Professional Documents
Culture Documents
Cryptococcosis
John R. Perfect, MDa,*, Arturo Casadevall, MD, PhDb
a
Epidemiology
Varieties of C. neoformans
Cryptococcus neoformans strains classically have been grouped into two
varieties that included ve serotypes known as C. neoformans variety neoformans (serotypes A, D, and AD) and C. neoformans variety gattii (serotypes
B and C). The serotype dierences between the dierent varieties reect antigenic dierences resulting from dierences in the structure of the capsular
polysaccharide. The serotype classication of a strain is determined using
absorbed rabbit sera [1]. Some monoclonal antibodies are now available
that are useful for typing strains [2,3]. C. neoformans var. neoformans is
found throughout the world in association with excreta from certain birds
including pigeons, canaries, and cockatoos. C. neoformans var. gattii is
found primarily in tropical and subtropical regions and has been associated
with several species of eucalyptus trees.
After many years of stable taxonomic classication the availability of
DNA typing data has shown major dierences between isolates grouped
within a serotype and, as a consequence, there is now considerable uncertainty as to the exact relationship between the varieties and serotypes. The
situation is made more complex by the fact that C. neoformans has a sexual
cycle and that some strains are capable of mating with consequent genetic
recombination. Recently it was proposed to separate serotype A into a
dierent variety known as grubii on account of signicant genetic differences from serotype D [4]. The varietal status for the serotype AD strains
* Corresponding author.
E-mail address: perfe001@mc.duke.edu (J.R. Perfect).
The authors are supported by the National Institutes of Health with NIAID grants
AI33774, AI3342, and HL59842 (AC); and AI28388, AI49975, PA 98100, and AI39115 (JRP).
0891-5520/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 8 9 1 - 5 5 2 0 ( 0 2 ) 0 0 0 3 6 - 3
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records in Northern California for the years 1971 to 1980 in the pre-AIDS
era yielded only 10 cases with an overall incidence of 0.8 cases per million
persons per year [26]. Extrapolation of these numbers to calculate a rate for
the United States per year would have yielded 176 cases [26], which is not far
o from the estimates of 200 to 300 cases per year made in the 1960s [27]. A
retrospective analysis of the data at the Centers for Disease Control and
Prevention, however, revealed a steady rise in the number of identied cases
through serologic testing from 24 cases in 1965 to 336 in 1976 [27]. Whether
these numbers reected increased awareness of the infection, improvements
in serologic detection, or a true increase in the incidence of cryptococcosis
cannot be discerned from the information available. Nevertheless, it is clear
that in the 1970s there was an increasing recognition of cryptococcal disease,
which may have reected the beginning of the AIDS epidemic, the increasing use of organ transplantation to treat certain incurable diseases, and
progress in cancer therapy resulting in larger numbers of immune-suppressed survivors. A recent population-based study using active surveillance
has documented that the incidence of cryptococcosis in nonHIV-infected
individuals varies with geographic location and ranges from 0.2 to 0.9 per
100,000 in Atlanta and San Francisco, respectively [28]. An active surveillance study in Alabama found an overall annual incidence of 0.84 cases per
100,000 of cryptococcosis in nonHIV-infected individuals [29]. Rates of
cryptococcosis approaching 1 case per 100,000 in patients without HIV
infection are comparable with the incidence rates described for meningococcal meningitis [30].
After the recognition of the AIDS epidemic in 1981 cryptococcosis in
individuals without an obvious cause of immune impairment became an
AIDS-dening diagnosis. Many studies documented a high prevalence of
cryptococcosis in AIDS patients with rates ranging from 2.9% to 13.3%
[3137]. The annual incidence of cryptococcosis in patients with advanced
HIV infection in 1992 to 1994 was 17 and 66 per 1000 persons living with
AIDS in San Francisco and Atlanta, respectively [28]. These incidence numbers predate the introduction of more eective antiretroviral therapy, which
has been associated with a decline in the prevalence of cryptococcosis in this
population (see later).
Two other groups are at signicantly higher risk for cryptococcosis: cancer patients and recipients of organ transplants. Lymphoproliferative disorders were associated with an increased risk for cryptococcosis in the
1950s [38,39]. Subsequent studies have conrmed a continuing association
between cryptococcosis and hematologic malignancies [4042]. Although
prospective population-based incidence data for cryptococcosis in patients
with cancer are not available a retrospective analysis of case records at the
M.D. Anderson Cancer Center (Houston, TX) for the years 1989 to 1999
revealed an incidence of 18 cases per 100,000 admissions. Cryptococcosis
occurred in 2.8% of organ transplant recipients with an overall associated
mortality of 42% [43]. Kidney and liver transplant recipients seemed to be
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at high risk for cryptococcosis and there was a signicantly higher prevalence of C. neoformans infection among organ transplant recipients in the
Northeastern region of the United States [43]. Furthermore, both in corneal
and lung transplantation, the transplanted organ has carried the cryptococcal infection to the host [44,45].
Sources of infection
Cryptococcus neoformans var. gattii (serotype B) is found in several species of eucalyptus trees, whereas C. neoformans varieties neoformans (serotype D) and grubii (serotype A) have been isolated from various sources
including fruits, trees, and avian excreta [46]. There is general agreement
in the eld that most cryptococcal infections are acquired by inhalation of
infectious propagules. The specic source of infection and the form of C.
neoformans responsible for human infection, however, have not been denitively established. Encapsulated yeast cells of the type found in laboratory
cultures and in clinical isolates are thought to be too large to be inhaled eciently. Dehydrated yeast cells or basidiospores (<5 to 10 lm), however, are
suciently small for inhalation and alveolar deposition. Analysis of soils
contaminated with pigeon excreta has shown the presence of large numbers
of propagules with diameters compatible with alveolar deposition [47,48].
Air in sites heavily contaminated with pigeon excreta has also been shown
to contain viable cryptococci. Analysis of the air in a tower in Oklahoma
City contaminated with pigeon excreta revealed an average concentration
of 45 viable cells of C. neoformans cells per 100 L of air with approximately
60% of the cells being less than 5 lm in diameter [49]. Based on these numbers it was estimated that a human exposed to this air for 1 hour would have
41 C. neoformans cells deposited in the lungs [49]. Several studies have
shown that clinical isolates are indistinguishable by molecular typing from
environmental isolates [5052].
Direct evidence for human infection from either eucalyptus trees or
pigeon excreta is not yet available. The nding of viable C. neoformans cells
of size compatible with alveolar deposition in air from sites contaminated
with pigeon excreta and the association of DNA types in clinical- and
excreta-derived isolates, however, provides strong circumstantial evidence
implicating this material as a potential source of infection. There is one
well-documented case that suggests acquisition of C. neoformans infection
from a pet cockatoo [17]. It is advisable that individuals at risk for cryptococcosis avoid sites that are contaminated with pigeon excreta and desist
from having certain birds, such as pigeons, canaries, and cockatoos, as pets.
Although there is not a strong seasonal association for the occurrence of
cryptococcosis, some studies have noted a trend toward higher rates in the
fall and winter [37]. A study from Thailand, however, noted no seasonal
association for C. neoformans infections while demonstrating a strong association for Penicillium marneei infection in the dry season [53].
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Risk factors
Life-threatening cryptococcal disease can occur in apparently normal
individuals but such cases are relatively rare. The likelihood of cryptococcosis rises dramatically, however, in individuals with impaired immunity. Specically, conditions that predispose to impaired cellular immunity have been
associated with a signicantly increased risk of cryptococcosis and these
include advanced HIV infection [32], lymphoproliferative disorders [39], steroid therapy [54], and organ transplantation [55]. Cryptococcosis has also
been associated with hyper-IgM syndrome in children [5658] and HIVnegative CD4+ T lymphopenia in adults [59]. A smoking habit may predispose to C. neoformans infection in certain individuals [28,60]. Populationbased studies have also yielded an association between outdoor activities
and the risk of acquiring cryptococcosis [60].
In patients with HIV infection the incidence of cryptococcosis is inversely
proportional to the CD4 lymphocyte count [61]. In patients with HIV infection the risk of cryptococcosis rises rapidly when the CD4 lymphocyte count
drops below 100/lL [37]. The average CD4 lymphocyte count of HIVinfected patients with cryptococcosis has been measured at 73/lL [61].
