Histoplasmosis occurs in 5–10% of HIV-infected patients in endemic areas and evolves to severe an... more Histoplasmosis occurs in 5–10% of HIV-infected patients in endemic areas and evolves to severe and disseminated infection with mortality rates over 50% in some regions. This report presents epidemiological, clinical and outcome data from HIV-infected patients with histoplasmosis confirmed by culture and/or at necropsy who were admitted to a Brazilian teaching hospital. Data from 65 patients were obtained from their respective medical and necropsy records. From 2005 to 2018, 36 HIV-infected patients were diagnosed with histoplasmosis confirmed by culture. At admission, most of these patients presented disseminated fungal infection, whereas 15 (41.7%) were simultaneously diagnosed with both HIV infection and histoplasmosis. Fever, weight loss, hepatosplenomegaly, respiratory and digestive symptoms were present in 86.2%, 50%, 44.4% and 41.7% of the patients, respectively. At admission, 24 patients had low CD4 T-cell count and high viral load values. Among the 30 patients who received antifungals, 16 (53.3%) were cured, 13 (43.3%) died, and one was lost to follow-up. Six patients died prior to therapy. From 1990 to 2018, 63 necropsies of patients with Histoplasma capsulatum infection were performed. Of these patients, 29 (46.0%) were HIV-infected individuals, including 21 (72.4%) who presented disseminated histoplasmosis and 21 (72.4%) who were diagnosed with histoplasmosis at necropsy. The epidemiological, clinical and outcome profiles presented herein are similar to those described elsewhere and reinforce the difficulties that are still present in limited-resource settings where advanced immunodeficiency, combined with severe fungal infection and late patient admissions, is related to poor outcomes.
Cryptococcosis is frequently associated to the immune reconstitution inflammatory syndrome (IRIS)... more Cryptococcosis is frequently associated to the immune reconstitution inflammatory syndrome (IRIS) in AIDS patients on highly active antiretroviral therapy (HAART). This study aimed to evaluate clinical and evolutive features of IRIS associated cryptococcosis patients in Uberaba, Brazil. Eighty-one AIDS individuals admitted at the teaching hospital with cryptococcal meningitis were evaluated and from these, 40 were prospectively followed. Of 40 patients with cryptococcosis, nine (22.5%) presented clinical and laboratory features of IRIS. Six (66.6%) were male, with a mean age of 37.2. Five (55.5%) presented cryptococcosis as first AIDS defining condition. In seven (77.9%) IRIS was characterised as a relapse of meningeal symptoms after 10 weeks, mean time of 72 days, of starting HAART whereas, two asymptomatic patients developed the syndrome as an unmasked cryptococcosis after 10 and 12 weeks on HAART. Lymphadenitis as isolated finding associated with IRIS was evidenced in three cases. All patients presented low CD4(+) and high RNA viral load baseline values. Cultures of cerebrospinal fluid and lymph-node fragments tissues of these cases were negative. Six of nine individuals developed high intracranial pressure requiring a daily relief lumbar puncture. No deaths occurred during the evolution of these patients. The incidence and clinical evolutive profile observed in this case series are in accordance with other reports elsewhere.
BACKGROUND Ocular involvement in AIDS patients is a common event mainly caused by inflammation or... more BACKGROUND Ocular involvement in AIDS patients is a common event mainly caused by inflammation or infection. Despite the high prevalence rate of cryptococcosis in these individuals, ocular features have been occasionally described. CASE REPORT A 20-year-old Brazilian female with HIV infection recently diagnosed was admitted with a respiratory profile presumptively diagnosed as Pneumocystis jirovecii pneumonia; an ophthalmologic exam suggested choroiditis by this agent as well. She was complaining of headaches and blurred vision which led to cryptococcal meningitis diagnosis by a CSF positive India ink stain and Cryptococcus neoformans positive culture. Despite therapy based on amphotericin B plus fluconazole, her clinical state progressively worsened and the patient died one week later. At necropsy, disseminated cryptococcal infection was evidenced in several organs including eyes, which presented bilateral chorioretinitis. CONCLUSIONS Cryptococcal ocular involvement in AIDS patients has been occasionally proved among the cases already reported. Thus, the post mortem exam is still pivotal to improve the quality of the clinical diagnosis, especially in limited-resource settings.
