Crypto lung infection
Conclusions Although rarely reported, pulmonary cryptococcal infection should be included in the differential diagnosis of hospitalized patients with respiratory symptoms, especially in those with predisposing risk factors. Chest image studies and further surgical biopsy are needed for confirmation. Peer Review reports Background Basidiomycetous fungi of the genus Cryptococcus are ubiquitously present in the environment worldwide. Of these, Cryptococcus neoformans and Cryptococcus gattii are the two main species causing disease in humans [ 1 ].
Most infected cases are community-acquired, through inhalation of infectious fungal cells from the environment, but some occasionally reported cases are related to direct traumatic inoculation or mother-to-child transmission [ 2 , 3 ]. Cases of hospital-acquired cryptococcal infections are quite rare.
Herein, we present a case of prolonged hospitalization which developed pulmonary infection by Cryptococcus neoformans after short-term steroid and azathioprine use, that was possibly related to reactivation of endogenous pulmonary foci. Case presentation A year-old female patient, who was hospitalized since 3 months, presented with complaints of paroxysmal dry cough since 2 weeks.
The patient was admitted initially due to progressive dyspnea. Respiratory distress occurred 2 days later and she was transferred to the intensive care unit ICU after intubation for mechanical ventilation. Her past medical history included hypertension and diabetes mellitus for approximately 20 years; both of which were in a stable condition with regular medication. Six months before admission, she underwent a median sternotomy and thymectomy for thymoma.
She denied having a recent travel history aboard but reported contact with a large pigeon population as there was a large dovecot near her residence. Consequently, she received several courses of plasma exchange followed by a high dose of prednisolone 30 mg daily and azathioprine 25 mg daily to treat the myasthenic crisis. Her respiratory condition improved after the therapy.
She was transferred to the general ward after successfully weaning off mechanical ventilation. Oral prednisolone and azathioprine therapy was continued. After receiving prednisolone and azathioprine therapy for nearly 3 months, she developed dry cough. The remainder of the examination including cardiovascular, respiratory, and other organ systems was unremarkable.
Arterial blood gas analysis with the patient breathing ambient air revealed pH 7. A thoracic CT scan was performed. On comparing it with the previous thoracic CT scan performed on admission Fig. Serum aspergillus galactomannan antigen testing, fungus stain and fungus culture of sputum, polymerase chain reaction PCR of sputum for mycobacterium tuberculosis were all negative. The CT-guided biopsy was performed, and its pathology revealed chronic granulomatous inflammation with multinucleated giant cells engulfing thick-wall micro-organisms Fig.
These organisms were 4—6 microns in diameter, stains bright red with Periodic Acid Schiff Fig. Because there were no neurologic symptoms and signs indicated cryptococcus meningoencephalitis, lumbar puncture was not performed. Immune status of the patient was then assessed. Except for recent immunosuppressive therapy for the myasthenic crisis, the patient revealed no evidence of malignancy or vasculitis, and human immunodeficiency virus testing was negative.
To determine the possibility of cross transmission from infected patients, we reviewed the incidence of cryptococcal infection cases in the ICU and the general ward for up to 1 month before the patient was diagnosed, but no new cryptococcal infection cases were reported. Intravenous fluconazole, mg daily, was administered for pulmonary cryptococcal infection for 14 days. Respiratory symptoms nearly resolved after treatment and the patient was discharged for outpatient follow-up with continuation of oral fluconazole mg daily.
The chest CT scan, 3 months after discharge, revealed complete clearance of the lesion Fig. No recurrence of the Cryptococcal infection has occurred to date. CT performed a at admission in the emergency department revealed no active lung lesions. The reason may be the extensive use of immune system-suppressing modalities in patients, including stem cell transplantation, organ transplantation, chemotherapy, and immunosuppressive drug therapy.
