|Year : 2013 | Volume
| Issue : 1 | Page : 56-60
Prevalence of cryptococcal meningitis in patients of acquired immunodeficiency syndrome: A single center experience from Regional Institute of Medical Sciences
S Bhagyabati Devi, Robinson Ningshen, G Arvind, Evangelyne Synrem, Th Shanti Devi, T Brojen Singh
Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||17-Aug-2013|
S Bhagyabati Devi
Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Objectives : To study the profile of cryptococcal meningitis in acquired immunodeficiency syndrome (AIDS) patients. Materials and Methods: AIDS cases admitted in the medicine ward of Regional Institute of Medical Sciences, Imphal from July 2003 to June 2011, with signs and symptoms of meningitis were included in the study. Routine cerebrospinal fluid (CSF) analysis, India ink preparation, cryptococcal antigen latex agglutination (CALA), adenosine deaminase, Vitek-2 technology for species identification, culture, and sensitivity for CSF, serum CALA, skin scraping, fine needle aspiration cytology from lymph nodes, sputum for Acid Fast Bacillus, Cryptococcus by Giemsa stain, computed tomography scan/magnetic resonance imaging brain, CD 4 T-cell count, HbsAg, Hepatitis C Virus-Ab and Venereal Disease Research Laboratory test were done for all patients. Results : Out of 391 AIDS cases, 89 had cryptococcal meningitis. Age ranged from 21 years to 61 years (Male:Female = 3.4:1). CSF findings were suggestive of chronic meningitis in 71 (78.86%) cases. Causative species of Cryptococcus strains were Cryptococcus neoformans in 86 cases and Cryptococcus albidus in 3 cases. India ink was positive in CSF examination in 74 (83.1%) cases while CSF and serum CALA were positive in 84.3% and 100% cases respectively.Mean CD4T-cell count was 44.64 ± 25.3. Commonest co-opportunistic infection was tuberculosis (n = 8). Hepatitis B virus and HCV co-infection was found in 2 and 5 cases respectively. Six cases out of 19 Anti-Retroviral treatment naοve patients developed cryptococcal meningitis as a result of Immune reconstitution inflammatory syndrome. Conclusion: Cryptococcosis is still prevalent in AIDS and new variants of cryptococcus other than C. neoformans have been detected.
Keywords: Cryptococcosis, Cryptococcus neoformans, Cryptococcus albidus
|How to cite this article:|
Devi S B, Ningshen R, Arvind G, Synrem E, Devi TS, Singh T B. Prevalence of cryptococcal meningitis in patients of acquired immunodeficiency syndrome: A single center experience from Regional Institute of Medical Sciences. J Med Soc 2013;27:56-60
|How to cite this URL:|
Devi S B, Ningshen R, Arvind G, Synrem E, Devi TS, Singh T B. Prevalence of cryptococcal meningitis in patients of acquired immunodeficiency syndrome: A single center experience from Regional Institute of Medical Sciences. J Med Soc [serial online] 2013 [cited 2020 Oct 21];27:56-60. Available from: https://www.jmedsoc.org/text.asp?2013/27/1/56/116647
| Introduction|| |
Cryptococcosis is a serious fungal infection in immune-compromised patients or other T-cell mediated host defense disturbed conditions.  The disease has been known to mankind since 1890's. Its incidence remained stable till the mid-twentieth century. Ever since the epidemic of HIV in the early 1980's, its incidence has increased among patients of acquired immunodeficiency syndrome (AIDS).Cryptococcus (C) neoformans (serotype A and D) and Cryptococcus gatti (serotype B and C) are the two major variants causing cryptococcosis in AIDS patients.
World-wide 90% of cryptococcal infection is due to C. neoformans.  Other variants of Cryptococcus like Cryptococcus albidus, C. curvatus, C. humicolus, C. uniguttulatus, C. laurentii etc. have been isolated as opportunistic pathogens among AIDS patients and other immunosuppressed patients. Such variants of Cryptococcus were thought to be non-pathogenic.They also possess capsular polysaccharide, a virulent co-factor as C. neoformans, and can be pathogenic in HIV infected patients. ,,,,,
About 10% of AIDS patients develop cryptococcal meningitis as their first AIDS defining disease. , It affects more than one million people and causes 600,000 deaths worldwide annually. In USA, there are more than 1000 cases of cryptococcal meningitis each year in New York alone, a figure far exceeding that of all cases of bacterial meningitis.  Kozel noted a higher incidence of the infection in developing countries than in developed countries. 
Clinically, cryptococcosis most frequently presents as meningitis (50%) and pulmonary infection (20%) while few may manifest with lesions in skin, bone, adrenals and lymph nodes. It may also present in sub-acute form without overt meningitis or encephalopathy. Diagnosis of the infection is confirmed by serum and cerebrospinal fluid (CSF) cryptococcal antigen latex agglutination (CALA), CSF routine examination, a positive India ink demonstration of the fungus and fungal culture and identification of the species variant.