American Journal of Tropical Medicine and Hygiene, Oct 5, 2016
Cryptococcosis occurs in acquired immunodeficiency syndrome (AIDS) patients with poor compliance ... more Cryptococcosis occurs in acquired immunodeficiency syndrome (AIDS) patients with poor compliance to antiretroviral therapy or unaware of their human immunodeficiency virus status who present severe immunosuppression at admission. Consequently, high mortality rates are observed due to disseminated fungal infection. This report presents clinical and postmortem data of AIDS patients with cryptococcosis in a teaching hospital in Brazil. Retrospectively, medical and necropsy records of AIDS patients with cryptococcosis clinically confirmed and/or postmortem verified were reviewed. Clinical data were compared with those of patients presenting a good outcome to evaluate disseminated fungal infection and the agreement between clinical and postmortem diagnosis. At admission, most of the 45 patients with cryptococcal meningitis who died, presented more altered consciousness (P = 0.0047), intracranial increased pressure (P = 0.047), and severe malnutrition (P = 0.0006) than the survivors. Of 29 (64.4%) patients with cryptococcal meningitis, 23 died before week 2 on antifungal therapy, and the other six during the next 3 months. The remaining 16 (35.6%) cases had other diagnoses and died soon after. At necropsy, 31 (68.9%) presented disseminated infection involving two or more organs, whereas 14 (31.1%) cases had meningeal or pulmonary localized infection. The agreement of 64.4% between clinical and postmortem diagnosis was similar to some studies. However, other reports have shown figures ranging from 34% to 95%. Currently, a progressive worldwide decrease of autopsies is worrying because the role of postmortem examination is pivotal to verify or identify the death causes, which contributes to improve the quality of clinical diagnosis and medical training.
Purpose of StudyTo review the literature on heteroresistance to fluconazole (FLC) and investigate... more Purpose of StudyTo review the literature on heteroresistance to fluconazole (FLC) and investigate the level of heteroresistance to FLC (LHF), we analyzed 100 clinical and environmental Brazilian Cryptococcus strains.Recent FindingsHeteroresistance is a phenomenon described as the emergence of resistant subpopulation cells within a single susceptible strain that can tolerate higher concentrations of fluconazole above the minimal inhibitory concentration (MIC) level.SummaryWe found lower FLC-MICs (0.12–64 mg/L) than LHF (8–128 mg/L). Highly heteroresistant adapted subpopulations (256 mg/L) was found in minority (9%) strains, but importantly, 33% showed low FLC-MIC (8 mg/L). We concluded for similar LHF in both species, but higher LHF in clinical strains in comparison to environmental ones. Our findings stressed that the LHF is not correlated to species and pretty is strain-dependent and alert about high heteroresistant subpopulations that hardly reverts to the original LHF even upon the removal of drug pressure.
Cryptococcosis by Cryptococcus gattii occurs mainly in immunocompetent hosts, however, during the... more Cryptococcosis by Cryptococcus gattii occurs mainly in immunocompetent hosts, however, during the last decades, a growing number of cases in immunocompromised individuals have been noticed around the world. This report presents epidemiological, clinical and outcome aspects of patients with cryptococcosis caused by this species from a non-endemic area in Brazil. Of 278 Cryptococcus spp. clinical isolates recovered during the same period, 267 (96%) were molecularly identified as Cryptococcus neoformans VNI genotype and 11 (4%) as C. gattii VGII genotype by URA-5 RFLP. Of the 11 C. gattii patients, eight were male, mean age of 47.5 years. Of these, four were HIV-infected, one was kidney transplanted, one presented low CD4 T cells values of unknown cause, another presented chronic liver disease meanwhile the remaining four were apparently immunocompetent. Disseminated disease and cryptococcal meningitis were present in four patients each. Most patients received amphotericin B plus fluconazole. Seven out of the 11 patients cured and four died before or during the therapy. The increased number of individuals with cryptococcosis by this species during the last decades needs to be carefully evaluated specially those who are HIV-infected. Nevertheless, Cryptococcus species differentiation is currently relevant in order to better know their relation with geographical, clinical host preference and outcome particularities.
Cryptococcal infections are mainly caused by members of the Cryptococcus neoformans species compl... more Cryptococcal infections are mainly caused by members of the Cryptococcus neoformans species complex (molecular types VNI, VNII, VNB, VNIV and the AD hybrid VNIII). PCR of the mating type loci and MLST typing using the ISHAM-MLST consensus scheme were used to evaluate the genetic relationship of 102 (63 clinical and 39 environmental) C. neoformans isolates from Uberaba, Brazil and to correlate the obtained genotypes with clinical, antifungal susceptibility and virulence factor data. All isolates were mating type alpha. MLST identified 12 known and five new sequence types (ST). Fourteen STs were identified within the VNI isolates, with ST93 (57/102, 56%) and ST77 (19/102, 19%) being the most prevalent. From the nine VNII isolates previously identify by URA5-RFLP only four (ST40) were confirmed by MLST. The remaining five grouped within the VNB clade in the phylogenetic analysis corresponding to the sequence type ST504. Other two environmental isolates also grouped within VNB clade wit...
