Pulmonary Cryptococcal Infection Research Articles

Murine Models of Cryptococcus Infection.

Cryptococcus is recognized as one of the emerging fungal pathogens that have major impact on diverse populations worldwide. Because of the high mortality rate and limited antifungal therapy options, there is an urgent need to understand the impact of dynamic processes between fungal pathogens and hosts that influence cryptococcal pathogenesis and disease outcomes. With known common limitations in human studies, experimental murine cryptococcosis models that can recapitulate human disease provide a valuable tool for studying fungal virulence and the host interaction, leading to development of better treatment strategies. Infection with Cryptococcus in mice via intranasal inhalation is mostly used because it is noninvasive and considered to be the most common mode of infection, strongly correlating with cryptococcal disease in humans. The protocols described in this article provide the procedures of establishing a murine model of Cryptococcus infection by intranasal inhalation and assessing the host immune response and disease progression during Cryptococcus infection. © 2024 Wiley Periodicals LLC. Basic Protocol 1: Murine model of pulmonary cryptococcal infection via intranasal inhalation Basic Protocol 2: Assessment of the pulmonary immune response during Cryptococcus infection Support Protocol: Evaluation of pulmonary gene expression by real-time PCR Basic Protocol 3: Enumeration of survival rate and organ fungal burden.

Cryptococcal Pneumonia in an Immunocompetent Patient: A Rare Occurrence

Cryptococcosis isan invasive yeast infection commonly found among immunosuppressed patients.Pulmonary cryptococcal infection can have variable presentations ranging from pulmonary nodulesand masses to consolidation. A patient can present with shortness of breath, cough, sputum production, chest pain, fatigue, and weight loss. Diagnosis can be made using fungal culture, histology, radiographic findings, and cryptococcal antigen in serum as well as in the cerebrospinal fluid. Treatment is usually with a combination or a single antifungal agent. Few cases have been reported in immunocompetent individuals. Here we present a case of 69-year-old immunocompetent individual, who was initially seen in the outpatient clinic for dyspnea, cough, and fatigue and was treated for pneumonia. The patientremained symptomatic despite multiple courses of oral antibiotics. He was then sent for inpatient admission. CT scan was obtained that showed patchy infiltrates and consolidations, followed by bronchoscopy. The cytology confirmed adenocarcinoma. The fungal smear and culture grew Cryptococcus neoformans. The patient was treated with fluconazole with improvement of his symptoms before starting chemotherapy. We are reporting this case as clinicians usually focus on bacterial etiologies in outpatient setting. Our patient, who wasimmunocompetent, had a new diagnosis of cryptococcal pneumonia and was also found to have lung adenocarcinoma. This case highlights the rare occurrence of this type of pneumonia in immunocompetent patientsand the importance of considering fungal causes of pneumonia in patients.