Such immunosuppressive therapies compromise the host immune system and make them vulnerable to invasive fungal infections [ 4 ]. The most common fungal species causing invasive disease is Candida, followed by Aspergillus. Macrophage receptor with collagenous structure MARCO is also a scavenger receptor which plays a role in cellular recruitment to the lung, cytokine production, and pathogen uptake by mononuclear phagocytes during early stages of cryptococcal infection However, during the adaptive phase of infection, mice deficient in MARCO have improved fungal clearance which is marker by a type-I skewed immune response.
There are other recognition receptors such as scavenger receptor A SR-A that are also associated with poorer response to Cryptococcus. SR-A-deficient mice show enhanced fungal clearance, which was correlated with decreased production of IL-4 and IL This may be linked to the unique cell wall composition of C.
Furthermore, the binding of PRRs will become hindered as the infectious propagule starts forming the polysaccharide capsule, thus, it is believed that the successful phagocytosis of Cryptococcus also requires antibody- or complement-type opsonins 41 , Current model of the immune response to Cryptococcus in health and disease. In health 1 inhaled cryptococcal spores are recognized by alveolar macrophages through pattern recognition receptors PRR.
The most common association with cryptococcal disease 7 is the absence or dysfunction of at least one aspect of the healthy immune response, which leads to uncontrolled fungal growth. Initiation of the Immune Response Although recognition and phagocytosis are important in induction of the immune response to Cryptococcus, the processes and pathways involved in breaking down and clearing pathogens and their antigens are also critical steps to mounting an optimal immune response.
One clinical study observed that in vitro macrophage phagocytosis was directly correlated with clinical outcome This suggests that other factors including phagocyte polarization and lysosomal activity may also need to be regulated for successful clearance. Unlike other intracellular pathogens such as Mycobacterium tuberculosis, cryptococci do not interfere with phagosome formation or maturation; however, they are capable of surviving within vesicles or escaping by phagosome permeabilization or vesicular release 44 — Alveolar macrophages are required; however, to recruit monocytes and dendritic cells DCs primarily through the production of macrophage chemotactic protein 1 MCP1.
These granulomas encompass the fungi and often resolve without additional medical assistance, but treatment with antifungal therapy or surgical removal of the lesions may expedite recovery. It has also been suggested that cryptococci may also be able to latently persist within granulomas and macrophages without degradation 51 , In patients with HIV-related pulmonary cryptococcosis, multinucleated giant cells are still present; however, the cryptococci are mainly extracellular and propagate within alveolar spaces DCs are considered the primary antigen-presenting cell APC in the context of cryptococcal infection and have an advantage over macrophages in stimulating T-cell proliferation Recruited DCs phagocytose cryptococcal bodies, which then are passaged through lysosomes to be degraded by both oxidative and non-oxidative mechanisms Figure 1.
For example, cathepsin-B has a non-enzymatic role to fracture the cell wall through osmotic lysis. Their ability to function as APCs is associated with a decrease in nitric oxide and hydrogen peroxide production, followed by migration to the lymphatic system However, their involvement in priming the adaptive immune response is associated with increased fungal burden and lung pathology by skewing immunity toward a type-II response 59 , The Adaptive Immune Response Involvement of the adaptive immune compartment is critical for control of a cryptococcal infection; however, it may also have a detrimental affect depending on the type of response.
On the other hand, Th2 cells, which are described as producers of IL-4, IL-5, and IL, are associated with more of a detrimental outcome such as increases in inflammation, worsened pathology, and increased risk of dissemination. In both humans and experimental murine models, deficiencies in type-II responses is linked with enhanced control of fungal burden and diminished eosinophilia, inflammation, airway damage, and dissemination 63 , Interestingly, patients with HIV infection will gradually shift from a type-I to a type-II immune response profile, thus developing an increased vulnerability to cryptococcal infection Profiling studies performed by Jarvis et al.