Cryptococcal meningitis (CM) is a life-threatening infection in HIV-infected patients, especially... more Cryptococcal meningitis (CM) is a life-threatening infection in HIV-infected patients, especially in resource-limited settings. Cytokine patterns in the cerebrospinal fluid (CSF) and sera may be related to clinical outcomes. This study aimed to evaluate cytokine patterns in the CSF and sera of HIV-infected patients with CM as well as the cytokines produced by peripheral blood mononuclear cells (PBMCs) when stimulated with LPS and cryptococcal GXM. CSF and serum levels of IL-2, IL-4, IL-8, IL-10, IL-12p40, IL-17A, INF-γ, TNF-α and CXCL-10 were measured in HIV-infected patients with CM (CM+ HIV+) at various time points. Cytokine levels were evaluated in the PBMC culture supernatants and the baseline values were compared to those of HIV-infected patients without CM (CM- HIV+) and healthy controls (CM- HIV-). CSF cytokine levels at admission (n = 33) were higher than levels among the 23 survivors at week 2, but statistically significant differences were observed for IL-8 and IFN-γ (p<...
The American journal of tropical medicine and hygiene, Feb 8, 2017
Paracoccidioidomycosis (PCM) is endemic to Latin America, where 10 million people may be infected... more Paracoccidioidomycosis (PCM) is endemic to Latin America, where 10 million people may be infected with Paracoccidioides brasiliensis/Paracoccidioides lutzii and 1,600,000 individuals live with human immunodeficiency virus (HIV) infection. An epidemiological overlapping of these infections occurred early in acquired immunodeficiency syndrome era with nearly 180 published cases. This study presents epidemiological, clinical, and outcome profiles for 31 PCM patients with HIV infection diagnosed in a teaching hospital in Brazil, and includes an update of previously reported cases. Medical records were reviewed and data compared with 64 PCM patients without HIV infection. Of the 31 PCM patients with HIV infection, 23 (74.1%) were male, with a median age of 36.7 years, whereas of the 64 PCM, 45 (70.3%) were male, with a median age of 35.1 years. Both groups presented similar proportions for smoking and alcoholism. PCM patients with HIV infection presented more fever, weight loss, and the ...
Your article is protected by copyright and all rights are held exclusively by Springer Science +B... more Your article is protected by copyright and all rights are held exclusively by Springer Science +Business Media Dordrecht. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com".
formerly considered to be restricted to tropical and subtropical regions, but several outbreaks o... more formerly considered to be restricted to tropical and subtropical regions, but several outbreaks of cryptococcosis involving both immunocompetent and immunocompromised individuals have been reported in Canada, the US Pacifi c Northwest, Australia, and South America, indicating its geographic expansion [2,3]. In Brazil, C. neoformans is distributed throughout the country, whereas C. gattii is mainly found in the North and Northeast regions [4]. Due to the increase in the number of immunocompromised individuals over the past several decades, the prevalence of invasive fungal infections has substantially increased worldwide [5]. This has led to high rates of therapeutic and/or prophylactic use of azole derivates and other antifungals, causing selective epidemiological pressure, which may have contributed to the decreased susceptibility to these drugs [6].
Cryptococcosis is an important fungal infection in immunocompromised individuals, especially thos... more Cryptococcosis is an important fungal infection in immunocompromised individuals, especially those infected with HIV. In Brazil, despite the free availability of antiretroviral therapy (ART) in the public health system, the mortality rate due to Cryptococcus neoformans meningitis is still high. To obtain a more detailed picture of the population genetic structure of this species in southeast Brazil, we studied 108 clinical isolates from 101 patients and 35 environmental isolates. Among the patients, 59% had a fatal outcome mainly in HIV-positive male patients. All the isolates were found to be C. neoformans var. grubii major molecular type VNI and mating type locus alpha. Twelve were identified as diploid by flow cytometry, being homozygous (AαAα) for the mating type and by PCR screening of the STE20, GPA1, and PAK1 genes. Using the ISHAM consensus multilocus sequence typing (MLST) scheme, 13 sequence types (ST) were identified, with one being newly described. ST93 was identified fr...