UNILATERAL EXUDATIVE PLEURAL EFFUSION DUE TO CRYPTOCOCCAL INFECTION IN AN IMMUNOCOMPETENT INDIVIDUAL

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pleural effusion, which can be exudative or transudative as per Light's criteria and has more than 50 recognized cases. It occurs as a result of increased fluid formation and /or reduced fluid resorption. Exudative effusion can be caused by malignancy, tuberculosis, PE, rheumatoid arthritis, pancreatitis, and rarely fungal infections. Cryptococcal infection causing pleural effusion is extremely rare with just 50 reported cases and that too in immunocompromised patients with reduced cellular function. [1]Pulmonary Cryptococcus is seen in immunocompromised patients with reduced cellular function and pleural presentation is rarely seen in pulmonary cryptococcosis. We are presenting a unique case in which this disease was found in an immunocompromised person. CASE PRESENTATION: Our patient is a 58 year old Male who had gone for Pre-op check up for his shoulder surgery where routine chest x-ray showed left sided pleural effusion. On presentation, he denied any complaints of dyspnea, chest pain, or fever. He is a non smoker, works in a plasma center and lives in a basement apartment complex. He further denied owning any pets or any outdoor hobbies such as hiking, camping, or canoeing. Auscultation of chest revealed reduced air entry on left side. Labs works showed serum cryptococcal antigen positive. Rest of the investigations were normal . The patient underwent thoracocentesis which drained out 1200 ml of green colored fluid which was sent for gram stain, AFB stain and culture sensitivity and were negative. Sputum and CSF analysis were negative as well. He was started on Amphotericin B and Fluconazole IV for 2 weeks as induction therapy following which patient improved clinically. Patient was discharged with continuation of consolidation therapy with fluconazole for 8 weeks on outpatient basis. He was followed up at the clinic where Chest X ray showed resolution of the infection. DISCUSSION: Pulmonary cryptococcus is an opportunistic infection usually seen in immunocompromised patients like those with HIV infection, hematological malignancies, immunosuppressive medications etc. Pleural effusion is rare presentation of pulmonary cryptococcus and even rarer in an immunocompetent individual. Only 35% of cases with pulmonary cryptococcal infection were in immunocompetent people and most of them were reported in Asia. Patients with immunocompetent state with cryptococcal infection usually showed pneumonia like manifestations or solitary and well defined nodules. Our case did not show any manifestations other than the pleural effusion. Cryptococcal Antigen(CrAg) testing in body fluids can guide us for confirmation of the disease. 56% of patients with Non HIV related Cryptococcal infection tested positive for CrAg. CONCLUSIONS: This Unique case shows that cryptococcal infection can present in immunocompetent person. That this case was found in North America with no risk factors in the person. REFERENCE #1: [1] Hooper C, Lee YCG, Maskell N Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010Thorax 2010;65:ii4-ii17. REFERENCE #2: Shirley RM, and Baddley JW. 2009. Cryptococcal lung disease. Curr. Opin. Pulm. Med. 15(3):254–260 REFERENCE #3: Zhang Y, Li N, Zhang Y, Li H, Chen X, Wang S, Zhang X, Zhang R, Xu J, Shi J, Yung RC. Clinical analysis of 76 patients pathologically diagnosed with pulmonary cryptococcosis. Eur Respir J. 2012;40:1191-1200Ye F, Xie JX, Zeng QS, Chen GQ, Zhong SQ, Zhong NS. Retrospective analysis of 76 Immunocompetent patients with primary pulmonary cryptococcosis. Lung. 2012;190:339-346. DISCLOSURES: No relevant relationships by Farhan Ali, source=Web Response No relevant relationships by Sucheta Kundu, source=Web Response

A CASE OF CRYPTOCOCCAL LAURENTII PNEUMONIA IN A PATIENT REQUIRING FREQUENT STEROID TAPERS

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cryptococcal laurentii as a primary pathogen in infection is rare. The understanding of this non-neoformans species remains unclear as a rare virulent factor with high associated mortality or incidental finding in an at-risk immunocompromised populations. Here we present the case of a patient with chronic severe respiratory disease with acute pneumonia symptoms, found to have Cryptococcus laurentii pneumonia. CASE PRESENTATION: A 49-year-old woman with a 24 pack-year smoking history, COPD and uncontrolled severe persistent asthma, frequent hospitalizations for respiratory failure presented with acute dyspnea, wheezing and productive cough. She has previously responded to steroids, with several long tapers over the past year. A CT was performed revealing scattered ground-glass opacities, tree in bud pattern, hilar and mediastinal adenopathy, mucus plugging, and airway thickening. Initial labs were remarkable only for peripheral eosinophilia, a count of 640, with serum quantitative IgE of 33. Aspergillus testing, viral panel, COVID, and MRSA PCR were negative. Serum Quantiferon and autoimmune antibody panel were negative. The patient was started on broad-spectrum antibiotics but failed to improve. Bronchoscopy with BAL was performed, cytology showed growth of Cryptococcus Laurentii. Other respiratory samples were negative. The patient was started on a fluconazole regimen, with improvement in respiratory symptoms. DISCUSSION: Cryptococcal infection can be difficult to diagnose. Imaging and symptom presentation can be nonspecific. The most frequent symptoms are dyspnea, cough, and fever. Imaging findings can include pulmonary nodules, consolidations, nodular interstitial pattern, reticular interstitial pattern, ground glass opacities and pleural effusions. Severity can range from asymptomatic nodules to life-threatening illness. (3) There have been limited case reports of these species causing infection and pre-existing lung disease is a risk factor for pulmonary cryptococcal infection. There is a high associated risk of mortality (25-35%) (1). Due to an elevated risk of disseminated infection, diagnostic evaluation and workup should be broad and thorough. Standard cryptococcal antigen testing has worse sensitivity for non-neoformans species (3). The most appropriate treatment regimen remains contested as there has been poor correlation between in vitro antifungal susceptibility and treatment outcomes in patients (2). CONCLUSIONS: Cryptococcus laurentii remains a rare cause of infection. The symptoms may be non-specific; a high degree of suspicion is required for diagnosis. A better understanding of epidemiology and pathogenesis is crucial for improved recognition and treatment. REFERENCE #1: Shankar E. Pneumonia and pleural effusion due to Cryptococcus laurentii in a clinically proven case of AIDS. Canadian Respiratory Journal, 2006 Jul-Aug, 275-278. REFERENCE #2: Kabi S. Cryptococcus Laurentii: an unusual cause for atypical pneumonia in hematological malignancy. Journal of Mahatma Gandhi institute of medical sciences 25 (1): 45 REFERENCE #3: Smith N. Perspectives on non neoformans cryptococcal opportunistic infections. Journal of community hospital internal medicine perspectives. Oct 2017. 214-217 DISCLOSURES: No relevant relationships by Timothy Carroll, source=Web Response No relevant relationships by Suhayb Ranjha, source=Web Response