Current trends in the epidemiology of cryptococcosis
After rising dramatically until the early 1990s, the prevalence of cryptococcosis in patients with HIV infection began to decline with the introduction of more eective antiretroviral therapy and the widespread use of
uconazole therapy for the treatment of oral candidiasis [28]. Temporal
trends noted a rising incidence of cryptococcosis in HIV-infected patients
from 1985 to 1992 [62], but by the mid-1990s there was evidence for fewer
infections in this population [63]. The introduction of highly active antiretroviral therapy (HAART) reduces viremia and increases CD4 counts,
resulting in an improved immunologic state that is associated with signicantly reduced risk for cryptococcosis. In The Netherlands the number of
patients with HIV infection complicated by C. neoformans infection has
declined by as much as 75% with the introduction of HARRT [64]. Another
important contributor is probably the use of uconazole for the suppression
of oropharyngeal candidiasis in patients with AIDS [65]. In this regard uconazole therapy has been shown to be eective prophylaxis against the
development of cryptococcal meningitis [66,67].
Because HIV infection is currently the major risk factor for cryptococcosis in countries aected by the AIDS epidemic the use of HAART has been
associated with a reduced incidence of cryptococcosis in areas where it is
available. The high cost of HAART and the complicated logistical infrastructure that is necessary for its administration, however, have precluded
its use in less-developed countries of Africa and Asia where the prevalence
of HIV infection and AIDS increased dramatically in the 1990s and so has
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mice [100]. The availability of specic antibody can help the host response
by providing opsonins for ecient phagocytosis, enhancing natural killer
cell function, and clearing capsular polysaccharide [101]. Antibodies to glucosylceramide [102] and melanin [103] in the cell wall have been shown to
modify the course of infection suggesting the existence of other targets for
humoral immunity in addition to the polysaccharide capsule. Serologic studies in patients at risk for infection suggest qualitative and quantitative dierences in the types of immunoglobulins present that may predispose to
disseminated disease [104].
Intracellular pathogenesis
Histologic examination of C. neoformansinfected tissue can reveal
diverse inammatory responses ranging from the virtual absence of tissue
reaction to intense granulomatous inammation resembling caseous
necrosis [79]. The budding index of C. neoformans in tissue is inversely proportional to the intensity of the granulomatous reaction which is consistent
with the view that strong cell-mediated tissue responses are required to contain infection [79]. The protean nature of tissue responses to this fungus
seems to be a function of both the immunologic status of the host and certain yet undened characteristics of C. neoformans. For example, switch variants of a single C. neoformans strain can elicit diverse inammatory
responses in rats ranging from minimal inammation to caseous necrosis
[105]. There is evidence that the size of the capsule aects the type of
response. In this regard, infection with small capsule variants often elicits
intense inammatory responses that have been confused with Histoplasma
capsulatum [106]. This phenomenon is believed to represent interference of
capsular polysaccharide during infection with these well-encapsulated
strains and the inammatory response (see later).
The location of C. neoformans vis-a`-vis inammatory cells is also a function of the inammatory response. Although the capsular polysaccharide
is antiphagocytic in vitro in conditions where there are no complement or
antibody opsonins, the fungus is rapidly ingested by alveolar macrophages
after experimental infection [107]. Granulomatous responses are associated
with a predominance of intracellular forms, whereas in the absence of inammation cryptococci can grow as extracellular fungal masses, which are
grossly visible in tissue and can give a soap suds appearance [79]. There is
increasing evidence, however, that C. neoformans can survive in macrophages for prolonged periods of time [89]. Studies on the course of C. neoformans infection in immunocompetent mice have shown that C. neoformans
can replicate inside alveolar macrophages resulting in host cell lysis [107].
At the initial stages of infection, before the immune response is established,
most of the replication occurs in the intracellular compartment. C. neoformans has a unique strategy of intracellular replication in macrophages
whereby capsular polysaccharide is secreted into vesicles resulting in
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emphasized, however, that C. neoformans can infect any organ in the body
[122]. There are also a few dierences that distinguish cryptococcosis in
patients with or without HIV infection, such as more CNS and extrapulmonary involvement, higher rate of positive India ink examinations, positive
blood cultures, and fewer cerebrospinal uid (CSF) inammatory cells. This
is primarily a distinction of severity of immunosuppression and burden of
yeast and not a specic feature or tropism between HIV and the fungus.
Lung
This organ is the most common portal of entry for infection and symptoms range from asymptomatic colonization [123] to life-threatening pneumonias [124]. Although at least a third of normal hosts are asymptomatic
and infection is found by an abnormal chest radiograph, patients may
present with evidence of acute infection, such as fever, chest pain, cough,
weight loss, and sputum production [125,126]. There are also a series of
unusual presentations of pulmonary cryptococcus, such as allergic cryptococcal pneumonia [127], pseudo-Pancoasts tumor [128], bronchiolitis
obliterans with organizing pneumonia [129], and superior vena cava syndrome [130,131]. It is also possible to have simultaneous infection with
other pathogens, such as tuberculosis, Nocardia, and Echinococcus [132135].
The chest radiographs in apparently normal hosts range from well-dened,
noncalcied, single or multiple lung nodules; indistinct mass-like inltrates;
hilar lymphadenopathy; pleural eusions; and lung cavitation [136]. There is
no characteristic radiograph, although single or multiple nodules are most
common and may radiographically mimic a malignant tumor. If the infection is limited to the lung, the serum cryptococcal antigen is generally negative and in the authors opinion a positive cryptococcal serum antigen is a
sign that the yeast may have disseminated from the lung to other body sites.
Patients with C. neoformans isolated from the lung and with an underlying
immunosuppressive risk factor for invasive infection should probably be
considered for lumbar puncture to rule out simultaneous CNS infection
with or without symptoms. In the apparently normal, asymptomatic patient
with C. neoformans isolated from the lung, however, the yield of positive
ndings with lumbar puncture is so low that it does not need to be performed routinely.
In the severely immunocompromised host, cryptococcal pneumonia can
progress more rapidly; the ability to disseminate outside the primary lung
focus to the CNS allows patients to present with a meningeal rather than
a pulmonary syndrome [137]. Patients can, however, develop an over
whelming cryptococcal pneumonia with features of adult respiratory distress
syndrome [138140] without CNS involvement. Unlike immunocompetent patients, most immunosuppressed patients have constitutional
symptoms, such as fever, malaise, chest pain, cough, dyspnea, weight
loss, or headaches. Chest radiographs are similar in spectrum to
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nonimmunocompromised hosts except that alveolar and interstitial inltrates may be more common and can potentially be confused with other
pathogens, such as Pneumocystis carinii. In AIDS patients, cryptococcal
pneumonia is primarily symptomatic and over 90% already have concomitant CNS infection at clinical presentation [124]. This observation reects
the extreme nature of the immunodeciency in these patients at the time
of cryptococcosis in which CD4 counts have generally fallen under 100
cells/lL. It should also be noted that all severely immunocompromised
patients with pulmonary cryptococcosis may present with other concomitant opportunistic pulmonary and disseminated infections, such as
typical or atypical mycobacteria, cytomegalovirus, Nocardia, and P. carinii
infections.
Central nervous system
Most patients with cryptococcal meningitis present with signs and symptoms of subacute meningitis or meningoencephalitis, such as headaches,
fever, lethargy, coma, or memory loss over 2 to 4 weeks. Patients may not
have classic symptoms, however, and present with acute (several days)
symptoms of severe headaches, intermittent headaches, or no headaches
with altered mental status. It is dicult to separate AIDS patients from
others in their presentation except to point out that symptoms may be
shorter; there is a greater chance of nding a secondary site of infection; a
greater likelihood of having a second CNS event with either infections, such
as Toxoplasma gondii, or lymphoma; and a higher burden of yeasts. A recent
new cryptococcal syndrome associated with HAART and partial immune
reconstitution has been described during HIV infection. Several patients
after starting or changing HAART developed acute symptoms of cryptococcal meningitis or pain and swelling in tissues [141]. It is hypothesized
that with an improved immune system produced by HAART, a silent or
latent cryptococcal infection was then clinically made apparent as an inammatory reaction was mobilized to the clinically silent yeast cells or polysaccharide antigen [141].
There are little data that relate the severity of CNS disease to the infecting
strain of C. neoformans and it is generally considered that the state of
host defenses primarily determines clinical manifestations. There are some
suggestions, however, that certain strains can inuence clinical presentation. For instance, in Australia, which attends to infections with both
C. neoformans var. neoformans-grubii and C. neoformans var. gattii, cerebral
cryptococcomas or hydrocephalus with pulmonary mass lesions in immunocompetent host, were generally found with the variety gattii infections [142].