The PLOS Neglected Tropical Diseases Staff S1-S3 Figs are incorrectly presented. The image that a... more The PLOS Neglected Tropical Diseases Staff S1-S3 Figs are incorrectly presented. The image that appears as S1 Fig should be S2 Fig, the image that appears as S2 Fig should be S3 Fig and the image that appears as S3 Fig should be S4 Fig. S1 Fig is omitted from the Supporting Information. It can be viewed below, along with the correct order of S1-S3 Figs and their respective captions. Supporting Information S1 Fig. Neighbor-joining (NJ) tree of the global Cryptococcus neoformans var. grubii VNI dataset using the concatenated sequences of the seven MLST loci (CAP59, GPD1, LAC1, PLB1, SOD1, URA5, and the IGS1 region). The optimal tree with the sum of branch length (0.0435) drawn to scale and measuring the number of substitutions per site is shown. Bootstrap values >50% based on 1,000 replicates are presented close to the branches. The analysis involved 92 nucleotide sequences with 3,992 positions revealing the two main clusters (red = major and blue = minor). The isolates are described according to the sequence type number (ST), followed by mating type (a or α) and country of isolation, which are abbreviated according to the alfa-2 code of ISO 3166-1. The colours of each country represent the continent of origin as follows:
Background: Although Cryptococcus laurentii has been considered saprophytic and its taxonomy is s... more Background: Although Cryptococcus laurentii has been considered saprophytic and its taxonomy is still being described, several cases of human infections have already reported. This study aimed to evaluate molecular aspects of C. laurentii isolates from Brazil, Botswana, Canada, and the United States. Methods: In this study, 100 phenotypically identified C. laurentii isolates were evaluated by sequencing the 18S nuclear ribosomal small subunit rRNA gene (18S-SSU), D1/D2 region of 28S nuclear ribosomal large subunit rRNA gene (28S-LSU), and the internal transcribed spacer (ITS) of the ribosomal region. Results: BLAST searches using 550-bp, 650-bp, and 550-bp sequenced amplicons obtained from the 18S-SSU, 28S-LSU, and the ITS region led to the identification of 75 C. laurentii strains that shared 99-100% identity with C. laurentii CBS 139. A total of nine isolates shared 99% identity with both Bullera sp. VY-68 and C. laurentii RY1. One isolate shared 99% identity with Cryptococcus rajasthanensis CBS 10406, and eight isolates shared 100% identity with Cryptococcus sp. APSS 862 according to the 28S-LSU and ITS regions and designated as Cryptococcus aspenensis sp. nov. (CBS 13867). While 16 isolates shared 99% identity with Cryptococcus flavescens CBS 942 according to the 18S-SSU sequence, only six were confirmed using the 28S-LSU and ITS region sequences. The remaining 10 shared 99% identity with Cryptococcus terrestris CBS 10810, which was recently described in Brazil. Through concatenated sequence analyses, seven sequence types in C. laurentii, three in C. flavescens, one in C. terrestris, and one in the C. aspenensis sp. nov. were identified. Conclusions: Sequencing permitted the characterization of 75% of the environmental C. laurentii isolates from different geographical areas and the identification of seven haplotypes of this species. Among sequenced regions, the increased variability of the ITS region in comparison to the 18S-SSU and 28S-LSU regions reinforces its applicability as a DNA barcode.
To evaluate Cryptococcus spp. molecular types isolated from captive birds&amp;amp;amp;amp;amp... more To evaluate Cryptococcus spp. molecular types isolated from captive birds&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; droppings, an epidemiological survey was carried out in Uberaba, Minas Gerais, Brazil, from December 2006 to September 2008. A total of 253 samples of bird excreta (120 fresh and 133 dry) were collected from pet shop cages and houses in different neighbourhoods. Cryptococcus neoformans was isolated in 19 (14.28%) dry samples and one fresh sample (0.84%). Cryptococcus laurentii was recovered from seven (5.26%) dry samples, but not in the fresh samples. The canavanine-glycine-bromothymol blue test was positive in all but one of the C. laurentii isolates. Cryptococcus neoformans molecular typing was performed using URA5-RFLP and the mating type locus using mating type specific PCR. Nineteen (95.0%) presented genotype VNI and one VNII (5.0%). In addition, all isolates presented mating type α. Thus, the genotype of the environmental C. neoformans isolates observed in this study is in accordance with others already reported around the world and adds information about its distribution in Brazil. Cryptococcus laurentii strains were typed using URA5-RFLP and M13 fingerprinting, which showed similar profiles among them. Thus, despite the low number of C. laurentii isolates analysed, their molecular profile is different from another already reported.
Cryptococcosis is frequently associated to the immune reconstitution inflammatory syndrome (IRIS)... more Cryptococcosis is frequently associated to the immune reconstitution inflammatory syndrome (IRIS) in AIDS patients on highly active antiretroviral therapy (HAART). This study aimed to evaluate clinical and evolutive features of IRIS associated cryptococcosis patients in Uberaba, Brazil. Patients: Eighty-one AIDS individuals admitted at the teaching hospital with cryptococcal meningitis were evaluated and from these, 40 were prospectively followed. Of 40 patients with cryptococcosis, nine (22.5%) presented clinical and laboratory features of IRIS. Six (66.6%) were male, with a mean age of 37.2. Five (55.5%) presented cryptococcosis as first AIDS defining condition. In seven (77.9%) IRIS was characterised as a relapse of meningeal symptoms after 10 weeks, mean time of 72 days, of starting HAART whereas, two asymptomatic patients developed the syndrome as an unmasked cryptococcosis after 10 and 12 weeks on HAART. Lymphadenitis as isolated finding associated with IRIS was evidenced in t...