Identification and assessment of pulmonary Cryptococcus neoformans infection by blood serum surface-enhanced Raman spectroscopy

Cryptococcus neoformans (C. neoformans) is a causative agent for acute pulmonary infection, which can further develop to lethal meningoencephalitis if untreated. The meningoencephalitis infection can be prevented, if timely treatment on pulmonary cryptococcal infection can be implemented based on its early diagnosis and accurate assessment. In this study, blood serum surface-enhanced Raman spectroscopy (SERS) method was investigated on identification and assessment of pulmonary C. neoformans infection. The serum SERS measurements were collected from the mice infected with C. neoformans and the healthy mice, in which the infected mice were further divided into four subgroups according to the duration of infection. Based on those SRES measurements, biochemical differences were analyzed among those different groups to investigate the potential biomarkers for identifying and assessing the pulmonary C. neoformans infection. Furthermore, partial least square (PLS) analysis followed by linear discriminant analysis (LDA) model was employed to identify pulmonary cryptococcal infection and to assess the degrees of infection with the accuracies of 96.7% and 85.3%, respectively. Therefore, our study has demonstrated the great clinical potential of using serum SERS technique for an accurate identification and assessment of pulmonary cryptococcal infection.

An unusual case of reactivated latent pulmonary cryptococcal infection in a patient after short\u2010term steroid and azathioprine therapy: a case report

BackgroundCryptococcus is one of the major fungal pathogens infecting the lungs. Pulmonary cryptococcal infection is generally considered a community-acquired condition caused by inhalation of dust contaminated with fungal cells from the environment. Here, we report a case developing pulmonary cryptococcosis 3 months after hospital admission, which has rarely been reported before.Case presentationA 73-year-old female patient who was previously immunocompetent experienced persistent dry cough for 2 weeks, 3 months after admission. Chest computed tomography (CT) showed a new solitary pulmonary nodule developed in the upper lobe of the left lung. Staining and culture of expectorated sputum smears were negative for bacteria, acid-fast bacilli, or fungus. The patient then underwent biopsy of the lesion. Histopathology findings and a positive serum cryptococcal antigen titer (1:8) indicated pulmonary cryptococcosis. Daily intravenous 400 mg fluconazole was administered initially followed by oral fluconazole therapy. Follow-up chest CT after 3 months of antifungal therapy showed complete disappearance of the pulmonary nodule. Respiratory symptoms of the patient also resolved. A complete investigation excluded the possibility of a patient-to-patient transmission or primarily acquiring the infection from the hospital environment. Based on the patient’s history of exposure to pigeons before admission and recent steroid and azathioprine use after admission for the treatment of myasthenic crisis, reactivation of a latent pulmonary cryptococcal infection acquired before admission, in this case, is impressed.ConclusionsAlthough 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.