In general, infection with this variety has longer survival rates than those
with variety neoformans-grubii. In a subgroup of patients with variety gattii
infection, however, there are more brain-enhancing lesions by scan, complications of hydrocephalus, cranial nerve palsies, and elevated intracranial
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Eye
Before the HIV pandemic, ocular signs and symptoms could be found in
45% of patients with cryptococcal meningitis [163]. Manifestations can
range from ocular palsies to retinal involvement. Ocular infections can occur
simultaneously with other pathogens, such as HIV or cytomegalovirus [164
166]. In one fourth of cases, eye involvement may occur before the diagnosis
of meningoencephalitis [165]. Ocular cryptococcosis may lead to visual loss.
In fact, most cases of cryptococcal endophthalmitis lead to blindness with
only an occasional case successfully managed [167]. There have also been
reports of catastrophic loss of vision in patients without evidence of endophthalmitis [168,169]. Two pathogenic processes have been hypothesized.
First, rapid visual loss associated with optic neuritis caused by inltration
of the optic nerve with yeasts. There are few therapeutic options for successful therapy of this form of visual loss. On the other hand, a second group of
patients presents with slower visual loss and later in therapy or during the
follow-up period. In this group, symptoms may be related to increased intracranial pressure and treatment with ventricular shunts or optic nerve fenestrations may halt progression of visual loss. Most eye infections are from an
endogenous source, such as the CNS and blood, but occasionally the yeast
can be introduced directly into the eye from outside sources, including
trauma and transplantation of human tissue [44,170].
Other Body Sites
Cryptococcus neoformans has been described to infect most areas of the
body. The previous ve sites and their clinical manifestations are the most
common. Cryptococcemia, bone and joint, and cryptococcal peritonitis,
however, have been reported enough not to be considered rare infections.
Cryptococcemia occurs in advanced HIV infection or during periods of high
amounts of immunosuppression from either the underlying disease or drug
treatments, such as corticosteroids. It generally reects a high burden of
yeasts in tissue but it can occur without an apparent secondary site of
involvement. Cryptococcemia rarely causes vascular instability (ie, shock
or endocarditis) but these conditions have been reported. Bone and joint
involvement is an occasional extraneural site. Before the HIV epidemic, it
had been reported that up to 5% of disseminated cases of cryptococcosis
showed bone and joint involvement [171]. Osteoarticular cryptococcosis can
occur in both immunocompromised and nonimmunocompromised hosts
and the only clinical link with infection is the suggestion that sarcoidosis
is a common underlying disease with this site of infection. In AIDS patients,
it might be found in a random bone marrow biopsy without any radiographic evidence of disease. Cryptococcal peritonitis is an occasional clinical
occurrence and generally presents in two groups of patients: patients on
chronic ambulatory peritoneal dialysis; and patients with severe underlying
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illnesses, such as cirrhosis [172]. The following body sites are considered rare
manifestations of cryptococcosis because less than a dozen cases per site
have been presented in the literature: genitourinary tract (pyelonephritis and
genital lesions); muscle (myositis); heart (native and prosthetic endocarditis,
mycotic aortitis or aneurysm, myocarditis, pericarditis, and vascular foreign
body); thyroid (thyroiditis and mass); adrenal gland (adrenal insuciency
and excess); head and neck (gingivitis, sinusitis, salivary gland involvement,
larynx, and neck mass); gastrointestinal (esophagitis, biliary tract, enteritis,
and hepatitis); breast (mastitis and mass); and lymph node (lymphadenopathy) [46].
Laboratory diagnosis
Direct microscopic examination
Clinical specimens from the CSF to aspirates of cutaneous lesions can be
examined by India ink examination for the 5 to 10 lm in diameter yeast cells
with capsules. Approximately 80% of AIDS patients and 50% of non-AIDS
patients with cryptococcal meningitis reveal the yeast with this simple and
immediate test. For a routine positive India ink test from CSF, it is estimated that the specimen needs to contain greater than 103 CFU/mL of CSF
(personal observations). Although calcouor white is not specic for C. neoformans, this solution can be used on tissue aspirates with a uorescent
microscope to nd these yeasts quickly when they are in a reduced number
within a specimen. In tissue sections, the encapsulated yeasts may be surrounded by empty spaces because the capsule does not routinely stain with
many of the standard histologic stains, such as hematoxylin and eosin. The
appearance of the polysaccharide capsule can be identied with specic
stains, such as mucicarmine and alcian blue. The Gomori methenamine silver stain for fungi identies C. neoformans as a yeast but it is not specic for
this yeast and the Fontana-Masson stain, which identies melanin, selectively stains these yeasts in tissue. Most clinical isolates in both tissue and
uids have evidence of a capsule, although occasionally there are reported
hypocapsular strains in which the capsule is dicult to observe histologically [173].
Cultures
Cryptococcus neoformans can be isolated on most routine mycologic or
bacteriologic media. Standard blood culture methods, including radiometric
methods, now routinely detect cryptococcemia. In fact, one study using a
lysis-centrifugation procedure showed over 70% sensitivity of detecting
cryptococcemia in AIDS patients with cryptococcosis [174]. Most C. neoformans isolates can be detected in culture between 3 and 7 days after the specimen has been placed into or on media.
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organism by culture. Despite its excellence as a diagnostic test, it is more difcult to use as a treatment barometer except as a general prognostic feature.
High titers (1:1024) generally reect high burden of yeasts, a poor host
immune response, and a greater likelihood of therapeutic failure. Cryptococcal antigen titers have been less useful to make specic clinical treatment
decisions. For instance, the use of serial antigen titers to develop a treatment
algorithm remains imprecise and not validated by clinical trials.
Antibodies to C. neoformans may not be detected or are at low levels during active infection because many patients are severely immunosuppressed,
but they may rise during clinical recovery. They are not useful, however, for
diagnosis or treatment decisions.
Radiology
Chest radiograph
The chest radiograph of pulmonary cryptococcosis in the immunocompetent host can show a variety of features including nodules, inltrates, hilar
lymphadenopathy, or pleural eusions [136,194198]. In AIDS patients the
radiograph may reveal either diuse or focal interstitial inltrates with or
without lymphadenopathy [124,199,200]. This radiograph may be confused
with P. carinii infection or represent co-infection with it or another
pathogen.
CT and MRI
CT and MRI are frequently used in the diagnosis and management of
cryptococcal meningitis. CT scan ndings in non-AIDS patients with meningitis can reveal hydrocephalus; gyral enhancement; or multiple nodules,
which may be enhancing or nonenhancing [201]. Cryptococcomas can be
either single or multiple and occur in up to 25% of patients [202,203].
Approximately one half of CT scans, however, are normal in cryptococcal
meningitis. In patients with HIV infection, the scans are similar to nonAIDS patients except approximately one third of patients have cortical atrophy from their underlying HIV infection [204].
The MRIs are more sensitive than CT scan for detecting abnormalities.
MRI ndings include numerous clustered foci that are hyperintense on
T2-weighted images and nonenhancing on postcontrast T1-weighted images
within basal ganglia and mid-brain, which represent Virchow-Robin spaces.
There may also be the multiple miliary enhancing parenchymal and leptomeningeal nodules with gadopentetate dimeglumine [205].
It should be emphasized that there is no pathognomonic radiographic
picture for cryptococcal meningitis. It may present simply as an idiopathic
hydrocephalus identied by CT or MRI [206]. In AIDS patients, however,
a scan may identify a parenchymal lesion, which represents a second CNS
disease process, such as toxoplasmosis or lymphoma. Finally, the use of
CT or MRI in follow-up of cryptococcal meningitis may show worsening
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Management
General
The management of cryptococcosis has been extremely well-studied and
although all aspects of treatment are not consistently successful or uniformly agreed on, there is substantial evidence-based data to make recommendations. A group of experts have attempted to collate the therapeutic
evidence into a series of guidelines for therapy of cryptococcosis [208]; these
guidelines are excellent starting points for therapeutic decisions, but this discussion adds the authors own insights and opinions. The breadth of decisions to be made in cases of cryptococcosis can be quite diverse. For
instance, it is clear that some individuals with asymptomatic isolation of
C. neoformans from respiratory secretions have been untreated without clinical compromise. A recent review of this issue suggested that approximately
20% of patients with positive pulmonary cultures received no treatment
[121]. Cryptococcal meningitis, however, is uniformly fatal without antifungal treatment. Before availability of antifungal agents, there were cases that
survived for years with this chronic CNS condition before succumbing. The
rapidity of progression to death for the natural history of this infection with
severe immune suppression, however, such as HIV infection, is illustrated
in the comprehensive report on meningitis in HIV-infected patients in
Zimbabwe [72]. Of 406 patients, 45% had cryptococcal meningitis and
almost 40% of those with this infection died during the initial hospitalization
without treatment. Therapeutic decisions do have a wide range of options
and consequences in the management of cryptococcosis.