Background: Although Cryptococcus laurentii has been considered saprophytic and its taxonomy is s... more Background: Although Cryptococcus laurentii has been considered saprophytic and its taxonomy is still being described, several cases of human infections have already reported. This study aimed to evaluate molecular aspects of C. laurentii isolates from Brazil, Botswana, Canada, and the United States. Methods: In this study, 100 phenotypically identified C. laurentii isolates were evaluated by sequencing the 18S nuclear ribosomal small subunit rRNA gene (18S-SSU), D1/D2 region of 28S nuclear ribosomal large subunit rRNA gene (28S-LSU), and the internal transcribed spacer (ITS) of the ribosomal region. Results: BLAST searches using 550-bp, 650-bp, and 550-bp sequenced amplicons obtained from the 18S-SSU, 28S-LSU, and the ITS region led to the identification of 75 C. laurentii strains that shared 99-100% identity with C. laurentii CBS 139. A total of nine isolates shared 99% identity with both Bullera sp. VY-68 and C. laurentii RY1. One isolate shared 99% identity with Cryptococcus rajasthanensis CBS 10406, and eight isolates shared 100% identity with Cryptococcus sp. APSS 862 according to the 28S-LSU and ITS regions and designated as Cryptococcus aspenensis sp. nov. (CBS 13867). While 16 isolates shared 99% identity with Cryptococcus flavescens CBS 942 according to the 18S-SSU sequence, only six were confirmed using the 28S-LSU and ITS region sequences. The remaining 10 shared 99% identity with Cryptococcus terrestris CBS 10810, which was recently described in Brazil. Through concatenated sequence analyses, seven sequence types in C. laurentii, three in C. flavescens, one in C. terrestris, and one in the C. aspenensis sp. nov. were identified. Conclusions: Sequencing permitted the characterization of 75% of the environmental C. laurentii isolates from different geographical areas and the identification of seven haplotypes of this species. Among sequenced regions, the increased variability of the ITS region in comparison to the 18S-SSU and 28S-LSU regions reinforces its applicability as a DNA barcode.
Histoplasmosis occurs in 5–10% of HIV-infected patients in endemic areas and evolves to severe an... more Histoplasmosis occurs in 5–10% of HIV-infected patients in endemic areas and evolves to severe and disseminated infection with mortality rates over 50% in some regions. This report presents epidemiological, clinical and outcome data from HIV-infected patients with histoplasmosis confirmed by culture and/or at necropsy who were admitted to a Brazilian teaching hospital. Data from 65 patients were obtained from their respective medical and necropsy records. From 2005 to 2018, 36 HIV-infected patients were diagnosed with histoplasmosis confirmed by culture. At admission, most of these patients presented disseminated fungal infection, whereas 15 (41.7%) were simultaneously diagnosed with both HIV infection and histoplasmosis. Fever, weight loss, hepatosplenomegaly, respiratory and digestive symptoms were present in 86.2%, 50%, 44.4% and 41.7% of the patients, respectively. At admission, 24 patients had low CD4 T-cell count and high viral load values. Among the 30 patients who received antifungals, 16 (53.3%) were cured, 13 (43.3%) died, and one was lost to follow-up. Six patients died prior to therapy. From 1990 to 2018, 63 necropsies of patients with Histoplasma capsulatum infection were performed. Of these patients, 29 (46.0%) were HIV-infected individuals, including 21 (72.4%) who presented disseminated histoplasmosis and 21 (72.4%) who were diagnosed with histoplasmosis at necropsy. The epidemiological, clinical and outcome profiles presented herein are similar to those described elsewhere and reinforce the difficulties that are still present in limited-resource settings where advanced immunodeficiency, combined with severe fungal infection and late patient admissions, is related to poor outcomes.
Cryptococcosis is frequently associated to the immune reconstitution inflammatory syndrome (IRIS)... more Cryptococcosis is frequently associated to the immune reconstitution inflammatory syndrome (IRIS) in AIDS patients on highly active antiretroviral therapy (HAART). This study aimed to evaluate clinical and evolutive features of IRIS associated cryptococcosis patients in Uberaba, Brazil. Eighty-one AIDS individuals admitted at the teaching hospital with cryptococcal meningitis were evaluated and from these, 40 were prospectively followed. Of 40 patients with cryptococcosis, nine (22.5%) presented clinical and laboratory features of IRIS. Six (66.6%) were male, with a mean age of 37.2. Five (55.5%) presented cryptococcosis as first AIDS defining condition. In seven (77.9%) IRIS was characterised as a relapse of meningeal symptoms after 10 weeks, mean time of 72 days, of starting HAART whereas, two asymptomatic patients developed the syndrome as an unmasked cryptococcosis after 10 and 12 weeks on HAART. Lymphadenitis as isolated finding associated with IRIS was evidenced in three cases. All patients presented low CD4(+) and high RNA viral load baseline values. Cultures of cerebrospinal fluid and lymph-node fragments tissues of these cases were negative. Six of nine individuals developed high intracranial pressure requiring a daily relief lumbar puncture. No deaths occurred during the evolution of these patients. The incidence and clinical evolutive profile observed in this case series are in accordance with other reports elsewhere.