POROGEN EFFECTS ON AEROSOLIZATION PROPERTIES OF FLUCONAZOLE LOADED PLGA LARGE POROUS PARTICLES

Objective: The most common fungal infection, which is usually occurs in immunocompromised patients, is pulmonary cryptococcosis. Fluconazole (FLZ) is a first-generation triazole which is used for the treatment of pulmonary cryptococcal infection during 6-12 mo. A non-invasive and targeted medication delivery to lung is highly desirable due to lower delivered dose and reduced systemic effects. Large Porous Particles (LPPs) have shown lower phagocytic clearance and higher bioavailability compared to non-porous particles of the same size with a remarkable safety profile.
 Methods: In the present study, the effect of two different porogen agents with different mechanisms on FLZ loaded PLGA LPPs properties were evaluated using design expert software®. These properties included volume diameter, drug loading, encapsulation efficiency, mass median aerodynamic diameter (MAAD), geometric standard deviation (GSD) and fine particle fraction (FPF).
 Results: All FLZ-loaded PLGA LPPs (FLZ-PLGA LPPs) showed acceptable volume diameter, drug loading and encapsulation efficiency with rapid FLZ release due to macroporous structure. Significant differences in aerosolization properties in which MAAD, GSD and FPF optimized formulation of the optimized formulation were 6.71±0.4 µm, 1.65±0.08 and 33.20±1.7%, respectively.
 Conclusion: It was suggested that gas foamed preparation technique using ammonium bicarbonate was a better technique to produce FLZ loaded PLGA LPPs with more suitable in vitro respirable properties.

Host resistance to pulmonary cryptococcal infection requires CX3CR1 expression

Abstract Cryptococcus neoformans is an opportunistic fungal pathogen, and a leading cause of death among HIV-infected individuals. These encapsulated yeast fungi are believed to enter the body through the respiratory tract and initially cause pulmonary infection. If the host immune system fails to contain the fungal cells within the lung, the organism will disseminate to the brain via the bloodstream, consequently resulting in fatal meningoencephalitis. As such, the early interactions between immune cells and C. neoformans in the lung are critical for determining the progression of the disease. CX3CR1 is a chemokine receptor commonly expressed by most myeloid lineage cells. Despite its prevalence though, the role of CX3CR1 during cryptococcal infection has not been fully examined. Here we report that pulmonary infection with C. neoformans enhanced CX3CR1 expression in the lung. Following infection, mice lacking CX3CR1 had significantly higher pulmonary fungal burdens, as well as decreased survival times compared to wild type mice. These infected CX3CR1 knockout mice also displayed higher expression of pro-inflammatory cytokines including MIP-2, MCP-1 and CCL7, but lower expression of anti-inflammatory cytokines such as IL-10. In addition, CX3CR1 deficiency resulted in mice having dramatically enhanced neutrophil accumulation in the lungs following infection. Interestingly, depletion of neutrophils drastically improved lung CFU in infected knockout mice, indicating that excessive inflammation drove fungal growth. Taken together, these data indicate that CX3CR1 expression is essential for host resistance to pulmonary cryptococcal infection by inhibiting excessive lung inflammation.

Coexistent pulmonary cryptococcal infection and pulmonary sarcoidosis: a case report and literature review

Cryptococcus is an encapsulated, yeast-like fungus commonly responsible for infections in individuals with impaired T cell-mediated immune responses, including those with acquired immune deficiency syndrome or taking immunosuppressive agents such as steroids or cyclosporine. However, pulmonary fungal infection is rare in patients with untreated sarcoidosis. We report a case of coexistent pulmonary cryptococcal infection in a 43-year-old man with pulmonary sarcoidosis in North-western China. The patient was diagnosed with sarcoidosis via right anterior mediastinal lymph node biopsy and lung biopsy by bronchoscopy. He was treated with oral prednisone 25 mg/day and achieved complete remission of all symptoms. However, repeat chest computed tomography examination revealed enlarged nodules in the left lower lobe, but decreased bilateral diffuse small nodules in the lungs. Computed tomography-guided percutaneous lung puncture biopsy revealed cryptococcal infection. This case highlights the need to consider fungal infection in patients with sarcoidosis at initial presentation, irrespective of their use of immunosuppressive medication.