In vitro susceptibility testing
Methods for testing C. neoformans isolates in vitro for minimum
inhibitory concentrations (MICs) have been standardized and modied for
media, inoculum, and end point determinations [209,210]. Most initial
isolates of C. neoformans have low MICs to amphotericin B, ucytosine, and
azoles [211,212]. Initial resistance to ucytosine is low [213] but rising MICs
occur during therapy with this agent and correlate with clinical relapse
[137,214,215]. There has been identied, however, only an occasional
C. neoformans isolate resistant to in vitro amphotericin B [216], and
most relapse isolates remain fully susceptible to this polyene. During the
HIV epidemic and before HAART the widespread use of azoles in severely
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Site of infection
In pulmonary cryptococcosis, there are few comparative studies to determine which drugs are the best when treatment is indicated. Azoles, however,
such as uconazole, at 200 to 400 mg/d for 3 to 6 months, are safe and easy
to administer and generally form the primary treatment strategy [261,262],
unless the patient is severely ill, in which case amphotericin B should be
used. In the authors opinion, it is clear that both symptomatic and asymptomatic immunosuppressed patients with C. neoformans isolated from lung
must be treated because dissemination from this site is a distinct possibility
[137]. In fact, the authors recommend that most patients irrespective of
immune status should probably be treated when C. neoformans is isolated
from nonsterile respiratory secretions with or without symptoms. Most CNS
cryptococcomas can be treated and although length of therapy is not
dened, the authors treat patients sometimes with 2 years of uconazole.
As previously mentioned, serial scans may not be helpful and complete resolution radiographically may take years. Surgery has been recommended for
large CNS lesions (>3 cm) [263], but in the authors opinion its use needs to
be individualized, with it rarely needed with present medical management.
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disease. It has been shown that cancer victims have a shorter survival than
AIDS patients because of their underlying disease state [277]. Another major
risk group is solid organ transplant recipients and recent data and prognosis
in this group are conicting. In one study the prognosis of cryptococcosis in
solid organ transplant was similar to patients without an underlying disease
[121] but in a second study there was a death rate of 42% [43]. More studies
are needed in this area. Two other prognostic ndings are burden of organisms at presentation and the level of patients sensorium. A poor prognosis is
found with a heavily positive India ink examination; high polysaccharide
antigen titers (1:1024); and a poor inammatory response in the CSF
(<20 cells/ll). Patients on presentation who have a lucid sensorium have a
better prognosis than those stuporous or in coma [236].
Specic factors have predicted outcome and generally relate to the three
factors previously described. On amphotericin B therapy, Diamond and
Bennett [278] found more than three decades ago that patients who died
during therapy were more likely to have: (1) an initial positive India ink
examination, (2) high CSF opening pressure, (3) low CSF glucose, (4) low
CSF leukocytes, (5) cryptococci isolated from extraneural site, (6) absence of
anticryptococcal antibody, (7) initial CSF or serum antigen titer of greater
than 32, and (8) corticosteroid therapy or lymphoreticular malignancy.
Patients who relapsed after treatment were characterized by: (1) abnormal
CSF glucose for greater than or equal to 4 weeks of therapy, (2) low initial
CSF leukocytes, (3) cryptococci isolated from extraneural sites, (4) absence
of anticryptococcal antibody, (5) posttreatment CSF or serum cryptococcal
antigen titer greater than or equal to 8, (6) no signicant decrease in CSF
and serum antigen titer during therapy, and (7) daily dose of corticosteroid
therapy equivalent to 20 mg of prednisone or more after therapy. These
insights may still help to predict failures today. Recent studies with amphotericin B and ucytosine treatment in non-AIDS patients indicated a better
prognosis if there was a normal mental status, headache on presentation,
and a CSF leukocyte count greater than 20 WBCs/lL [236]. In AIDS
patients during treatment with amphotericin B or uconazole, important
positive pretreatment predictors for death during treatment were abnormal
mental status, a CSF antigen titer greater than 1:1024, and CSF leukocyte
count less than 20 WBC/lL [241]. Identication of these high-risk patients
for failure and relapse should allow the clinician to design specic antifungal
regimens for these subsets of patients.
Prevention
There are at least four methods for approaching high-risk patients to prevent cryptococcosis. First, antifungal prophylaxis for AIDS patients has
been eective in reducing the incidence of cryptococcosis with the use of uconazole [67,279]. Both HAART and concerns about widespread exposure
to azoles worked together, however, to reduce enthusiasm for its general
861
862
[16] Fessel WJ. Cryptococcal meningitis after unusual exposures to birds. N Engl J Med
1993;328:13545.
[17] Nosanchuk JD, Shoham S, Fries BC. Evidence for zoonotic transmission of Cryptococcus
neoformans from a pet cockatoo to an immunocompromised patient. Ann Intern Med
2000;132:2058.
[18] Schimp SC, Bennett JE. Abnormalities in cell-mediated immunity in patients with
Cryptococcus neoformans infection. J Allergy Clin Immunol 1975;55:43041.
[19] Newberry Jr. WM, Walter JE, Chandler Jr. JW, Tosh FE. Epidemiologic study of
Cryptococcus neoformans. Ann Intern Med 1967;67:72432.
[20] Chen L-C, Goldman DL, Doering TL. Antibody response to Cryptococcus neoformans
proteins in rodents and humans. Infect Immunol 1999;67:221824.
[21] Goldman DL, Khine H, Abadi J. Serologic evidence for cryptococcus infection in early
childhood. Pediatrics 2001;107:66.
[22] Howard DH. The commensalism of Cryptococcus neoformans. Sabouraudia 1973;11:
1714.
[23] Randhawa HS, Paliwal DK. Occurrence and signicance of Cryptococcus neoformans in
the oropharynx and on the skin of a healthy human population. J Clin Microbiol
1977;6:3257.
[24] Randhawa HS, Pal M. Occurrence and signicance of Cryptococcus neoformans in the respiratory tract of patients with bronchopulmonary disorders. J Clin Microbiol 1977;5: 58.
[25] Tynes B, Mason KN, Jennings AE, Bennett JE. Variant forms of pulmonary
cryptococcosis. Ann Intern Med 1968;69:111725.
[26] Friedman GD. The rarity of cryptococcosis in Northern California: the 10-year
experience of a large dened population. Am J Epidemiol 1983;117:2304.
[27] Kaufman L, Blumer S. Cryptococcosis: the awakening giant. Proceedings of the Fourth
International Conference on the Mycoses. Pan-American Health Organization 1977;356:
17682.
[28] Hajjman A, Conn LA, Stephens DS. Cryptococcosis: population-based multistate active
surveillance and risk factors in human immunodeciency virus-infected persons.
Cryptococcal Active Surveillance Group. J Infect Dis 1999;179:44954.
[29] Thomas CJ, Lee JY, Conn LA. Surveillance of cryptococcosis in Alabama, 19921993.
Ann Epidemiol 1998;8:2126.
[30] Hajjeh RA, Brandt ME, Pinner RW. Emergency of cryptococcal disease: epidemiologic
perspective 100 years after its discovery. Epidemiol Rev 1995;17:30320.
[31] Kovacs JA, Kovacs AA, Polis M, Wright WC, Gill VJ, Tuazon CU, et al. Cryptococcosis
in the acquired immunodeciency syndrome. Ann Intern Med 1985;103:5338.
[32] Zuger A, Louie E, Holzman RS, Simberko MS, Rahal JJ. Cryptococcal disease in
patients with acquired immunodeciency syndrome: diagnostic features and outcome of
treatment. Ann Intern Med 1986;104:23440.
[33] Eng RHK, Bishburg E, Smith SM. Bacteremia and fungemia in patients with the acquired
immune deciency syndrome. Am J Clin Pathol 1986;86:1057.
[34] Chuck SL, Sande MA. Infections with Cryptococcus neoformans in the acquired
immunodeciency syndrome. N Engl J Med 1989;321:7949.
[35] Clark RA, Greer D, Atkinson W, Valainis GT, Hyslop N. Spectrum of Cryptococcus
neoformans infection in 68 patients infected with acquired immunodeciency virus. Rev
Infect Dis 1990;12:76877.
[36] Currie BP, Casadevall A. Estimation of the prevalence of cryptococcal infection among
HIV-infected individuals in New York City. Clin Infect Dis 1994;19:102933.
