Cryptococcosis

Cryptococcosis (also known as torulosis and European blastomycosis) usually begins as a pulmonary infection that produces no signs or symptoms. It then disseminates to extrapulmonary sites, including the central nervous system (CNS), skin, bones, prostate gland, liver, and kidneys.

With treatment, the prognosis in pulmonary cryptococcosis is good. Without treatment (particularly in immunocompromised patients), the disease can lead to CNS infection and death (invariably within 3 years). Treatment dramatically reduces mortality but not necessarily neurologic deficits, such as paralysis and hydrocephalus.

Cryptococcosis is especially likely to arrack immunocompromised patients, particularly those with Hodgkin's disease, sarcoidosis, leukemia, or lymphomas and those taking immunosuppressant drugs. The incidence is increasing, especially in patients with acquired immunodeficiency syndrome (AIDS).

Causes

Cryptococcus is one of the most common life-threatening fungal infections in AIDS patients. Cryptococcosis is an infectious disease that affects parts of the body, especially the brain and central nervous system. Most cases occur in people whose resistance to infection is lowered.

Cryptococcus neoformans, the fungus that causes this disease, is ordinarily found in soil. The onset of neurological symptoms is gradual. The majority of people with this condition have meningoencephalitis at the time of diagnosis.

• Wound or cutaneous cryptococcosis
• Pulmonary cryptococcosis
• Cryptococcal meningitis

Symptoms and Signs

• Chest pain
• Dry cough
• Headache
• Nausea
• Confusion
• Abdominal pain
• Weakness
• Fatigue
• Fever
• Glands
• Abdomen, swollen
• Prolonged bleeding

Diagnostic tests

Although imaging tests (a routine chest X-ray or computed tomography scan of the chest) showing a pulmonary lesion may point to pulmonary cryptococcosis, this infection commonly escapes diagnosis until it disseminates. A definitive diagnosis requires identification of C. neoformans by analysis or culture of the sputum, urine, prostatic secretions, or bone marrow aspirate. Other test procedures include tissue or neural biopsy.

In CNS infection, C. neoformans detected in an India ink preparation of cerebrospinal fluid (CSF) is diagnostic. Blood cultures are positive only in severe infection.

Test results that support the diagnosis include elevated antigen titer in serum and CSF in disseminated infection; increased CSF pressure, protein levels, and white blood cell count in CNS infection; and moderately decreased CSF glucose levels in about 50% of patients. Patients with AIDS typically have slight or no CSF abnormalities, although C. neoformans usually can be cultured.

Treatment

Cryptococcosis is best treated with a combination of amphotericin Band flucytosine, typically for 6 weeks. Because flucytosine may produce adverse reactions, amphotericin B alone may be used in selected cases. This therapy is continued indefinitely in the patient with AIDS. In the non-AIDS patient, weekly lumbar punctures should be performed until cultural conversion occurs.

Prevention

Minimize doses of corticosteroid medications. Safer sex practices reduce the risk of acquiring HIV and the subsequent opportunistic infections associated with a weakened immune system.

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