Cryptococcal meningitis can also manifest as a result of immune reconstitution inflammatory syndrome (IRIS) which can occur in two forms (1) Unmasking IRIS in which cryptococcal symptoms appear after initiation of highly active antiretroviral therapy (HAART) and (2) Paradoxical IRIS which occurs during treatment of cryptococcosis and initiation of HAART. It can occur within few days or as late as 6 months, due to restoration of pathogen specific CD4 T-cells. Risk-factors for developing IRIS in cryptococcal meningitis are (1) severe cryptococcal fungaemia, (2) extremely low CD4 T-cell count, (3) Cryptococcus revealing initial HIV infection, (4) non-initiation of antiviral therapy, (5) failure to achieve CSF sterilization at the 2 nd week of treatment, (6) induction of HAART during early part of antifungal induction therapy, and (7) rapid initial decrease in HIV load in response to HAART. 18 With the introduction of HAART, cryptococcal meningitis incidence has decreased drastically in developed countries. However, the incidence and mortality rates are still high in countries where there is limited access to HAART, and HIV infection still remains uncontrolled.
| Materials and Methods|| |
AIDS patients admitted from July 2003 to June 2011 in the medicine ward, Regional Institute of Medical Sciences Hospital were included in the study after clearance from the ethics committee. Written consent was taken for all the patients having signs and symptoms of meningitis. All cases were sent for hematological examination, serum CALA and CSF examination for routine, India ink preparation, acid fast bacillus, adenosine deaminase, CALA and gram stain. Tissue specimens from skin scraping and fine needle aspiration cytology from lymph nodes or skin lesions were also sent for detection of Cryptococcus by Giemsa stain. Culture of the CSF by Saboroud dextrose agar without cycloheximide at 25°C and 37°C was done for 5-7 days. Identification of the species was done by Vitek-2 technology. Sputum for AFB, gram stain, and culture sensitivity was done from patients associated with cough. Stool and urine were also examined for the presence of Cryptococcus. Venereal Disease Research Laboratory test, Hepatitis C virus-Ab and HbsAg screening for co-infection were also done. CD4 T-cell count was done by Flourescent Activated Cell Sorter method.
Kidney function Test was repeated 3 times a week during induction phase with IV amphotericin-B. Treatment was started with IV amphotericin-B 0.5 mg/kg body weight as test dose on the 1 st day followed by 1 mg/kg body weight in 500 ml of 5% D/W from 2 nd day without flucytosine till CSF culture became sterile. This was followed by oral fluconazole 200 mg daily for 8-12 weeks. HAART was initiated on the 15 th day after the initiation of antifungal therapy. All patients were advised to attend Anti-Retroviral treatment center for follow-up.
| Results|| |
Out of the 391 AIDS cases admitted with signs and symptoms of meningitis, 89 (22.7%) cases were cryptococcal meningitis. The age of the patients ranged from 21 years to 65 years with a mean of 30.8 ± 8.88 years [Table 1] and male to female ratio was 3.4:1. Risk-factors were intravenous drug use (IDU)(64.73%) and sexual promiscuity (35.27%). Major clinical features were headache in 86% (n = 78), fever in 61% (n = 55), meningismus in 61% (n = 55), seizures in 23% (n = 21). 20.22% (n = 18) patients presented with altered sensorium, 8.9% patients had photophobia, 1.1% patient had 7 th cranial nerve palsy with pyramidal tract lesion [Figure 2]. Duration of the signs and symptoms ranged from 14 days to 21 days. One case presented with associated pulmonary involvement and dissemination to the skin, gastrointestinal and urinary tract. Another case associated with cervical lymphadenopathy with dissemination to skin and gastrointestinal tract presented with fever and jaundice on admission. Isolated cryptococcal variants were C. neoformans in 86 cases and C. albidus in 3 cases. CSF picture was normal in 19 cases. Seventy cases had increased protein level (134.47 ± 98 mg/dl), low sugar (37.68 ± 20.8 mg/dl), cells (28.26 ± 28 ± 68/cumm) with lymphocytes 92%, and neutrophils 8% in CSF routine examination.
|Table 1: The epidemiological profile of the cryptococcal meningitis patients |
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CSF India ink positivity rate was 82.1% whereas CSF and serum CALA were positive in 84.3% and 100% respectively. Three (3.3%) cases had papilloedema with signs of increased intracranial pressure of which one had associated Cytomegalovirus retinitis with choroiditis. There were 8 (8.9%) cases of co-infection with tuberculosis (pulmonary = 3 and extra pulmonary = 5), 7.8% (n = 7) cases with associated oral candidiasis, 4.4% (n = 4) with CMV retinitis, 3.3% (n = 3) with herpes zoster, 3.3% (n = 3) with herpes labialis, 2.2% (n = 2) with HBV co-infection and 5.6% (n = 5) with HCV co-infection [Figure 1]. CD4 T-cell count ranged from 4 cells/cumm to 101 cells/cummwith a mean of 44.69 ± 25.31 cells/cumm with the highest incidence of cryptococcal infection (52 patients) occurring in the range of 20-40 cells/cumm [Table 2]. Six (31.5%) patients out of the 19 HAART naive patients developed cryptococcal meningitis with 1 week of initiation of HAART. Their CD4 T-cell count ranged from 7 cells/cumm to 20 cells/cumm.
