Induction of Protective Immunity Against Cryptococcosis

Cryptococcus neoformans, the predominant etiological agent of cryptococcosis, is an encapsulated fungal pathogen that can cause life-threatening infections of the central nervous system in immune compromised individuals resulting in high morbidity and mortality. Consequently, several studies have endeavored to understand those mechanisms that mediate resistance and susceptibility to Cryptococcus infection. In this review, we will examine the contributions of various components of the innate and adaptive immune response toward protection against cryptococcosis. We will focus our discussion on studies presented at the 8th International Conference on Cryptococcus and Cryptococcosis (ICCC). Remarkable progress has been made toward our understanding of host immunity and susceptibility to cryptococcal infection and the potential for vaccine development.     

Cryptococcosis and pets

This paper is a review of cryptococcosis in domestic animals. Cryptococcosis is an uncommon mycosis in domestic animals and its occurrence is sporadic. The disease is caused by Cryptococcus neoformans, although Cryptococcus gattii has been also isolated from different animal species. Although cryptococcosis has been reported in several animal species, the most frequently affected domestic animal is the cat. The present paper deals with feline and canine cryptococcosis, its common clinical signs and the different clinical forms of the disease in these species. The diagnosis and treatment of cryptococcosis is also discussed. Diagnosis usually includes cytologic examination, capsular antigen detection and culture and identification of the Cryptococcus species. The management of criptococcosis will review the most common therapeutic agents and their role in therapy. Finally, we will address the situation of cryptococcosis in domestic animals in Spain and the role of cryptococcosis as a zoonotic disease and its public health importance.     

Ten Challenges on Cryptococcus and Cryptococcosis

Cryptococcosis has become a significant public global health problem worldwide. Caused by two species, Cryptococcus neoformans or Cryptococcus gattii, this life-threatening infection afflicts not only immunocompromised individuals but also apparently immunocompetent subjects. Hence, cryptococcosis should no longer be considered merely an opportunistic infection. In this article, we focus on ten unanswered questions/topics in this field with the hope to stimulate discussion and research on these topics that would lead not only to a better understanding of the physiopathology of this disease but also to a better diagnosis and prognosis.     

肝移植后播散性隐球菌病1例及其实验研究

目的播散性隐球菌病临床及实验研究。方法患者女,47岁,肝移植术后2 d,面部、肩部、四肢皮肤出现多发溃疡,伴昏迷。通过脑计算机断层扫描、皮损组织病理检查、PAS染色、皮损组织真菌培养及激光俘获显微切割结合PCR扩增序列分析确诊,并对获得菌株进行尿素酶试验、API试验、PCR扩增测序等实验研究。结果皮损组织病理可见大量圆形和椭圆形菌体,PAS染色阳性。血液和脑脊液真菌镜检均为阴性。皮损组织真菌培养可见酵母样菌落生长,菌株尿素酶试验阳性,API试验鉴定为新生隐球菌。ITS区序列分析鉴定为新生隐球菌grub ii变种。激光俘获显微切割结合PCR扩增,序列分析与培养获得的菌株直接PCR扩增后序列分析结果一致。脑脊液特异性隐球菌抗原（＋＋）,血液特异性隐球菌抗原（＋＋＋＋）。脑CT显示为多发结节灶。依据临床及实验室检查确诊为播散性隐球菌病,致病菌为新生隐球菌grubii变种。结论通过对该病例的深入研究,为临床明确诊断播散性隐球菌病奠定基础,确立了显微切割技术在皮肤真菌感染中的应用价值。     

Know Your Enemy: How to Build and Vanquish a Global Fungal Scourge

The 8th International Conference on Cryptococcus and Cryptococcosis, chaired by Maurizio Del Poeta (Medical University of South Carolina), and organized together with June Kwon-Chung (National Institute of Allergy and Infectious Diseases), Stuart Levitz (University of Massachusetts Medical School), and John Perfect (Duke University), occurred in May 2011. This meeting brought together the world's leading researchers on Cryptococcus and cryptococcosis, including basic scientists, epidemiologists, and clinicians, to discuss new developments in Cryptococcus biology. With more than 60 oral presentations and 180 posters, this meeting enhanced our understanding of pathogenicity of Cryptococcus and served as a robust forum that facilitated cross-disciplinary discussions, research, and clinical collaborations. Due to space constraints, this brief overview highlights only a few of the topics discussed in this meeting, focusing on the evolution of virulence, host and pathogen interactions, fungal and host signaling, new advances of genomics studies on Cryptococcus, and the current status of the outbreak caused by C. gattii. The 8th International Conference on Cryptococcus and Cryptococcosis brought together scientists from across the globe in the beautiful historical downtown setting of Charleston to share their latest findings and highlight advances in Cryptococcus research. With more than 250 participants, this meeting was the largest gathering of the Cryptococcus international community in the 24-year history. Here, we review the advances presented and the current state of knowledge in the field.     