INCIDENTAL LUNG MASS PRESENTING AS CRYPTOCOCCOMA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cryptococcus neoformans is one of the most common invasive fungal organisms worldwide and is associated with significant morbidity and mortality. Here, we present a case of a patient with a lung mass suspicious for malignancy but confirmed to be cryptococcoma. CASE PRESENTATION: 64-year-old male with past medical history of diabetes mellitus type 2, cirrhosis, obstructive sleep apnea, and testicular cancer presented to pulmonology clinic after he was found to have an incidental lung mass on imaging. His only complaint was shortness of breath. Initial CT of the chest with and without contrast showed a new 3.5 cm x 1.6 cm lobulated soft tissue density mass in the superior segment of the left lower lobe concerning for malignancy. QuantiFERON and fungal serology panel were negative. Biopsy was recommended but deferred by patient. Repeat CT chest 2 months after the initial CT showed interval enlargement of the mass to 3.8 cm x 1.7 cm. Transthoracic needle biopsy was pursued but did not reveal any malignancy or granulomatous inflammation. Tissue GMS and AFB stains were negative. Bacterial and mycobacterial cultures did not grow any organisms, however, fungal cultures grew Cryptococcus neoformans. Subsequent serum cryptococcal antigen was elevated at 1:8. He was started on fluconazole and was found to have subjective improvement in his shortness of breath at his next follow-up appointment. Serum cryptococcal antigen performed one month after starting fluconazole trended up to 1:32 and subsequently decreased to 1:16 at two months. Unfortunately, he was subsequently lost follow-up due to health insurance and financial issues. DISCUSSION: Pulmonary cryptococcal infection often presents a challenging diagnosis for clinicians as it can present with nonspecific signs and symptoms such as dry cough, fever, malaise, dyspnea, and pleuritic chest pain [1]. Clinical manifestations range from asymptomatic infection to disseminated or fulminant disease. The diagnosis is more difficult to make by the fact that radiographic findings of cryptococcal pneumonia are often highly variable. The radiographic pattern can also vary depending on immune function and duration of disease. Furthermore, only about half of patients have findings on imaging [1]. The most common radiographic findings are pulmonary nodules or masses regardless of immune status [2]. Diffuse lung involvement, reticulonodular interstitial infiltrates, and pleural effusions are more common among immunocompromised hosts [2-3]. Cavitary lesions are more common in the immunosuppressed but have been noted to occur in immunocompetent individuals as well [2]. CONCLUSIONS: The clinical and radiographic presentation of cryptococcal pneumonia is highly variable. Clinicians should keep high suspicion and consider cryptococcoma within the differential diagnosis of pulmonary masses regardless of patient immune function. Reference #1: Skolnik K, Huston S, Mody CH. Cryptococcal Lung Infections. Clinics in Chest Medicine. 2017;38(3):451-464. https://doi.org/10.1016/j.ccm.2017.04.007. Reference #2: Khoury MB, Godwin JD, Ravin CE, Gallis HA, Halvorsen RA, Putman CE. Thoracic cryptococcosis: immunologic competence and radiologic appearance. AJR Am J Roentgenol 1984; 142: 893–6. Reference #3: Lacomis JM, Costello P, Vilchez R, Kusne S. The Radiology of Pulmonary Cryptococcosis in a Tertiary Medical Center. Journal of Thoracic Imaging. 2001;16(3):139-148. https://doi.org/10.1097/00005382-200107000-00001. DISCLOSURES: No relevant relationships by Mirza Ali, source=Web Response No relevant relationships by Johnathan Fagg, source=Web Response No relevant relationships by Mingchen Song, source=Web Response No relevant relationships by Saad Ullah, source=Web Response

Incidental Cryptococcal lung mass in an immunocompetent patient

ABSTRACTCryptococcus is an encapsulated fungal organism often implicated in central nervous system and pulmonary disease in patients with AIDS or other immunocompromising diseases. However, immunocompetent hosts can also be infected. In these cases, symptoms are generally mild and common radiographic findings include small, well-defined, smoothly marginated pulmonary nodules. We present a case of a 31-year-old man without any immunocompromising factors found to have pulmonary Cryptococcal infection presenting as a large lung mass.