[37] Sorvillo F, Beall G, Turner PA. Incidence and factors associated with extrapulmonary
cryptococcosis among persons with HIV infection in Los Angeles County. AIDS
1997;11:6739.
[38] Collins VP, Gellhorn A, Trimble JR. The coincidence of cryptococcosis and disease of the
reticulo-endothelial and lymphatic systems. Cancer 1995;4:8839.
863
864
[61] Crowe SM, Carlin JB, Stewart KI, Lucas CR, Hoy JF. Predictive value of CD4
lymphocyte numbers for the development of opportunistic infections and malignancies in
HIV-infected persons. J Acquir Immune Dec Syndr Hum Retrovirol 1991;4:7706.
[62] Bacellar H, Munoz A, Miller EN. Temporal trends in the incidence of HIV-1-related
neurologic diseases. Neurology 1994;44:1892900.
[63] McNeill JI, Kan VL. Decline in the incidence of cryptococcosis among HIV-related
patients. J Acquir Immune Dec Syndr Hum Retrovirol 1995;206:207.
[64] van Elden LJ, Walenkamp AM, Lipovsky MM. Declining number of patients with
cryptococcosis in The Netherlands in the era of highly active antiretroviral therapy. AIDS
2000;14:27878.
[65] Newton JA, Tasker SA, Bone WD, Oldeld EC, Olson PE, Nguyen MT, et al. Weekly
uconazole for the suppression of recurrent thrush in HIV seropositive patients: impact
on the incidence of disseminated cryptococcal infection. AIDS 1995;9:12867.
[66] Ammasari A, Linzalone A, Murr R, Marasea G, Morace G, Antinori A. Fluconazole for
prophylaxis of AIDS-associated cryptococcosis: a case-control study. Scand J Infect Dis
1995;27:2357.
[67] Powderly WG, Finkelstein DM, Feinberg J, Frame P, He W, van der Horst C, et al.
A randomized trial comparing uconazole with clotrimazole troches for the prevention
of fungal infections in patients with advanced human immunodeciency virus infection.
N Engl J Med 1995;332:7005.
[68] Archibald LK, McDonald LC, Rheanpumikankit S. Fever and human immunodeciency
virus infection as sentinels for emerging mycobacterial and fungal bloodstream infections
in hospitalized patients >15 years old. Bangkok J Infect Dis 1999;180:8792.
[69] Gordon SB, Walsh AL, Chaponda M. Bacterial meningitis in Malawian adults:
pneumococcal disease is common, severe, and seasonal. Clin Infect Dis 2000;31:537.
[70] Clumeck N, Sonnet J, Taelman H, Mascart-Lemone F, De Bruyere M, Vandeperre P,
et al. Acquired immunodeciency syndrome in African patients. N Engl J Med 1984;
310:4927.
[71] Van de Perre P, Lepage P, Kestelyn P. Acquired immunodeciency syndrome in Rwanda.
Lancet 1984;2:625.
[72] Hakim JG, Gangaidzo IT, Heyderman RS. Impact of HIV infection on meningitis in
Harare, Zimbabwe: a prospective study of 406 predominantly adult patients. AIDS
2000;14:14017.
[73] Molez J. The historical question of acquired immunodeciency syndrome in the 1960s in
the Congo River basin area in relation to cryptococcal meningitis. Am J Trop Med Hyg
2001;58:2736.
[74] Dore GJ, Li Y, McDonald A, Kaldor JM. Spectrum of AIDS-dening illnesses in
Australia, 1992 to 1998: inuence of country/region of birth. J Acquir Immune Dec
Syndr Hum Retrovirol 2000;26:28390.
[75] Atkinson AJ, Bennett JE. Experience with a new skin test antigen prepared from
Cryptococcus neoformans. Am Rev Respir Dis 1968;97:63743.
[76] Bennett JE. Cryptococcal skin test antigen: preparation variables characterization. Infect
Immunol 1981;32:373.
[77] Mitchell TG, Perfect JR. Cryptococcosis in the era of AIDS 100 years after the discovery
of Cryptococcus neoformans. Clin Microbiol Rev 1995;8:51548.
[78] Goldman D, Lee SC, Casadevall A. Pathogenesis of pulmonary Cryptococcus neoformans
infection in the rat. Infect Immunol 1994;62:475561.
[79] Schwartz DA. Characterization of the biological activity of Cryptococcus infections in
surgical pathology. Ann Clin Lab Sci 1988;18:38897.
[80] Levitz SM. Overview of host defenses in fungal infections. Clin Infect Dis 1992;14:S3742.
[81] Lipscomb MF. Lung defenses against opportunistic infections. Chest 1989;96:13939.
[82] Lee SC, Dickson DW, Casadevall A. Pathology of cryptococcal meningoencephalitis:
analysis of 27 patients with pathogenetic implications. Hum Pathol 1996;27:83947.
865
[83] Goldman DL, Casadevall A, Cho Y, Lee SC. Cryptococcus neoformans meningitis in the
rat. Lab Invest 1996;75:75970.
[84] Perfect JR, Lang SDR, Durack DT. Chronic cryptococcal meningitis: a new experimental
model in rabbits. Am J Pathol 1980;101:17794.
[85] Aguirre K, Havell EA, Gibson GW, Johnson LL. Role of tumor necrosis factor and
gamma interferon in acquired resistance to Cryptococcus neoformans in the central
nervous system of mice. Infect Immunol 1995;63:172531.
[86] Kawakami K, Tohyama M, Teruya K. Contribution of interferon-gamma in protecting
mice during pulmonary and disseminated infection with Cryptococcus neoformans. FEMS
Immunol Med Microbiol 1996;13:13340.
[87] Levitz SM. Macrophage-Cryptococcus interactions. In: Zwilling BS, Eisenstein TK,
editors. Macrophage-pathogen interactions. New York: Marcel Dekker; 1994. p. 533.
[88] Goldman D, Cho Y, Zhao ML. Expression of inducible nitric oxide synthase in rat
pulmonary Cryptococcus neoformans granulomas. Am J Pathol 1996;148:127582.
[89] Goldman DL, Lee SC, Mednic AJ. Persistent Cryptococcus neoformans infection in the rat
is associated with intracellular parasitism, decreased inducible nitric oxide synthase
expression and altered antibody responsiveness. Infect Immunol 2000;68:8328.
[90] Hunagle GB, Strieter RM, McNeil LK. Macrophage inammatory protein-1 alpha
(MIP-alpha) is required for the eerent phase of pulmonary cell-mediated immunity to a
Cryptococcus neoformans infection. J Immunol 1997;159:31827.
[91] Levitz SM, DiBenedetto DJ. Paradoxical role of capsule in murine bronchoalveolar
macrophage-mediated killing of Cryptococcus neoformans. J Immunol 1989;142:65965.
[92] Hunagle GB, Traynor TR, McDonald RA. Leukocyte recruitment during pulmonary
Cryptococcus neoformans infection. Immunopharmacology 2000;48:2316.
[93] Vecchiarelli A. Cytokines and costimulatory molecules: positive and negative regulation
of the immune response to Cryptococcus neoformans. Arch Immunol Ther Exp 2000;
48:46572.
[94] Hill JO. CD4+ T cells cause multinucleated giant cells to form around Cryptococcus
neoformans and conne the yeast within the primary site of infection in the respiratory
tract. J Exp Med 1992;175:168595.
[95] Casadevall A. Antibody immunity and invasive fungal infections. Infect Immunol
1995;63:42118.
[96] Dromer F, Charreire J, Contrepois A, Carbon C, Yeni P. Protection of mice against
experimental cryptococcosis by anti- Cryptococcus neoformans monoclonal antibody.
Infect Immunol 1987;55:74952.
[97] Sanford JE, Lupan DM, Schlageter AM, Kozel TR. Passive immunization against
Cryptococcus neoformans with an isotype-switch family of monoclonal antibodies reactive
with cryptococcal polysaccharide. Infect Immunol 1990;58:191923.
[98] Mukherjee J, Shar MD, Casadevall A. Protective murine monoclonal antibodies to
Cryptococcus neoformans. Infect Immunol 1992;60:453441.
[99] Fleuridor R, Zhong Z, Pirofski L-A. A human IgM monoclonal antibody prolongs
survival of mice with lethal cryptococcosis. J Infect Dis 1998;178:12136.
[100] Devi SJN. Preclinical ecacy of a glucuronoxylomannan-tetanus toxoid conjugate
vaccine of Cryptococcus neoformans in a murine model. Vaccine 1996;14:8412.
