuncture and laboratory processing. Clinic-based point of care (POC) CrAg screening tests using urine or fingerprick whole blood could facilitate early diagnosis of CD. We evaluated the diagnostic performance of POC clinic-based fingerprick whole blood and urine CrAg compared to the gold standard laboratory sCrAg LFA in screening for CD among asymptomatic individuals with CD4 counts of <200 cells/µL in Harare, Zimbabwe. sCrAg positive participants who consented to a lumbar puncture also had cerebrospinal fluid (CSF) CrAg testing and titers for CSF-positive specimens. A total of 1,333 individuals were screened, and over half (56.6%) were males. The median (interquartile range) CD4 count was 27.5 (11-46) cells/µL. We found a sensitivity of 63.8% (95% CI: 54.8-72.1) and specificity of 84.0% (95% CI: 81.7-86.0) for urine CrAg, and a sensitivity of 48.0% (95% CI: 39.1-57.1) and specificity of 99.5% (95% CI: 98.9-99.8) was found for fingerprick whole blood. The sensitivity of both POC CrAg tests increased in individuals with sCrAg titers of ≥1:160, CD4 count of <50 cells/µL and disseminated central nervous system (CNS) disease. Clinic-based POC urine and fingerprick whole blood CrAg testing performed better in screening for CD among AHD patients with CNS disease. More sensitive assays to identify AHD patients with asymptomatic CD are needed. IMPORTANCE Cryptococcal disease (CD) remains a leading cause of morbidity and mortality among individuals with advanced HIV disease (AHD). Identifying point of care (POC) approaches to screening for CD in asymptomatic individuals is important to guide therapeutic management. We evaluated the use of POC fingerprick whole blood and urine testing for cryptococcal disease in patients with AHD as compared with laboratory-based serum antigen testing. POC fingerprick whole blood and urine testing had low sensitivity and specificity in asymptomatic individuals with AHD. Most analysis has focused on evaluating test performance in symptomatic individuals. Here we show that POC testing with whole blood and urine samples should not be used to screen for asymptomatic CD in AHD.

Integrated healthcare approach can curb the increasing cases of cryptococcosis in Africa.

Cryptococcosis is a neglected tropical infection and a major cause of morbidity and mortality, especially in HIV-positive persons in Africa. Efforts to manage HIV infection have not had any significant impact on the fatalities due to cryptococcosis. An integrated healthcare approach that includes universal care coverage for Africans, expanded national care guidelines to include CrAg screening for vulnerable groups in all African countries, collaborative research, infection surveillance, and data sharing within Africa will mark a turnaround point.