Pleural fluid secondary to pulmonary cryptococcal infection: a case report and review of the literature

BackgroundPulmonary Cryptococcosis (PC) is diagnosed with increasing incidence in recent years, but it does not commonly involve the pleural space. Here, we report a HIV-negative case with advanced stage IIIB non-small cell lung cancer (NSCLC) treated with radiation therapy presented with dyspnea, a new PET-positive lung mass and bilateral pleural effusion suspecting progressive cancer. However, the patient has been diagnosed as pulmonary cryptococcal infection and successfully treated with oral fluconazole therapy.Case presentationA 77-year-old male with advanced stage non-small cell lung cancer treated with combined chemo-radiation therapy who presented with progressive dyspnea, a new PET-positive left lower lobe lung mass and bilateral pleural effusions. Initial diagnostic thoracentesis and bronchoscopy yielded no cancer, but instead found yeast forms consistent with cryptococcal organisms in the transbronchial biopsies of the left lower lobe lung mass. Subsequent to this, the previously collected pleural fluid culture showed growth of Cryptococcus neoformans. The same sample of pleural effusion was tested and was found to be positive for crytococcal antigen (CrAg) by a lateral flow assay (LFA). The patient has been treated with oral fluconazole therapy resulting in gradual resolution of the nodular infiltrates.ConclusionPC should be considered in immunosuppressed cancer patients. Additionally, concomitant pleural involvement in pulmonary cryptococcal infections may occur. The incidence of false positive 18FDG-PET scans in granulomatous infections and the use of CrAg testing in pleural fluid to aid in diagnosis are reviewed.

Disseminated Cryptococcal Infection in a Patient Receiving Acalabrutinib for Chronic Lymphocytic Leukemia

Abstract A 61-year-old man with chronic lymphocytic leukemia (CLL) developed disseminated cryptococcal infection, diagnosed 7 months after commencement of acalabrutinib, a Bruton's tyrosine kinase inhibitor. To our knowledge, this is the first reported case of cryptococcal infection occurring in a patient being treated with acalabrutinib (with approximately 10 cryptococcal infections previously related to ibrutinib). Other unusual features included the development of mild hypercalcemia, which has been a rare complication of cryptococcal infection, and a probable immune reconstitution inflammatory syndrome–like response to extensive pulmonary cryptococcal infection. The case further emphasizes the need for vigilance for possible invasive fungal infection (particularly Cryptococcus) in patients treated with Bruton's tyrosine kinase inhibitors.

Clinical features and cause analysis of false positive results of Aspergillus galactomannan assay in pulmonary cryptococcosis patients.

There have been conflicting reports of false positive galactomannan assay results in patients with systemic cryptococcosis. We sought to determine the frequency of GM positivity in patients with pulmonary cryptococcosis and confirm the source of this cross-reactivity in vitro. We conducted a retrospective study to elucidate the rate of galactomannan (GM) false positivity and cause in a cohort of 29 patients with pulmonary cryptococcal disease. The production of GM cross-reacting substances by clinical isolates and laboratory isolates of C. neoformans was tested in vitro. The mean serum GM index (Platelia Aspergillus) in patients with pulmonary cryptococcosis was 1.06, with 16 (55.2%) of patients having values above the positive cutoff value of 0.5. GM index values significantly decreased after treatment of cryptococcosis. There was no significant correlation between galactomannan and cryptococcal glucuronoxylomannan antigen (Eiken Latex test) results. Culture supernatants from clinical isolates and wild-type C. neoformans did not react in the GM assay; however, growth in the presence of 6% sodium chloride induced the production of cross-reacting GM antigens in culture supernatants from clinical isolates, wild type and a glucuronoxylomannan-deficient mutant of C. neoformans, but not in culture supernatants from a galactoxylomannan-deficient strain. Our results support the cross-reactivity of cryptococcal galactoxylomannan with the serum GM assay in vitro and in patients with pulmonary cryptococcal infection.