[101] Vecchiarelli A, Casadevall A. Antibody-mediated eects against Cryptococcus neoformans: evidence for interdependency and collaboration between humoral and cellular
immunity. Res Immunol 1998;149:32133.
[102] Rodriques ML, Travassos LR, Miranda KR. Human antibodies against a puried
glucosylceramide from Cryptococcus neoformans inhibit cell budding and fungal growth.
Infect Immunol 2000;68:704960.
[103] Rosas AL, Nosanchuk JD, Casadevall A. Passive immunization with melanin-binding
monoclonal antibodies prolongs survival in mice with lethal Cryptococcus neoformans
infection. Infect Immunol 2001;69:341012.
866
[104] Fleuridor R, Lyles RH, Pirofski L. Quantitative and qualitative dierences in the serum
antibody proles of human immunodeciency virus-infected persons with and without
Cryptococcus neoformans meningitis. J Infect Dis 1999;180:152635.
[105] Goldman DL, Fries BC, Franzot SP, Montella L, Casadevall A. Phenotypic switching in
the human pathogenic fungus, Cryptococcus neoformans, is associated with changes in
virulence and pulmonary inammatory response in rodents. Proc Natl Acad Sci USA
1998;95:1496772.
[106] Gutierrez F, Fu YS, Lurie H. Cryptococcosis histologically resembling histoplasmosis:
a light and electron microscopic study. Arch Pathol Lab Med 1975;99:347.
[107] Feldmesser M, Kress Y, Noviko P, Casadevall A. Cryptococcus neoformans is
a facultative intracellular pathogen in murine pulmonary infection. Infect Immunol
2000;68:422537.
[108] Feldmesser M, Tucker SC, Casadevall A. Intracellular parasitism of macrophages by
Cryptococcus neoformans. Trends Microbiol 2001;9:2738.
[109] Murphy JW. Inuence of cryptococcal antigens on cell-mediated immunity. Rev Infect
Dis 1988;10:S4325.
[110] Murphy JW. Cryptococcal immunity and immunostimulation. Adv Exp Med Biol
1992;319:22530.
[111] Buchanan KL, Murphy JW. What makes Cryptococcus neoformans a pathogen? Emerg
Infect Dis 1998;4:7183.
[112] Vecchiarelli A. Immunoregulation by capsular components of Cryptococcus neoformans.
Med Mycol 2000;38:40717.
[113] Wong B, Perfect JR, Beggs S, Wright KA. Production of the hexitol D-mannitol by
Cryptococcus neoformans in vitro and in rabbits with experimental meningitis. Infect
Immunol 1990;58:166470.
[114] Chaturvedi VP, Wong B, Newman SL. Oxidative killing of Cryptococcus neoformans by
human neutrophils: evidence that fungal mannitol protects by scavengering reactive
oxygen intermediates. J Immunol 1996;156:383640.
[115] Williamson PR. Biochemical and molecular characterization of the diphenol oxidase of
Cryptococcus neoformans: identication as a laccase. J Bacteriol 1994;176:65664.
[116] Nosanchuk JD, Rosas AL, Lee SC. Melanisation of Cryptococcus neoformans in human
brain tissue. Lancet 2000;355:204950.
[117] Rosas AL, Nosanchuk JD, Feldmesser M. Synthesis of polymerized melanin by
Cryptococcus neoformans in infected rodents. Infect Immunol 2000;68:284553.
[118] Casadevall A, Rosas AL, Nosanchuk JD. Melanin and virulence in Cryptococcus
neoformans. Curr Opin Microbiol 2000;4:3548.
[119] Hunagle GB, Chen GH, Curtis JL, McDonald RA, Streiter RM, Toews GB. Downregulation of the dierent phase of T cell-mediated pulmonary inammation and
immunity by a high melanin-producing strain of Cryptococcus neoformans. J Immunol
1995;155:350716.
[120] Noverr MC, Phare SM, Toews GB. Pathogenic yeasts Cryptococcus neoformans and
Candida albicans produce immunomodulatory prostaglandins. Infect Immunol 2001;
69:295763.
[121] Pappas PG, Perfect JR, Cloud GA, Larsen RA, Pankey GA, Lancaster DJ, et al.
Cryptococcosis in HIV-negative patients in the era of eective azole therapy. Clin Infect
Dis 2001;33:6909.
[122] Perfect JR. Cryptococcosis. Infect Dis Clin North Am 1989;3:77102.
[123] Duperval R, Hermans PE, Brewer NS, Roberts GD. Cryptococcosis, with emphasis on
the signicance of isolation of Cryptococcus neoformans from the respiratory tract. Chest
1977;72:139.
[124] Cameron ML, Bartlett JA, Gallis HA, Waskin HA. Manifestations of pulmonary
cryptococcosis in patients with acquired immunodeciency syndrome. Rev Infect Dis
1991;13:647.
867
[125] Campbell GD. Primary pulmonary cryptococcosis. Am Rev Respir Dis 1966;94:23643.
[126] Warr W, Bates JH, Stone A. The spectrum of pulmonary cryptococcosis. Ann Intern Med
1968;69:110916.
[127] Gerstenhaber BJ, Weiner B, Morecki R, Bernstein R, Luftschein S. Allergic
cryptococcal pneumonia. Lung 1977;154:1959.
[128] Mitchell DH, Sorrell TC. Pancoasts syndrome due to pulmonary infection with
Cryptococcus neoformans variety gatti. Clin Infect Dis 1992;14:11424.
[129] Cary CF, Mueller L, Fotopoulos CL, Dall L. Bronchitis obliterans - organizing pneumonia
associated with Cryptococcus neoformans infection. Rev Infect Dis 1991;13:12534.
[130] Lehmann PF, Morgan RJ, Freimer EH. Infection with Cryptococcus neoformans var.
gattii leading to a pulmonary cryptococcoma and meningitis. J Infect 1984;9:3016.
[131] Menon A, Rajamani R. Giant cryptococcomas of the lung. Br J Dis Chest 1976;70:
26972.
[132] Corpe RF, Parr LH. Pulmonary torulosis complicating pulmonary tuberculosis treated by
resection. J Thorac Cardiovasc Surg 1953;27:3928.
[133] Kahn FW, England DM, Jones JM. Solitary pulmonary nodule due to Cryptococcus
neoformans and Mycobacterium tuberculosis. Am J Med 1985;78:67781.
[134] Riley E, Cahan WG. Pulmonary cryptocococcis followed by pulmonary tuberculosis:
a case report. Am Rev Respir Dis 1972;106:5949.
[135] Dalgleish AG. Concurrent hydatid disease and cryptococcosis in a 16-year-old girl. Med
J Aust 1981;2:1445.
[136] Feigin DS. Pulmonary cryptococcosis: radiologic-pathologic correlates of its three forms.
AJR Am J Roentgenol 1983;141:126372.
[137] Kerkering TM, Duma RJ, Shadomy S. The evolution of pulmonary cryptococcosis:
clinical implications from a study of 41 patients with and without compromising host
factors. Ann Intern Med 1981;94:6116.
[138] Henson DJ, Hill AR. Cryptococcal pneumonia: a fulminant presentation. Am J Med
1984;228:221.
[139] Kent TH, Layton JM. Massive pulmonary cryptococcosis. Am J Clin Pathol 1962;38:
596604.
[140] Murray RJ, Becker P, Furth P, Criner GJ. Recovery from cryptococcemia and the adult
respiratory distress syndrome in the acquired immunodeciency syndrome. Chest 1988;
93:13047.
[141] Woods ML, MacGinley R, Eisen DP, Allworth AM. HIV combination therapy: partial
immune restitution unmasking latent cryptococcal infection. AIDS 1998;12:14914.
[142] Mitchell DH, Sorrell TC, Allworth AM, Heath CH, McGregor AR, Papahaoum K, et al.
Cryptococcal disease of the CNS in immunocompetent hosts: inuence of cryptococcal
variety on clinical manifestations and outcome. Clin Infect Dis 1995;20:6116.
[143] Speed B, Dunt D. Clinical and host dierences between infections with the two varieties of
Cryptococcus neoformans. Clin Infect Dis 1995;21:2834.
[144] Cauley LK, Murphy JW. Response of congenital athymic (nude) and phenotypically
normal mice to Cryptococcus neoformans infection. Infect Immunol 1979;23:64451.
[145] Littman ML, Zimmerman LE. Cryptococcosis, torulosis or European blastomycosis. In:
Anonymous. Cryptococcosis. New York: Grune and Stratton; 1956. p. 38.