BACKGROUND Ocular involvement in AIDS patients is a common event mainly caused by inflammation or... more BACKGROUND Ocular involvement in AIDS patients is a common event mainly caused by inflammation or infection. Despite the high prevalence rate of cryptococcosis in these individuals, ocular features have been occasionally described. CASE REPORT A 20-year-old Brazilian female with HIV infection recently diagnosed was admitted with a respiratory profile presumptively diagnosed as Pneumocystis jirovecii pneumonia; an ophthalmologic exam suggested choroiditis by this agent as well. She was complaining of headaches and blurred vision which led to cryptococcal meningitis diagnosis by a CSF positive India ink stain and Cryptococcus neoformans positive culture. Despite therapy based on amphotericin B plus fluconazole, her clinical state progressively worsened and the patient died one week later. At necropsy, disseminated cryptococcal infection was evidenced in several organs including eyes, which presented bilateral chorioretinitis. CONCLUSIONS Cryptococcal ocular involvement in AIDS patients has been occasionally proved among the cases already reported. Thus, the post mortem exam is still pivotal to improve the quality of the clinical diagnosis, especially in limited-resource settings.
American Journal of Tropical Medicine and Hygiene, Oct 5, 2016
Cryptococcosis occurs in acquired immunodeficiency syndrome (AIDS) patients with poor compliance ... more Cryptococcosis occurs in acquired immunodeficiency syndrome (AIDS) patients with poor compliance to antiretroviral therapy or unaware of their human immunodeficiency virus status who present severe immunosuppression at admission. Consequently, high mortality rates are observed due to disseminated fungal infection. This report presents clinical and postmortem data of AIDS patients with cryptococcosis in a teaching hospital in Brazil. Retrospectively, medical and necropsy records of AIDS patients with cryptococcosis clinically confirmed and/or postmortem verified were reviewed. Clinical data were compared with those of patients presenting a good outcome to evaluate disseminated fungal infection and the agreement between clinical and postmortem diagnosis. At admission, most of the 45 patients with cryptococcal meningitis who died, presented more altered consciousness (P = 0.0047), intracranial increased pressure (P = 0.047), and severe malnutrition (P = 0.0006) than the survivors. Of 29 (64.4%) patients with cryptococcal meningitis, 23 died before week 2 on antifungal therapy, and the other six during the next 3 months. The remaining 16 (35.6%) cases had other diagnoses and died soon after. At necropsy, 31 (68.9%) presented disseminated infection involving two or more organs, whereas 14 (31.1%) cases had meningeal or pulmonary localized infection. The agreement of 64.4% between clinical and postmortem diagnosis was similar to some studies. However, other reports have shown figures ranging from 34% to 95%. Currently, a progressive worldwide decrease of autopsies is worrying because the role of postmortem examination is pivotal to verify or identify the death causes, which contributes to improve the quality of clinical diagnosis and medical training.
Purpose of StudyTo review the literature on heteroresistance to fluconazole (FLC) and investigate... more Purpose of StudyTo review the literature on heteroresistance to fluconazole (FLC) and investigate the level of heteroresistance to FLC (LHF), we analyzed 100 clinical and environmental Brazilian Cryptococcus strains.Recent FindingsHeteroresistance is a phenomenon described as the emergence of resistant subpopulation cells within a single susceptible strain that can tolerate higher concentrations of fluconazole above the minimal inhibitory concentration (MIC) level.SummaryWe found lower FLC-MICs (0.12–64 mg/L) than LHF (8–128 mg/L). Highly heteroresistant adapted subpopulations (256 mg/L) was found in minority (9%) strains, but importantly, 33% showed low FLC-MIC (8 mg/L). We concluded for similar LHF in both species, but higher LHF in clinical strains in comparison to environmental ones. Our findings stressed that the LHF is not correlated to species and pretty is strain-dependent and alert about high heteroresistant subpopulations that hardly reverts to the original LHF even upon the removal of drug pressure.