Clinicopathologic Features of Pulmonary Cryptococcus

SESSION TITLE: Chest Infections SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Pulmonary cryptococcal infection is commonly seen in immunocompromised patients (ProPts), although immunocompetent patients (PePts) may also be infected. Our aim is to describe the clinicopathologic features of pulmonary cryptococcosis METHODS: We reviewed the clinicopathologic data of 21 patients with pulmonary cryptococcosis who were admitted to our hospital from 2008 to 2016. It was pathologically proven in all patients RESULTS: The patients were 14 ProPts and 7 PePts. Among 14 ProPts, it was composed of 5 cancer patients, 4 diabetes mellitus, 3 hematologic malignancy, 1 post-transplanted, and 1 rheumatoid arthritis. Mean patient age was 62 years, but, age of PePts was lower (mean age : 50). Male to female ratio was 1:1 in all patients. But, male ratio was more in PePts (71.4%) than ProPts (42.9%). Two-thirds of patients were asymptomatic. The pulmonary lesion was incidentally detected in health medical examination or during follow-up radiology of previous disease. Lesions were more common in lower than upper lung (5 pts, 71.4%) of PePts, but common in upper than lower (8 pts, 64.2%) of ProPts. More lesions (12 pts, 57.1%) were characterized by patchy consolidations, which was described as unusual. But, in 3 patients, cavitary lesion, suspicious for malignancy, was found. Of all patients, 14 were diagnosed by surgical complete removal, and 7 diagnosed by bronchoscopy. In pathologic features, most of cases (20 cases) showed the granuloma. But, necrosis was shown in 9 cases (8 in ProPts and 1 PePts). All patients had been treated by antifungal agent and showed a favorable outcome. CONCLUSIONS: Clinicopathologic features of pulmonary cryptococcosis was variable between ProPts and PePts. Early recognition and pathologic examination may help with improvement of its diagnosis and prognosis. CLINICAL IMPLICATIONS: Pulmonary cryptococcal infection is commonly seen in immunocompromised patients (ProPts), although immunocompetent patients (PePts) may also be infected. but, clinicopathologic features of pulmonary cryptococcosis was variable between ProPts and PePts. DISCLOSURE: The following authors have nothing to disclose: Yu-Deok Choi, Sang-Yun Song, Chang-Soo Park No Product/Research Disclosure Information

Different Lymphocyte Populations Direct Dichotomous Eosinophil or Neutrophil Responses to Pulmonary Cryptococcus Infection.

Many pulmonary infections elicit lymphocyte responses that lead to an accumulation of granulocytes in the lungs. A variety of lymphocytes are capable of directing eosinophils or neutrophils to the lungs, but the contribution of each subset remains enigmatic. In this study, we used a murine model to examine lymphocyte subsets that ultimately drive the eosinophil or neutrophil response to infection with the fungal pathogen Cryptococcus neoformans. We show that granulocytes are produced in the bone marrow, released into the blood stream, and accumulate in the lungs under the instruction of lung parenchymal lymphocytes. The eosinophils that populated the lungs of wild-type animals were highly dependent on Th cells or IL-5. Surprisingly, infected mice with Th cell impairment experienced a compensatory neutrophil response that required IL-17A. This unexpected swing in the response prompted us to investigate the ability of different lymphocyte subsets to produce this dichotomous eosinophilia or neutrophilia. We used mice with lymphocyte deficiencies to determine which of the remaining IL-5- or IL-17A-producing lymphocyte subsets dominated the neutrophil or eosinophil response. Finally, skewing the response toward neutrophil-inducing lymphocytes correlated with accelerated disease. Our data collectively demonstrate that the predominance of a lymphocyte subset determines the functional consequences of an immune response to pulmonary fungal infection that can ultimately affect disease.

Disseminated Cryptococcosis Due to Anti-Granulocyte-Macrophage Colony-Stimulating Factor Autoantibodies in the Absence of Pulmonary Alveolar Proteinosis