[146] Sarosi GA, Parker JD, Doto IL, Tosh FE. Amphotericin B in cryptococcal meningitis:
long-term results of treatment. Ann Intern Med 1969;71:107987.
[147] Schupbach CW, Wheeler CE, Briggaman RA. Cutaneous manifestations of disseminated
cryptococcosis. Arch Dermatol 1976;112:173444.
[148] Borton LK, Wintroub BU. Disseminated cryptococcosis presenting as herpetiform lesions
in a homosexual man with acquired immunodeciency syndrome. J Am Acad Dermatol
1984;10:38790.
[149] Concus AP, Helfand RF, Imber MJ, Lerner SA, Sharpe RJ. Cutaneous cryptococcosis
mimicking Molluscum contagiosum in a patient with AIDS. J Infect Dis 1988;158:8978.
868
869
[174] Yagupsky P, Menegus MA. Cumulative positivity rates of multiple blood cultures for
Mycobacterium avium intracellulare and Cryptococcus neoformans in patients with the
acquired immunodeciency syndrome. Arch Pathol Lab Med 1990;114:9235.
[175] Chaskes S, Tyndall RL. Pigment production by Cryptococcus neoformans and other
Cryptococcus species from aminophenols and diaminobenzenes. J Clin Microbiol
1978;7:14652.
[176] Kwon-Chung KJ, Bennett JE. Cryptococcosis. Anonymous. Medical mycology.
Philadelphia: Lea & Febiger; 1992. p. 397.
[177] Staib F. Cryptococcus neoformans und Guizotia abyssinica (Syn. G. oleifera) Farbreaktion
fur C. neoformans. ZentralblHyg Umweltmed 1962;148:46675.
[178] el-Zaatari M, Pasarell L, McGinnis MR, Buckner J, Land GA, Salkin IF. Evaluation of
the updated Vitek yeast identication data base. J Clin Microbiol 1990;28:193841.
[179] St. Germain G, Beauchesne D. Evaluation of the microscan rapid yeast identication
panel. J Clin Microbiol 1991;29:22969.
[180] Hunagle KE, Gander RM. Evaluation of Gen-probes Histoplasma capsulatum and
Cryptococcus neoformans ACCU probes. J Clin Microbiol 1993;31:41921.
[181] Mitchell TG, Freedman EZ, White TJ, Taylor JW. Unique oligonucleotide primers in
PCR for identication of Cryptococcus neoformans. J Clin Microbiol 1994;32:2535.
[182] Kwon-Chung KJ, Polacheck I, Bennett JE. Improved diagnostic medium for separation
of Cryptococcus neoformans var. neoformans (serotypes A and D) and Cryptococcus
neoformans var gattii (serotypes B and C). Ann Intern Med 1985;103:5338.
[183] Ikeda R, Shinoda R, Fukazawa Y, Kaufman L. Antigenic characterization of
Cryptococcus neoformans serotypes and its application of serotyping of clinical isolates.
J Clin Microbiol 1982;16:229.
[184] Kabasawa K, Itagaki H, Ikeda R, Shinoda T, Kagaya K, Fukazawa Y. Evaluation of a
new method for identication of Cryptococcus neoformans which uses serologic tests aided
by selected biological tests. J Clin Microbiol 1991;29:28736.
[185] Brandt ME, Bragg SL, Pinner RW. Multilocus enzyme typing of Cryptococcus
neoformans. J Clin Microbiol 1993;31:281923.
[186] Crampin AC, Matthews RC, Hall D, Evans EGV. PCR ngerprinting Cryptococcus
neoformans by random amplication of polymorphic DNA. J Med Vet Mycol 1993;
31:4635.
[187] Spitzer ED, Spitzer SG. Use of a dispersed repetitive DNA element to distinguish clinical
isolates of Cryptococcus neoformans. J Clin Microbiol 1992;30:10947.
[188] Varma A, Kwon-Chung KJ. DNA probe for strain typing of Cryptococcus neoformans.
J Clin Microbiol 1992;30:29607.
[189] Campbell CK, Payne AL, Teall AJ, Brownell A, Mackenzie DWR. Cryptococcal latex
antigen test positive in patient with Trichosporon beigelii infection. Lancet 1985;2:43.
[190] Chanock SJ, Toltzis P, Wilson C. Cross-reactivity between Stomatococcus mucilaginosus
and latex agglutination for cryptococcal antigen. Lancet 1993;342:111920.
[191] McManus EJ, Jones JM. Detection of a Trichosporon beigelii antigen cross-reactive with
Cryptococcus neoformans capsular polysaccharides in serum from a patient with
disseminated Trichosporon infection. J Clin Microbiol 1985;21:6815.
[192] Baughman RP, Rhodes JC, Dohn MN, Henderson H, Frame PT. Detection of
cryptococcal antigen in bronchoalveolar lavage uid: a prospective study of diagnostic
utility. Am Rev Respir Dis 1992;145:12269.
[193] Desmet P, Kayembe KD, DeVroey C. The value of cryptococcal serum antigen screening
among HIV positive AIDS patients in Kinshasa, Zaire. AIDS 1989;3:778.
[194] Hunt Jr. KK, Enquist RW, Bowen TE. Multiple pulmonary nodules with central
cavitation. Chest 1976;69:52930.
[195] Khoury MB, Godwin JD, Ravin CE, Gallis HA, Halvorsen RA, Putnam CE. Thoracic
cryptococcosis: immunologic competence and radiologic appearance. AJR Am J
Roentgenol 1984;141:8936.
870
[196] McAllister CK, Davis Jr. CE, Ognibene AJ, Carpenter JL. Cryptococcal pleuropulmonary disease: infection of the pleural uid in the absence of disseminated
cryptococcosis. Case report. Mil Med 1984;149:6846.
[197] Young EJ, Hirsh DD, Fainstein V, Williams TW. Pleural eusions due to Cryptococcus
neoformans: a review of the literature and report of two cases with cryptococcal antigen
determinations. Am Rev Respir Dis 1980;121:7436.
[198] Zlupko GM, Fochler FJ, Goldschmidt ZH. Pulmonary cryptococcosis presenting with
multiple pulmonary nodules. Chest 1980;77:575.
[199] Clark RA, Greer DL, Valainis GT, Hyslop NE. Cryptococcus neoformans pulmonary
infection in HIV-1-infected patients. J Acquir Immune Dec Syndr Hum Retrovirol 1990;
3:4805.
[200] Miller WT, Edelman JM. Cryptococcal pulmonary infection in patients with AIDS:
radiographic appearance. Radiology 1990;175:7258.
[201] Cornell SH, Jacoby CG. The varied computed tomographic appearance of intracranial
cryptococcosis. Radiology 1982;143:7037.
[202] Tan CT, Kuan BB. Cryptococcus meningitis, clinical-CT scan considerations. Neuroradiology 1987;29:436.
[203] Long JA, Herdt JR, DiChiro G, Cramer HR. Cerebral mass lesions in torulosis
demonstrated by computer tomography. J Comput Assist Tomogr 1980;4:7669.
[204] Poprich MJ, Arthur RH, Helmer E. CT of intracranial cryptococcosis. AJR Am J
Roentgenol 1990;154:6036.
[205] Wehn SM, Heinz R, Burger PC. Dilated Virchow-Robin spaces in cryptococcal meningitis
associated with AIDS: CT and MR ndings. J Comput Assist Tomogr 1989;13:
75662.
[206] Ingram CW, Haywood HB, Morris VM, Allen RL, Perfect JR. Cryptococcal ventricular
peritoneal shunt infection: clinical and epidemiological evaluation of two closely
associated cases. Infect Immunol 1993;14:71922.
[207] Hospenthal D, Bennett JE. Persistence of cryptococcomas on neuroimaging. Clin Infect
Dis 2000;31:13036.
[208] Saag MS, Graybill JR, Larsen RA, Pappas PG, Perfect JR, Powderly WG, et al. Practice
guidelines for the management of cryptococcal disease. Infectious Disease Society of
America. Clin Infect Dis 2000;30:7108.
[209] Espinel-Ingro A, Kish Jr. CW, Kerkering TM, Fromtling RA, Bartizal K, Galgiani JN,
et al. Collaborative comparison of broth macrodilution and microdilution antifungal
susceptibility tests. J Clin Microbiol 1992;30:313845.
[210] Fromtling RA, Galgiani JN, Pfaller MA, Espinel-Ingro A, Bartizal KF, Bartlett MS,
et al. Multicenter evaluation of a broth macrodilution antifungal susceptibility test for
yeasts. Antimicrob Agents Chemother 1993;37:3945.