Cryptococcosis by Cryptococcus gattii occurs mainly in immunocompetent hosts, however, during the... more Cryptococcosis by Cryptococcus gattii occurs mainly in immunocompetent hosts, however, during the last decades, a growing number of cases in immunocompromised individuals have been noticed around the world. This report presents epidemiological, clinical and outcome aspects of patients with cryptococcosis caused by this species from a non-endemic area in Brazil. Of 278 Cryptococcus spp. clinical isolates recovered during the same period, 267 (96%) were molecularly identified as Cryptococcus neoformans VNI genotype and 11 (4%) as C. gattii VGII genotype by URA-5 RFLP. Of the 11 C. gattii patients, eight were male, mean age of 47.5 years. Of these, four were HIV-infected, one was kidney transplanted, one presented low CD4 T cells values of unknown cause, another presented chronic liver disease meanwhile the remaining four were apparently immunocompetent. Disseminated disease and cryptococcal meningitis were present in four patients each. Most patients received amphotericin B plus fluconazole. Seven out of the 11 patients cured and four died before or during the therapy. The increased number of individuals with cryptococcosis by this species during the last decades needs to be carefully evaluated specially those who are HIV-infected. Nevertheless, Cryptococcus species differentiation is currently relevant in order to better know their relation with geographical, clinical host preference and outcome particularities.
Cryptococcal infections are mainly caused by members of the Cryptococcus neoformans species compl... more Cryptococcal infections are mainly caused by members of the Cryptococcus neoformans species complex (molecular types VNI, VNII, VNB, VNIV and the AD hybrid VNIII). PCR of the mating type loci and MLST typing using the ISHAM-MLST consensus scheme were used to evaluate the genetic relationship of 102 (63 clinical and 39 environmental) C. neoformans isolates from Uberaba, Brazil and to correlate the obtained genotypes with clinical, antifungal susceptibility and virulence factor data. All isolates were mating type alpha. MLST identified 12 known and five new sequence types (ST). Fourteen STs were identified within the VNI isolates, with ST93 (57/102, 56%) and ST77 (19/102, 19%) being the most prevalent. From the nine VNII isolates previously identify by URA5-RFLP only four (ST40) were confirmed by MLST. The remaining five grouped within the VNB clade in the phylogenetic analysis corresponding to the sequence type ST504. Other two environmental isolates also grouped within VNB clade wit...
Cryptococcal meningitis (CM) is a life-threatening infection in HIV-infected patients, especially... more Cryptococcal meningitis (CM) is a life-threatening infection in HIV-infected patients, especially in resource-limited settings. Cytokine patterns in the cerebrospinal fluid (CSF) and sera may be related to clinical outcomes. This study aimed to evaluate cytokine patterns in the CSF and sera of HIV-infected patients with CM as well as the cytokines produced by peripheral blood mononuclear cells (PBMCs) when stimulated with LPS and cryptococcal GXM. CSF and serum levels of IL-2, IL-4, IL-8, IL-10, IL-12p40, IL-17A, INF-γ, TNF-α and CXCL-10 were measured in HIV-infected patients with CM (CM+ HIV+) at various time points. Cytokine levels were evaluated in the PBMC culture supernatants and the baseline values were compared to those of HIV-infected patients without CM (CM- HIV+) and healthy controls (CM- HIV-). CSF cytokine levels at admission (n = 33) were higher than levels among the 23 survivors at week 2, but statistically significant differences were observed for IL-8 and IFN-γ (p<...
The American journal of tropical medicine and hygiene, Feb 8, 2017
Paracoccidioidomycosis (PCM) is endemic to Latin America, where 10 million people may be infected... more Paracoccidioidomycosis (PCM) is endemic to Latin America, where 10 million people may be infected with Paracoccidioides brasiliensis/Paracoccidioides lutzii and 1,600,000 individuals live with human immunodeficiency virus (HIV) infection. An epidemiological overlapping of these infections occurred early in acquired immunodeficiency syndrome era with nearly 180 published cases. This study presents epidemiological, clinical, and outcome profiles for 31 PCM patients with HIV infection diagnosed in a teaching hospital in Brazil, and includes an update of previously reported cases. Medical records were reviewed and data compared with 64 PCM patients without HIV infection. Of the 31 PCM patients with HIV infection, 23 (74.1%) were male, with a median age of 36.7 years, whereas of the 64 PCM, 45 (70.3%) were male, with a median age of 35.1 years. Both groups presented similar proportions for smoking and alcoholism. PCM patients with HIV infection presented more fever, weight loss, and the ...
Your article is protected by copyright and all rights are held exclusively by Springer Science +B... more Your article is protected by copyright and all rights are held exclusively by Springer Science +Business Media Dordrecht. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com".
formerly considered to be restricted to tropical and subtropical regions, but several outbreaks o... more formerly considered to be restricted to tropical and subtropical regions, but several outbreaks of cryptococcosis involving both immunocompetent and immunocompromised individuals have been reported in Canada, the US Pacifi c Northwest, Australia, and South America, indicating its geographic expansion [2,3]. In Brazil, C. neoformans is distributed throughout the country, whereas C. gattii is mainly found in the North and Northeast regions [4]. Due to the increase in the number of immunocompromised individuals over the past several decades, the prevalence of invasive fungal infections has substantially increased worldwide [5]. This has led to high rates of therapeutic and/or prophylactic use of azole derivates and other antifungals, causing selective epidemiological pressure, which may have contributed to the decreased susceptibility to these drugs [6].