我国新生隐球菌临床株基因型分析

为了解中国大陆地区新生隐球菌临床株基因型分布情况, 我们对来自我国中东部地区的18个省、直辖市的120株血清A型和9株血清B型新生隐球菌临床株采用PCR指纹分析、IGS序列测定和MLST(Multilocus sequencing test)方法进行分析。结果显示血清A型菌株的M13指纹图谱中主要条带与VNI型标准株相同, 但次要条带与VNI现有各亚型均不相符, 我们将这种新VNI亚型命名为VNIc型, 但VNIc型并不只分布在中国大陆, MLST分析显示中国大陆地区的VNIc型菌株同来自美国、日本、马拉维和巴西的7株菌株亲缘关系高达75, 提示VNIc型可能是一种世界范围内分布的基因型; 对血清A型菌株采用(GACA)4和URA-5 RFLP指纹分析则呈现与VNI标准株完全一致的主次条带; 9株血清B型菌株基因型为VGI型。本研究初步揭示了我国大陆地区新生隐球菌临床株的基因型分布。     

Cryptococcal therapies and drug targets: the old,the new and the promising

Half a century after the introduction of Amphotericin B the management of cryptococcosis remains unsatisfactory. The disease, caused primarily by the two fungal species Cryptococcus neoformans and Cryptococcus gattii, remains responsible for considerable morbidity and mortality despite standard medical care. Current therapeutic options are limited to Amphotericin B, azoles and 5‐flucytosine. However, this organism has numerous well‐characterized virulence mechanisms that are amenable to pharmacological interference and are thus potential therapeutic targets. Here, we discuss existing approved antifungal drugs, resistance mechanisms to these drugs and non‐standard antifungal drugs that have potential in treatment of cryptococcosis, including immunomodulatory strategies that synergize with antifungal drugs, such as cytokine administration or monoclonal antibodies. Finally, we summarize attempts to target well‐described virulence factors of Cryptococcus, the capsule or fungal melanin. This review emphasizes the pressing need for new therapeutic alternatives for cryptococcosis.     

面部原发性皮肤隐球菌病1例

报道1例自身免疫功能正常的原发性皮肤隐球菌病。患者因"面部红斑进行性加重半年,破溃伴结痂2个月余"来我科就诊,皮肤科检查可见左侧面颊部3 cm×5 cm大小红斑,边界清楚,中央可见数片浅溃疡,覆盖灰褐色痂皮。病理检查示真皮浅层及深层可见大量炎性细胞浸润,PAS染色见大量紫红色孢子聚集在多核巨细胞内外;阿申蓝染色阳性;粘蛋白卡红染色阳性;免疫组化染色(抗体为兔抗隐球菌抗体)可见棕色圆形孢子。根据其临床症状、病理检查、特殊染色及免疫组化染色,确诊为原发性皮肤隐球菌病。经伊曲康唑治疗痊愈。     

Cryptococcosis in HIV-negative Patients with Renal Dialysis: A Retrospective Analysis of Pooled Cases

Cryptococcosis is a lethal fungal infection mainly caused by Cryptococcus neoformans/C. gattii species. Currently, our understanding of cryptococcosis episodes in HIV-negative patients during renal dialysis remains scarce and fragmented. Here, we performed an analysis of pooled cases to systemically summarize the epidemiology and clinical characteristics of cryptococcosis among HIV-negative patients with renal dialysis. Using pooled data from our hospital and studies identified in four medical databases, 18 cases were identified and analyzed. The median duration time of renal dialysis for peritoneal renal dialysis and hemodialysis cases was 8 months and 36 months, respectively. Several non-neoformans/gattii species were identified among the renal dialysis recipients with cryptococcosis, particularly Cryptococcus laurentii and Cryptococcus albidus, which share similar clinical manifestations as those caused by C. neoformans and C. gattii. Our analyses suggest that physicians should consider the possibility of the occurrence of cryptococcosis among renal dialysis recipients even when cryptococcal antigen test result is negative. The timely removal of the catheter is crucial for peritoneal dialysis patients with cryptococcosis. In addition, there is a need for optimized antifungal treatment strategy in renal dialysis recipients with cryptococcal infections.     

Recovery of Cryptococcus neoformans from the nasopharynx of AIDS patients

Nasopharyngeal swabbings, obtained from AIDS patients, were plated onto Niger seed agar containing antibiotics. Cryptococcus neoformans was isolated from 35 out of 84 patients (41.7%) diagnosed as primary cryptococcal cases before antifungal administration, and 8 out of 86 (9.3%) cryptococcosis patients on antifungal therapy. The fungus could not be isolated from any of 447 samples from 194 AIDS patients not diagnosed with cryptococcosis. These findings are novel in that the presence of C. neoformans in AIDS patients at this site has never been looked at previously. This revised version was published online in June 2006 with corrections to the Cover Date.     