Computed tomography (CT) scan/Magnetic resonance imaging (MRI) brain was normal in 73.03% (n = 65) cases. 3 had tuberculoma, 7 cases had cryptococcoma, 4 had lacunar infarction in the basal ganglia with pyramidal tract lesion, 2 had cerebellar infarct, 1 had fronto-parietal infarct and 1 had parietal infarct. 5 patients were positive for Toxoplasmosis serology (both IgG and IgM). 4 patients were positive of CMV Ab (IgG and IgM) and 3 cases had herpes simplex antibody positivity along with cryptococcal infection.
|Table 2: CD4+ T cell count of the patients with cryptococcal meningitis |
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|Figure 1: A Chest X-ray in the patient in the study showing a pulmonary cryptococcoma in the left middle zone|
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|Figure 2: MRI Brain T1W image of a patient in the study having multiple cryptococcomas in the brain and clinically presenting with 7th cranial nerve palsy|
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| Discussion|| |
Cryptococcosis is the second most common isolated fungal pathogen in patients with AIDS and is the most life-threatening mycotic infection.  Risk-factors include cigarette smoking, IDU, exposure to dust enriched with bird droppings, and a low CD4 T-cell count. In males, prostate is the most common site, where the fungus harbors and lungs are the common site for both males and females. 
In our study, we found the male to female ratio of 3.4:1 which is in conformity with that of Bogaerts et al.  while it was lower than that of Lakshmi et al.  In Manipur, the peak season for this disease is during dry and windy season (December to March) and is more common in people residing in hilly areas.It is usually seen in patients with CD4 T-cell count of <100 cells/cumm.  Our cases also had low CD4 T-cell counts ranging from 4 cells/cumm to 101 cells/cumm with an incidence of 65.9% with CD4 T-cell count between 20 cells/cumm and 60 cells/cumm. There were cases associated with other opportunistic infections like tuberculosis, oral candidiasis, toxoplasmosis, herpes zoster, and herpes simplex and co-infections with HBV and HCV. On the other hand, the incidence of this fungal infection is a declining trend after the introduction of ART center in our hospital since April 2004 (2003-2007 vs. 2007-2011:28.7%vs. 3.2).
India Ink preparation positivity was 82.1%. CSF CALA was positive in 84.3% and serum CALA was positive in all cases (100%). India Ink preparation can be negative if the fungal cells have higher number of less capsulated fungal particles. Rugen Wan from China developed a less expensive, cost effective stain known as Wan's stain which is superior to Alcian blue and India Ink preparation. 
Out of the 89 cases of Cryptococcus in our study, we found 86 cases of C. neoformans and 3 cases of C. albidus (detected by Vitek-2 technology). They were treated with IV amphotericin-B. C.albidus was traditionally not a pathogenic yeast, but shares many biochemical characteristics like capsular antigen similar to C. neoformans. CALA has been reported to yield negative results in many of them.However, sometimes titre was considerably high in both serum as well as CSF. This fungus grows at 25°C but fails to grow at 37°C unlike other species of cryptococcus.  In this study, 6 patients out of 19 HAART naive AIDS cases developed cryptococcal meningitis on the 5 th -7 th day after initiation of HAART as a result of IRIS. The presence of cerebral lesions during the initial treatment phase of the disease is not predictive of the subsequent occurrence of symptomatic cerebral IRIS.  Three cases which had associated tuberculoma were differentiated from cryptococcoma as a result of the presence of surrounding inflammatory perilesional cerebral edema with the presence of their supportive test for tuberculosis and positive inflammatory granuloma in the brain. Cryptococcoma mimics parenchymal brain mass which needs biopsy or aspiration study of the brain lesion for confirmation. MRI was more effective than CT scan in identifying central nervous system cryptococcal lesions. 7.8% (n = 7) cases of cryptococcal meningitis showed enhancement of CT/MRI pictures with signs of raised intracranial pressure in 3.7% cases with papilledema which was in accordance with other studies. ,, The case of pulmonary cryptococcoma showed multiple reticular lesions with positive sputum, urine, and stool for C.neoformans by Giemsa stain. Skin scrapings and FNAC from lymph nodes also demonstrated presence of C. neoformans by Giemsa stain. Cryptococcal meningitis was treated as per National AIDS Control Organisation guidelines. 
| Conclusion|| |
There are many reports of increasing number of recombinant strains in nature becoming more virulent than their parent species and drug resistance to conventional antifungals. Thus physicians dealing with HIV/AIDS should have proper knowledge of the various species and strains of Cryptococcus. This study reveals that C. neoformans is not the only variant that is prevalent in Manipur. Further studies are required to identity other strains of the species.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]