Humoral Immunity to Cryptococcus As previously mentioned, serum antibodies to Cryptococcus can be detected in early life. However, immunocompromised patients at risk for cryptococcal infection appear to have a defect in antibody responses, such as loss of glucuronoxylomannan GXM , a capsular component reactive B-cells, as well as overall lower levels of peripheral blood memory IgM B cells 69 , Antibody-mediated phagocytosis may be important as the increase in capsular size has been shown to reduce complement-mediated phagocytosis Furthermore, murine studies have demonstrated that the murine equivalent of IgM memory B cells, B-1 cells, can dampen fungal growth in vitro and in vivo, by inducing an earlier T-cell response, reducing dissemination, and enhancing macrophage phagocytosis 75 — The use of vaccines or antibody therapy to boost antifungal titers may thus provide protection against the development of cryptococcal disease 79 — Cryptococcal Elimination The primary mechanism for pulmonary clearance is the formation and resolution of granulomas by macrophages.
M1 and M2 macrophages in vitro have demonstrated different outcomes during intracellular parasitism by C. Furthermore, STAT1-deficient mice, which are deficient in M1 macrophages due to an inability to generate a strong Th1 profile, have a defect in anti-cryptococcal activity, which correlated with a decrease in NO production There are currently three known methods of cryptococcal dissemination from the lung: 1 the disruption of blood vesicle integrity allowing passive transport into the blood stream, 2 intact endothelial cells may phagocytose the spores from the lung and expulse them into the blood stream, 3 macrophages may act as a Trojan Horse by transporting phagocytosed spores to the brain, and regurgitating the spores in a process known as vomocytosis.
Both microbial and host factors have been identified to be involved in CNS invasion, including cryptococcal matrix metalloprotease, production of a urease enzyme 88 , and increases in host brain inositol levels 89 , Studying this population reveals unique vulnerability risks, including previously undiagnosed, rare immune-associated monogenic disorders or autoimmune diseases.
Interestingly, poor macrophage function was also demonstrated in a cohort of clinically refractory patients by a lack of iNOS expression and intact M2-related CDR1 expression using immunohistochemistry of infected brain tissue However, ICL is a very heterogeneous disorder that has been implicated as a serious risk factor 92 , 93 but many patients with ICL remain healthy.
Similarly, patients with monocytopenia, such as patients with a GATA2 deficiency, also have increased risk of developing CM 95 — Monogenic disorders such as X-linked CD40L deficiency, chronic granulomatous disease, and Job syndrome are also associated with susceptibility to CM 98 — T-cell suppressing biological therapy such as natalizumab or fingolimod is also a risk factor , Cryptococcal Disease: A Reflection of Host and Microbiological Factors Recently, there has been a greater appreciation that host damage can occur from either the toxic products of an overwhelming microbial infection or a pathological inflammatory response to the invading pathogen Figure 1.
Cryptococcal disease is a classic example of this phenomenon, often occurring within the same patient during different stages of treatment , For example, in the setting of HIV infection, clinical outcomes of primary therapy are related to clearance of the fungus , However, a paradoxical immune reconstitution syndrome can also be seen in these same patients whereby, in the setting of microbiological control, reconstitution of the immune system after initiation of antiretroviral therapy ART results in a pathological central nervous system inflammatory response 7 , —
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These cookies may also be used for advertising purposes by these third parties. Confirm Choices Confirmed! Laboratory findings are nonspecific but inflammatory markers such as the erythrocyte sedimentation rate or C-reactive protein and the lymphocyte count are frequently elevated.
The loose connective tissue plugs occupying the alveolar spaces often connect to other connective tissue plugs in nearby alveoli via the pores of Kohn creating a characteristic butterfly pattern on histology. The white patches may seem to migrate from one area of the lung to another as the disease persists or progresses. Computed tomography CT may be used to confirm the diagnosis.
Often the findings are typical enough to allow the doctor to make a diagnosis without ordering additional tests. Many times, a larger specimen is needed and must be removed surgically.
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Lung Infection; Lung Abscess, Aspiration Syndromes, Systemic fungi
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