1 / 13

Cryptococcosis in the Non-HIV Patient

Cryptococcosis in the Non-HIV Patient. Kristen Amann, MD Morning Report August 12, 2009. Brief Overview. Yeast-like fungus Most common predisposing factor: HIV Usually CD 4 <200/  L Pathogenesis: Not entirely clear Likely inhalation Rare: cutaneous entry from minor trauma

aqua
Download Presentation

Cryptococcosis in the Non-HIV Patient

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cryptococcosis in the Non-HIV Patient Kristen Amann, MD Morning Report August 12, 2009

  2. Brief Overview • Yeast-like fungus • Most common predisposing factor: HIV • Usually CD4 <200/L • Pathogenesis: Not entirely clear • Likely inhalation • Rare: cutaneous entry from minor trauma • Non-HIV associated: • 50%: glucocorticoids, immunosuppression • Remainder: transplant, lymphoma, sarcoidosis, idiopathic CD4 lymphocytopenia

  3. Clinical Presentation • Most common presentation at the time of diagnosis is meningoencephalitis • Fatal without treatment • Early: headache, nausea, confusion, irritability, confusion • Fever and nuchal rigidity are mild to lacking • Progression: deep coma, brainstem compression • Neuroimaging: usually normal • Cryptococcomas

  4. Clinical Presentation • Pulmonary cryptococcosis • Chest pain (40%), cough (20%), +/- fever • Cutaneous lesions • One to a few papules that enlarge slowly, develop central ulceration or softening

  5. Diagnosis • CSF •  glucose,  protein • Lymphocytic pleocytosis • 90% will have a positive Ag in CSF or serum • Poor prognostic indicators • WBC < 10/µL • OP >25 cm • Fungemia: 10-30% of non-HIV patients

  6. Treatment (Meningoencephalitis) • Induction therapy (2 weeks): • Amphotericin B (0.7-1 mg/kg/d) OR Ambisome (4-5 mg/kg/d) • Flucytosine (25mg/kg q6hr) • Consolidation therapy (8 weeks): • Fluconazole 400mg/d • Maintenance therapy (4-12 months): • Fluconazole 200mg/d

  7. Idiopathic CD4 Lymphocytopenia (ICL) • Heterogeneous syndrome • Recognized in 1992 • CD4+ <300/L or <20% of total T cells on more than one occasion • Absence of any defined immunodeficiency or therapy associated with decreased levels of CD4+ T cells

  8. Idiopathic CD4 Lymphocytopenia (ICL) • Although some develop opportunistic infections like those seen in HIV-infected patients, this syndrome is not like HIV • <1/2 with HIV risk factors • Wide geographic and age distributions • 1/3 are female (versus 16% for HIV) • Many remain clinically stable and do not progressively deteriorate • Reports of spontaneous reversal of the lymphocytopenia

  9. Idiopathic CD4 Lymphocytopenia (ICL) • Immunological abnormalities tend to differ compared to HIV • ICL:  CD8+ T cells,  B cells, normal or  Ig levels, no evidence of HIV-1, HIV-2, HTLV-1, HTLV-2, or any other mononuclear cell-tropic virus • No clustering of cases • Close contacts studied were HIV negative • Should be placed on OI prophylaxis depending on CD4 counts

  10. Thanks!

  11. References • Duncan, et al. Idiopathic CD4+ T-Lymphocytopenia -- Four Patients with Opportunistic Infections and No Evidence of HIV Infection. NEJM. Volume 328:393-398. • Kasper, et al. Harrison’s Principles of Internal Medicine, 16th edition. McGraw-Hill, New York. Volume I:1123,1183-1185.

More Related