The granuloma in cryptococcal disease

Although we have recognized cryptococcosis as a disease entity for well over 100 years, there are many details about its pathogenesis which remain unknown. A major barrier to better understanding is the very broad range of clinical and pathological forms cryptococcal infections can take. One such form has been historically called the cryptococcal granuloma, or the cryptococcoma. These words have been used to describe essentially any mass lesion associated with infection, due to their presumed similarity to the quintessential granuloma, the tubercle in tuberculosis. Although clear distinctions between tuberculosis and cryptococcal disease have been discovered, cellular and molecular studies still confirm some important parallels between these 2 diseases and what we now call granulomatous inflammation. In this review, we shall sketch out some of the history behind the term “granuloma” as it pertains to cryptococcal disease, explore our current understanding of the biology of granuloma formation, and try to place that understanding in the context of the myriad pathological presentations of this infection. Finally, we shall summarize the role of the granuloma in cryptococcal latency and present opportunities for future investigations.     

The pursuit of cryptococcal pathogenesis: heterologous hosts and the study of cryptococcal host-pathogen interactions

Analysis of the molecular mechanisms by which a pathogen interacts with the human host is most commonly performed using a mammalian model of infection. However, several virulence-related genes previously shown to be involved in mammalian infection with Cryptococcus neoformans have also been shown to play a role in the interaction of these pathogens with invertebrates, such as Acanthamoeba castellanii, Caenorhabditis elegans, Dictyostelium discoideum, Drosophila melanogaster and Galleria mellonella. The study of host-pathogen interactions using these model hosts has allowed rapid screening of mutant libraries and can be used for the study of evolutionarily preserved aspects of microbial virulence and host response.     

Emerging themes in cryptococcal capsule synthesis

Cryptococcus neoformans, a basidiomycete yeast and opportunistic pathogen, expends significant biosynthetic effort on construction of a polysaccharide capsule with a radius that may be many times that of the cell. Beyond posing a stimulating challenge in terms of defining biosynthetic pathways, the capsule is required for this yeast to cause fatal disease. This combination has focused the attention of researchers on this system. Here we briefly review two aspects of the rapidly advancing field of capsule synthesis: the extensive variation that occurs in capsule polymers and the regulation of capsule biosynthesis.     

Mammalian model hosts of cryptococcal infection

The rising incidence of serious fungal diseases represents a growing threat to human health. Cryptococcus neoformans, an encapsulated yeast saprophyte with global distribution, has been recognized as an important emerging pathogen. Humans frequently develop asymptomatic or mild infection with C. neoformans, but individuals with impaired host defense systems may develop severe pneumonia and potentially fatal meningoencephalitis. Insight into the biology and virulence of C. neoformans is advancing rapidly and will be propelled even further by the recently completed and published genome sequences for two related strains of C. neoformans serotype D. Several mammalian model hosts including the guinea pig, rabbit, rat, and mouse have been developed for the study of cryptococcosis. The combination of microbial genomics with well-characterized model hosts that are amenable to immunologic and genetic manipulation represents a powerful resource for comprehensive study of cryptococcal disease pathogenesis as well as vaccine and antifungal drug therapy. This review provides an introduction to each mammalian model host and briefly highlights the advantages, limitations, and potential of each system for future research involving cryptococci.     

隐球菌性脑膜炎治疗的更新

隐球菌性脑膜炎(cryptococcal meningitis,CM)是一种由新型隐球菌和格特隐球菌引起的机会性真菌感染性疾病。尽管近些年来,随着CM诊断方法与治疗手段的重大进展,患者整体病死率明显下降,但其发病率在世界范围内仍呈升高趋势,在我国尤为明显。虽然CM常发生在有免疫缺陷的人群如HIV患者,但HIV阴性的人群患病率却逐年升高,且二者的治疗方案不尽相同。本文总结了国内外关于HIV阳性与HIV阴性隐球菌性脑膜炎患者治疗的新进展,旨在对HIV阳性和HIV阴性隐球菌性脑膜炎患者的治疗提供依据。     

儿童隐球菌性脑膜炎临床分析

目的分析并讨论儿童隐球菌性脑膜炎的临床特点、诊断及治疗方法等。方法回顾性分析上海长征医院皮肤科在1993年3月至2008年6月间16例经病原学确诊的隐球菌性脑膜炎患儿临床资料。结果患儿平均年龄7．25岁（2～15岁）,男女比例2．2：1,主要症状包括头痛（87．5％）、发热（81．25％）、恶心呕吐（75％）等,10例颅内压升高。确诊依据脑脊液真菌涂片、培养或隐球菌抗原检查。治疗采用两性霉素B和（或）两性霉素B脂质体静滴,5一氟胞嘧啶口服,辅以两性霉素B鞘内注射,联合氟康唑、伊曲康唑等药物治疗。16例患儿痊愈9例,病情明显好转5例,死亡2例。结论儿童隐球菌性脑膜炎起病缓慢,临床症状缺乏特异性,对疑有中枢神经系统感染性疾病时,应及早行脑脊液检查,并反复多次检查、联合检查以确定诊断,减少误诊、漏诊。早期诊断和及时、系统、足量、长程的抗真菌治疗是提高治愈率和患儿生存质量的关键。     

Functional testing and chemical composition of cryptococcal extracts

Three antigens were compared for their ability to detect immune responses in C57Bl/6 mice sensitized to Cryptococcus neoformans. Elicitation of responses in vitro was greatest with a urea extract antigen, followed in efficiency by an alkali extract and a soluble capsular polysaccharide preparation. The reactivity paralleled the protein content of the preparation.     