适应性策略：人类致病真菌新生隐球菌的“杀手锏”

绝大多数引发人体系统感染的致病真菌来自于环境,这些环境来源的真菌往往是条件致病菌,其毒力衍生于它们独特的生境适应策略。新生隐球菌是进化最为成功的环境真菌之一,在自然界中的分布极为广泛。而作为人类致病菌,新生隐球菌能够引发致命的隐球菌病和真菌脑膜炎,据统计全球每年由于隐球菌病死亡的人数超过60万人。近几年的研究表明,新生隐球菌的环境适应策略对其条件致病性至关重要。细胞-细胞交流、细胞形态转换和细胞异质性等重要环境适应行为在协调新生隐球菌的致病性方面都扮演了重要的角色。文章从致病菌-自然栖居环境-人类宿主三方的关系解析了新生隐球菌环境适应策略影响毒力的机制及相关进化动机,并对其潜在的研究前景和临床应用提出了一些思考。     

Cutaneous Cryptococccosis Due to Cryptococcus gattii in Immunocompetent Hosts: Case Report and Review

Cutaneous cryptococcosis caused by C. gattii, in immunocompent patients is a rare manifestation of disease, and may be one of the first manifestations of disseminated cryptococcosis. We report a case of disseminated cryptococcosis caused by Cryptococcus gattii presenting as cutaneous lesions in an immunocompetent patient. Previously to our report, only five cases of cutaneous involvement by Cryptococcus gattii in immunocompetent patients have been reported in the literature. Risk factors for C. gattii infection included exposure to the eucalypt reservoirs in tropical and subtropical areas. Skin involvement corresponded to the disseminated form of cryptococcosis in the majority of patients, and commonly affected the face and neck with different morphologies including papules, pustules, plaques, ulcers, subcutaneous masses, cellulitis or acneiform lesions. Due to the severity of this infection and the life threatening condition that it represents, clinicians must be aware that cutaneous involvement may be one of the first manifestations of disseminated cryptococcosis caused by C. gattii especially in patients living and coming from endemic areas.     

Cryptococcus neoformans of Unusual Morphology

A case of primary cryptococcosis of the lungs was caused by an isolate of Cryptococcus neoformans that assumes a giant form in tissue but which has a normal appearance on artificial culture. Electron microscopy revealed gross enlargement of the capsule and plasma membranes in the tissue form.     

Intra-abdominal Cryptococcosis by Cryptococcus gattii: Case Report and Review

Although abdominal cryptococcomas and visceral cryptococcal lymphadenitis as part of disseminated fungal infection have been reported mostly in HIV-infected patients, localized intra-abdominal involvement due to Cryptococcus gattii has not been previously described in non-HIV-infected patients. In general, a smaller proportion of cryptococcosis is caused by C. gattii. We report here on a type II diabetic HIV-negative patient who presented with a localized intra-abdominal cryptococcal mass due to C. gattii. In addition, we review the general aspects of intra-abdominal and gastrointestinal involvement by Cryptococcus neoformans in the literature and discuss the importance of identifying the C. neoformans varieties and C. gattii in routine laboratories.     

Epidemiological Profile of Cryptococcal Meningitis Patients in Rio Grande do Sul,Brazil

Cryptococcosis is a major opportunistic mycosis which has meningitis as its most frequent clinical presentation and can be fatal in the absence of antifungal therapy. The aetiological agents are Cryptococcus neoformans, which affects mainly immunocompromised subjects, and C. gattii, the aetiologic agent for cryptococcosis in healthy individuals. A recent outbreak of cryptococcosis on Vancouver Island, Canada, raised the level of concern about the epidemiology of this disease. In Brazil, between 1980 and 2002, six per cent of AIDS patients had cryptococcosis in course at the time of diagnosis. To identify the profile of cryptococcal meningitis patients in Rio Grande do Sul (RS), Brazil, a retroactive study was realized using data from patients registered at Laboratório Central de Saúde Pública IPB-LACEN/RS from 2000 to 2005. Most of the patients were men (77.12%), Caucasian (83.5%), median age between thirty and thirty-nine years old (46.24%) and HIV positive (95%).     