Autoantibodies to granulocyte-macrophage colony-stimulating factor (GM-CSF) can cause acquired pulmonary alveolar proteinosis (PAP). Cases of acquired PAP susceptible to typical respiratory pathogens and opportunistic infections have been reported. Anti-GM-CSF autoantibodies have been reported in a few patients with cryptococcal meningitis. This study evaluated the presence of neutralizing anti-GM-CSF autoantibodies in patients without known congenital or acquired immunodeficiency with severe pulmonary or extrapulmonary cryptococcal infection but without PAP. We took a clinical history and performed an immunologic evaluation and screening of anti-cytokine autoantibodies in patients with cryptococcal meningitis. The impact of autoantibodies to GM-CSF on immune function was assessed by intracellular staining of GM-CSF-induced STAT5 phosphorylation and MIP-1α production in normal peripheral blood mononuclear cells incubated with plasma from patients or normal control subjects. Neutralizing anti-GM-CSF autoantibodies were identified in four patients with disseminated cryptococcosis, none of whom exhibited PAP. Plasma from patients blocked GM-CSF signaling and inhibited STAT5 phosphorylation and production of MIP-1α. One patient died of disseminated cryptococcosis involving the central nervous system, which was associated with defective GM-CSF activity. Anti-GM-CSF autoantibodies increase susceptibility to cryptococcal infection in adults without PAP. Cryptococcal central nervous system infection associated with anti-GM-CSF autoantibodies could result in neurological sequelae or be life-threatening. Therefore, timely detection of neutralizing anti-GM-CSF autoantibodies and development of an effective therapy are necessary to prevent deterioration of cryptococcal infection in these patients.

Transcription levels of Cyp450s, H99, Hsps and Dmp53 in Drosophila melanogaster larvae treated with zearalenona

Cryptococcus neoformans is an opportunistic fungal pathogen that threatens individuals with impaired cell-mediated immunity (CMI). Presently, there are no standardized vaccines available to prevent cryptococcal infections and conventional anti-fungal drug therapy does not induce host immune reactivity and thus cannot efficiently resolve C. neoformans infections in immunocompromised individuals. The present study was designed to characterize pulmonary immune responses following infection with an avirulent temperature-sensitive (ts) mutant, calcineurin A1 (cna1) compared to the pathogenic C. neoformans strain H99 and its potential to induce protective anti-cryptococcal immunity. Host CMI responses in cna1-inoculated mice were observed to be dose-dependent, and comprise increases in pulmonary macrophages and CD4+ T lymphocytes. However, cytokine analysis demonstrated a mixed pulmonary cytokine response (increases in IL-4, and MCP-1) with no induction of IFN-γ. Also, pre-immunization with the ts cna1 mutant did not result in protection from a subsequent secondary pulmonary infection with the pathogenic C. neoformans strain H99. Taken together, these results suggest that host pulmonary CMI responses to the ts cna1 mutant that is eventually eliminated from the host without the induction of IFN-γ appear to be dose-dependent, diverse, and require further stimulation to induce C. neoformans-specific Th1-type cytokine responses to resolve subsequent experimental pulmonary cryptococcal infections.

Regulatory T Cell Induction and Retention in the Lungs Drives Suppression of Detrimental Type 2 Th Cells During Pulmonary Cryptococcal Infection.

Lethal disease caused by the fungus Cryptococcus neoformans is a consequence of the combined failure to control pulmonary fungal replication and immunopathology caused by induced type 2 Th2 cell responses in animal models. In order to gain insights into immune regulatory networks, we examined the role of regulatory T (Treg) cells in suppression of Th2 cells using a mouse model of experimental cryptococcosis. Upon pulmonary infection with Cryptococcus, Treg cells accumulated in the lung parenchyma independently of priming in the draining lymph node. Using peptide-MHC class II molecules to identify Cryptococcus-specific Treg cells combined with genetic fate-mapping, we noted that a majority of the Treg cells found in the lungs were induced during the infection. Additionally, we found that Treg cells used the transcription factor, IFN regulatory factor 4, to dampen harmful Th2 cell responses, as well as mediate chemokine retention of Treg cells in the lungs. Taken together, induction and IFN regulatory factor 4-dependent localization of Treg cells in the lungs allow Treg cells to suppress the deleterious effects of Th2 cells during cryptococcal infection.

Regulatory T Cell Induction and Retention in the Lungs Drives Suppression of Detrimental Type 2 Th Cells During Pulmonary Cryptococcal Infection

Regulatory T Cell Induction and Retention in the Lungs Drives Suppression of Detrimental Type 2 Th Cells During Pulmonary Cryptococcal Infection