[211] Ghannoun MA, Ibrahim AS, Fu Y, Shag MC, Edwards JE, Criddle RS. Susceptibility
testing of Cryptococcus neoformans: a microdilution technique. J Clin Microbiol 1992;
30:28816.
[212] Shadomy S, Pfaller MA. Laboratory studies with antifungal agents: susceptibility tests
and quantitation in body uids. In: Balows A, Hausler Jr. WJ, Herrmann KL, Isenberg
HD, Shadomy HJ, editors. Manual of clinical microbiology. 5th edition. Washington:
American Society for Microbiology; 1991. p. 1173.
[213] Polak A. 5-urocytosine and its combination with other antifungal agents. In: Yamaguchi
H, Kobayashi G, Takahashi H, editors. Recent progress in antifungal chemotherapy.
New York: Marcel-Dekker; 1992. p. 77.
[214] Utz JP, Shadomy S, McGehee RF. 5-ucytosine: Experience in patients with pulmonary
and other forms of cryptococcosis. Am Rev Respir Dis 1969;99:975.
[215] Albert MM, Graybill JR, Rinaldi MG. Treatment of murine cryptococcal meningitis with
an SCH 39304-amphotericin B combination. Antimicrob Agents Chemother 1991;
35:17215.
871
872
[234] Utz JP, Shadomy S, McGehee RF. Flucytosine. N Engl J Med 1972;286:7778.
[235] Utz JP, Garrigues IL, Sande MA, Warner JF, Mandell GL, McGhee RF, et al. Therapy
of cryptococcosis with a combination of ucytosine and amphotericin B. J Infect Dis
1975;132:36873.
[236] Dismukes WE, Cloud G, Gallis HA, Kerkering TM, Medo G, Craven PL, et al. Natl
Institute of Allergy and Infectious Diseases Mycoses Study Group. Treatment of
cryptococcal meningitis with combination amphotericin B and ucytosine for four as
compared with six weeks. N Engl J Med 1987;317:33441.
[237] Larsen RA, Leal MAE, Chan LS. Fluconazole compared with amphotericin B plus
ucytosine for cryptococcal meningitis in AIDS. Ann Intern Med 1990;113:1837.
[238] DeGans J, Portegies P, Tiessens G. Itraconazole compared with amphotericin B plus
ucytosine in AIDS patients with cryptococcal meningitis. AIDS 1992;6:18590.
[239] Saag MS, Cloud GA, Graybill JR, Sobel JD, Tuazon CV, Johnson PC, et al.
A comparison of itraconazole versus uconazole as maintenance therapy for AIDSassociated cryptococcal meningitis. Clin Infect Dis 1999;28:2916.
[240] Witt MD, Lewis RJ, Larsen RA, Milefchik EN, Leal M, Haubrich RH, et al.
Identication of patients with acute AIDS-associated cryptococcal meningitis who can
be eectively treated with uconazole: the role of antifungal susceptibility testing. Clin
Infect Dis 1996;22:3228.
[241] van der Horst C, Saag MS, Cloud GA, Hamill RJ, Graybill JR, Sobel JD, et al.
Treatment of cryptococcal meningitis associated with the acquired immunodeciency
syndrome. N Engl J Med 1997;337:1521.
[242] Ding JC, Bauer M, Diamond DM, Leal MA, Johnson D, Williams BK, et al. Eect of
severity of meningitis on fungicidal activity of ucytosine combined with uconazole in a
murine model of cryptococcal meningitis. Antimicrob Agents Chemother 1997;41:158993.
[243] Lortholary O, Nicholas M, Soreda S, Improvisi L, Ronin O, Petitjean O, et al.
Fluconazole with or without dexamethasone for experimental cryptococcosis: impact of
treatment timing. J Antimicrob Chemother 1999;43:81724.
[244] Berry AJ, Rinaldi MG, Graybill JR. Use of high dose uconazole as salvage therapy for
cryptococcal meningitis in patients with AIDS. Antimicrob Agents Chemother 1992;
36:6902.
[245] Allendoerfer R, Marquis AJ, Rinaldi MG, Graybill JR. Combined therapy with
uconazole and ucytosine in murine cryptococcal meningitis. Antimicrob Agents
Chemother 1991;35:7269.
[246] Larsen RA, Bozzette SA, Jones BE, Haghighat D, Leal MA, Forthal D, et al. Fluconazole
combined with ucytosine for treatment of cryptococcal meningitis in patients with AIDS.
Clin Infect Dis 1994;19:7415.
[247] Bozzette SA, Larsen RA, Chin J. A placebo-controlled trial of maintenance therapy with
uconazole after treatment of cryptococcal meningitis in the acquired immunodeciency
syndrome. N Engl J Med 1991;324:5804.
[248] Powderly WG, Saag MS, Cloud GA, Robinson P, Meyer R, Jacobson JM, et al.
A controlled trial of uconazole or amphotericin B to prevent relapse of cryptococcal
meningitis in patients with the acquired immunodeciency syndrome. N Engl J Med
1992;326:7938.
[249] Denning DW, Tucker RM, Hanson LH, Hamilton JR, Stevens DA. Itraconazole therapy
for cryptococcal meningitis and cryptococcosis. Arch Intern Med 1989;149:23018.
[250] Viviani MA, Tortorano AM, Langer M, Alma-viva M, Negri E, Christina S, et al.
Experience with itraconazole in cryptococcosis and aspergillosis. J Infect 1989;18:15165.
[251] Viviani MA, Tortorano AM, Giani PC, Arici C, Goglio A, Crocchiolo P, et al.
Itraconazole for cryptococcal infection in the acquired immunodeciency syndrome
[letter]. Ann Intern Med 1987;106:166.
[252] Sung JP, Campbell GD, Grendahl JG. Miconazole therapy for fungal meningitis. Arch
Intern Med 1978;35:4437.
873
874
[270] Powderly WG, Cloud GA, Dismukes WE, Saag MS. Measurement of cryptococcal
antigen in serum and cerebrospinal uid: value in the management of AIDS-associated
cryptococcal meningitis. Clin Infect Dis 1994;18:78992.
[271] Feldmesser M, Harris C, Reichberg S, Khan S, Casadevall A. Serum cryptococcal antigen
in patients with AIDS. Clin Infect Dis 1996;23:82730.
[272] Torres R, Villarreal C, Robles M, Aparicio P, Cano P. Comparative study with two
treatments for Cryptococcus neoformans meningitis in patients with AIDS: granulocytemacrophage colony-stimulating factor (GM-CSF) and amphotericin B vs amphotericin B
alone: preliminary report [abstract]. Presented at the 2nd International Conference on
Cryptococcus and Cryptococcosis. Milan, Italy, September 1923, 1993.
[273] Clemons KV, Lutz JE, Stevens DA. Ecacy of recombinant gamma interferon for
treatment of systemic cryptococcosis in SCID mice. Antimicrob Agents Chemother 2001;
45:6869.
[274] Mukherjee J, Pirofski LA, Schar MD, Casadevall A. Antibody-mediated protection in
mice with lethal intracerebral Cryptococcus neoformans infection. Proc Natl Acad Sci
U S A 1993;90:363640.
[275] Mukherjee J, Zuckier LS, Schar MD, Casadevall A. Therapeutic ecacy of monoclonal
antibodies to Cryptococcus neoformans glucuronoxylomannan alone and in combination
with amphotericin B. Antimicrob Agents Chemother 1994;38:5807.
[276] Dromer F, Charreire J. Improved amphotericin B activity by a monoclonal antiCryptococcus neoformans antibody: study during murine cryptococcosis and mechanisms
of action. J Infect Dis 1991;163:111420.
[277] White M, Cirrincione C, Blevins A, Armstrong D. Cryptococcal meningitis with AIDS
and patients with neoplastic disease. J Infect Dis 1992;165:9606.
[278] Diamond RD, Bennett JE. Prognostic factors in cryptococcal meningitis: a study of 111
cases. Ann Intern Med 1974;80:17681.
[279] Nightingale SD, Cal SX, Peterson DM, Loss SD, Gamble BA, Watson DA, et al. Primary
prophylaxis with uconazole against systemic fungal infections in HIV-positive patients.
AIDS 1992;6:1914.
[280] Devi SJ, Scheerson R, Egan W, Ulrich TJ, Bryla D, Robbins JB, et al. Cryptococcus
neoformans serotype A glucuronoxylomannan protein conjugate vaccines: synthesis,
characterization, and immunogenicity. Infect Immunol 1991;59:37007.