Identification and characterization of Cryptococcus neoformans protein fractions that induce protective immune responses

Cryptococcus neoformans, the main causative agent of cryptococcosis, is a fungal pathogen that causes life‐threatening meningoencephalitis in immunocompromised patients. To date, there is no vaccine or immunotherapy approved to treat cryptococcosis. Cell‐ and antibody‐mediated immune responses collaborate to mediate optimal protection against C. neoformans infections. Accordingly, we identified cryptococcal protein fractions capable of stimulating cell‐ and antibody‐mediated immune responses and determined their efficacy to elicit protection against cryptococcosis. Proteins were extracted from C. neoformans and fractionated based on molecular mass. The fractions were then evaluated by immunoblot analysis for reactivity to serum extracted from protectively immunized mice and in cytokine recall assays for their efficacy to induce pro‐inflammatory and Th1‐type cytokine responses associated with protection. MS analysis revealed a number of proteins with roles in stress response, signal transduction, carbohydrate metabolism, amino acid synthesis, and protein synthesis. Immunization with select protein fractions containing immunodominant antigens induced significantly prolonged survival against experimental pulmonary cryptococcosis. Our studies support using the combination of immunological and proteomic approaches to identify proteins that elicit antigen‐specific antibody and Th1‐type cytokine responses. The immunodominant antigens that were discovered represent attractive candidates for the development of novel subunit vaccines for treatment and/or prevention of cryptococcosis.     

Medium Containing Trypan Blue and Antibiotics for the Detection of Cryptococcus neoformans in Clinical Samples

A medium containing trypan blue, gentamicin, and chloramphenicol is introduced for the detection of Cryptococcus neoformans and Cryptococcus species from clinical samples. Ten recently isolated strains of Cryptococcus species as well as several clinical isolates of C. neoformans incorporated trypan blue and produced dark blue colonies on this mycological medium, whereas other common yeasts were light blue. The laboratory diagnosis of two cases of cryptococcosis was accomplished by the isolation of C. neoformans on the antibiotic-dye-containing medium. Compared to conventional media supporting large numbers of Pseudomonas aeruginosa and other gram-negative bacilli, the new medium was selective for yeasts. In one instance, the colonization of the respiratory tract by C. neoformans which led to fungemia was traced by the use of the antibiotic-dye medium. The antibiotic mixture, utilized herein, was more effective in suppressing bacteria contained in samples from patients than a medium containing cycloheximide and chloramphenicol.     

Clonality and recombination in genetically differentiated subgroups of Cryptococcus gattii

Cryptococcus gattii is a pathogenic yeast that together with Cryptococcus neoformans causes cryptococcosis in humans and animals. High numbers of viable C. gattii propagules can be obtained from certain species of Australian Eucalyptus camaldulensis trees, and an epidemiological link between Eucalyptus colonization and human exposure has been proposed. However, the highest prevalence of C. gattii cryptococcosis occurs in Papua New Guinea and in regions of Australia where the eucalypt species implicated to date are not endemic. This study investigated the population structure of three geographically distinct clinical and veterinary populations of C. gattii from Australia and Papua New Guinea. All populations that consisted of a genotype found frequently in Australia (VGI) were strongly clonal and were highly differentiated from one another. Two populations of the less common VGII genotype from Sydney and the Northern Territory had population structures inferring recombination. In addition, there was some evidence of reduced genetic differentiation between these geographically remote regions. In a companion study presented in this issue, VGII isolates were overwhelmingly more fertile than those of the VGI genotype, giving biological support to the indirect assessment of sexual exchange. It appears that the VGI genotype propagates clonally on eucalypts in Australia and on an unknown substrate in Papua New Guinea, with infection initiated by an unidentified infectious propagule. VGII isolates are completing their life cycles and may be dispersed via sexually produced basidiospores, which are also likely to initiate respiratory infection.     

The Eiken Latex test for detection of a cryptococcal antigen in cryptococcosis

A latex agglutination test for cryptococcal antigen, the Eiken Latex test (Eiken, Tokyo, Japan), was compared with a monoclonal antibody-based agglutination assay, Pastorex^® Cryptococcus (Diagnostics Pasteur, Marneur-la-Coquette, France). In a murine model of disseminated cryptococcosis, the kinetics of the antigen titers by the Eiken Latex were similar to those by the Pastorex^® Cryptococcus, but sensitivity was much higher. In HIV-negative patients with pulmonary cryptococcosis, a cryptococcal antigen was detected in 6 of 10 patients by the Eiken Latex test and in only 3 of those patients by the Pastorex^® Cryptococcus. The results indicate that the Eiken Latex is more sensitive for the detection of the cryptococcal antigen, even in non-disseminated cryptococcosis. The sensitivity and specificity of the Eiken Latex were examined using 195 sera from 25 patients with pulmonary cryptococcosis and 170 patients with non-cryptococcosis. The cutoff value of 1:8 showed a sensitivity of 76% (19/25) and a specificity of 98.9% (168/170).