Development of an enzyme immunoassay for cryptococcal antibody

An enzyme immunoassay (ELISA) for measurement of cryptococcal Ig G antibody in human serum is described. Clinical studies indicate that the assay is a useful addition to the currently available techniques for measuring antibodies in cryptococcosis. IgG-specific antibody (titers 4 to 1,024) was detected in the serum of 78 % of the cryptococcosis patients tested and in 61 % of the serum from healthy individuals with positive delayed skin hypersensitivity to cryptococcin. The micro-ELISA for cryptococcal antibody is of potential value in patient management, and in epidemiological studies.     

Clinico-pathological studies on experimental cryptococcal mastitis in goats

Unilateral intramammary inoculation of 10 goats withCryptococcus neoformans (2×10⁶ yeast cells) resulted in the development of mastitis, with gross and microscopic lesions being restricted to the infected udder halves only and there was no dissemination of infection to the opposite uninfected udder halves as well as to other organs of the body. The experiment was continued for 40 days, with 2 animals each from the infected and control groups being killed on 5th, 10th, 20th, 30th and 40th day postinoculation (DPI). Initial enlargement of the infected udder halves was followed by marked decrease in size leading to very small, firm and nodular udder halves. After infection, there was also sharp fall in the milk yield. Cryptococcal organisms were demonstrated in the mastitic milk and udder impression smears with special stains.C. neoformans was reisolated from the milk of only infected udder halves up to 25th DPI. Microsopically, there was initially acute diffuse purulent mastitis which later on became chronic, characterised by marked infiltration of lymphocytes, macrophages, extensive fibrosis and development of multiple granulomas. The cryptococcal organisms could be demonstrated in the udder sections only up to 30th DPI. It is concluded that intramammary inoculation ofCryptococcus neoformans in goats leads to severe mastitis with sharp fall in milk yield.     

Ig heavy chain complex-linked genes influence the immune response in a murine cryptococcal infection.

A murine pulmonary infection with Cryptococcus neoformans (Cne) has been used to determine mechanisms regulating effective T cell-mediated immunity in the lungs. In BALB/c and C.B-17 mice, following intratracheal deposition of Cne, the fungus initially grows rapidly and is then progressively cleared from the lungs. Cne clearance in C.B-17 mice requires CD4 and CD8 T cells, IFN-gamma, and NO. Clearance in congenic BALB/c mice proceeds more slowly than in C.B-17 mice, even though the only genetic difference between these strains is at the Ig H chain-containing region of chromosome 12. Examination of the pulmonary immune response in the two strains revealed that both cleared lung Cne by T cell-dependent mechanisms and generated equivalent levels of NO. Furthermore, both strains recruited equal numbers of macrophages, lymphocytes, and neutrophils to the lungs, although BALB/c mice recruited higher numbers of eosinophils. Notably, leukocytes isolated from BALB/c lungs during infection secreted lower levels of IFN-gamma and higher levels of the Th2 cytokines IL-4 and IL-5 as compared with lung leukocytes from C.B-17 mice. Furthermore, serum levels of IgM, IgG1, IgG2a, and IgG3 anti-Cne Abs generated during infection were significantly greater in BALB/c mice than C.B-17 mice. These data suggest that although both BALB/c and C.B-17 mice clear pulmonary cryptococcosis through T cell-mediated mechanisms, Ig H chain-linked genes in BALB/c mice are associated with a decreased effectiveness of the host response, which we suggest might influence the balance in Th1/Th2 T cell subset development or increase anti-Cne Abs, or both.     

Automated analysis of cryptococcal macrophage parasitism using GFP-tagged cryptococci

The human fungal pathogens Cryptococcus neoformans and C. gattii cause life-threatening infections of the central nervous system. One of the major characteristics of cryptococcal disease is the ability of the pathogen to parasitise upon phagocytic immune effector cells, a phenomenon that correlates strongly with virulence in rodent models of infection. Despite the importance of phagocyte/Cryptococcus interactions to disease progression, current methods for assaying virulence in the macrophage system are both time consuming and low throughput. Here, we introduce the first stable and fully characterised GFP-expressing derivatives of two widely used cryptococcal strains: C. neoformans serotype A type strain H99 and C. gattii serotype B type strain R265. Both strains show unaltered responses to environmental and host stress conditions and no deficiency in virulence in the macrophage model system. In addition, we report the development of a method to effectively and rapidly investigate macrophage parasitism by flow cytometry, a technique that preserves the accuracy of current approaches but offers a four-fold improvement in speed.     

Suppression of responses to cryptococcal antigen in murine cryptococcosis

Subpopulations of spleen cells responsible for responsiveness and unresponsiveness to cryptococcal antigen in vitro were identified. Lymphocytes which responded in lymphocyte transformation (LT) assays were nylon wool nonadherent and theta antigen positive. These lymphocytes required the presence of an accessory cell which could be supplied by normal peritoneal exudate cells. Spleen cells taken from mice which had been infected for 3 to 15 days were tested to determine their ability to respond to cryptococcal antigen in LT assays. A minimal response was detected at the ninth day of infection. The response of infected spleen cells was attributed to a nonadherent lymphocyte. Nonadherent spleen cells of infected animals had enhanced responses after removal of adherent cells and addition of normal peritoneal exudate cells. Suppressor cells were detected in the spleens of infected mice by the 12th day of infection and thereafter. A nonadherent suppressor cell was identified, but indirect evidence suggested that an adherent cell could also be present in infected spleens.