Cryptococcosis is an important fungal infection in immunocompromised individuals, especially thos... more Cryptococcosis is an important fungal infection in immunocompromised individuals, especially those infected with HIV. In Brazil, despite the free availability of antiretroviral therapy (ART) in the public health system, the mortality rate due to Cryptococcus neoformans meningitis is still high. To obtain a more detailed picture of the population genetic structure of this species in southeast Brazil, we studied 108 clinical isolates from 101 patients and 35 environmental isolates. Among the patients, 59% had a fatal outcome mainly in HIV-positive male patients. All the isolates were found to be C. neoformans var. grubii major molecular type VNI and mating type locus alpha. Twelve were identified as diploid by flow cytometry, being homozygous (AαAα) for the mating type and by PCR screening of the STE20, GPA1, and PAK1 genes. Using the ISHAM consensus multilocus sequence typing (MLST) scheme, 13 sequence types (ST) were identified, with one being newly described. ST93 was identified fr...
The PLOS Neglected Tropical Diseases Staff S1-S3 Figs are incorrectly presented. The image that a... more The PLOS Neglected Tropical Diseases Staff S1-S3 Figs are incorrectly presented. The image that appears as S1 Fig should be S2 Fig, the image that appears as S2 Fig should be S3 Fig and the image that appears as S3 Fig should be S4 Fig. S1 Fig is omitted from the Supporting Information. It can be viewed below, along with the correct order of S1-S3 Figs and their respective captions. Supporting Information S1 Fig. Neighbor-joining (NJ) tree of the global Cryptococcus neoformans var. grubii VNI dataset using the concatenated sequences of the seven MLST loci (CAP59, GPD1, LAC1, PLB1, SOD1, URA5, and the IGS1 region). The optimal tree with the sum of branch length (0.0435) drawn to scale and measuring the number of substitutions per site is shown. Bootstrap values >50% based on 1,000 replicates are presented close to the branches. The analysis involved 92 nucleotide sequences with 3,992 positions revealing the two main clusters (red = major and blue = minor). The isolates are described according to the sequence type number (ST), followed by mating type (a or α) and country of isolation, which are abbreviated according to the alfa-2 code of ISO 3166-1. The colours of each country represent the continent of origin as follows:
Background: Although Cryptococcus laurentii has been considered saprophytic and its taxonomy is s... more Background: Although Cryptococcus laurentii has been considered saprophytic and its taxonomy is still being described, several cases of human infections have already reported. This study aimed to evaluate molecular aspects of C. laurentii isolates from Brazil, Botswana, Canada, and the United States. Methods: In this study, 100 phenotypically identified C. laurentii isolates were evaluated by sequencing the 18S nuclear ribosomal small subunit rRNA gene (18S-SSU), D1/D2 region of 28S nuclear ribosomal large subunit rRNA gene (28S-LSU), and the internal transcribed spacer (ITS) of the ribosomal region. Results: BLAST searches using 550-bp, 650-bp, and 550-bp sequenced amplicons obtained from the 18S-SSU, 28S-LSU, and the ITS region led to the identification of 75 C. laurentii strains that shared 99-100% identity with C. laurentii CBS 139. A total of nine isolates shared 99% identity with both Bullera sp. VY-68 and C. laurentii RY1. One isolate shared 99% identity with Cryptococcus rajasthanensis CBS 10406, and eight isolates shared 100% identity with Cryptococcus sp. APSS 862 according to the 28S-LSU and ITS regions and designated as Cryptococcus aspenensis sp. nov. (CBS 13867). While 16 isolates shared 99% identity with Cryptococcus flavescens CBS 942 according to the 18S-SSU sequence, only six were confirmed using the 28S-LSU and ITS region sequences. The remaining 10 shared 99% identity with Cryptococcus terrestris CBS 10810, which was recently described in Brazil. Through concatenated sequence analyses, seven sequence types in C. laurentii, three in C. flavescens, one in C. terrestris, and one in the C. aspenensis sp. nov. were identified. Conclusions: Sequencing permitted the characterization of 75% of the environmental C. laurentii isolates from different geographical areas and the identification of seven haplotypes of this species. Among sequenced regions, the increased variability of the ITS region in comparison to the 18S-SSU and 28S-LSU regions reinforces its applicability as a DNA barcode.
To evaluate Cryptococcus spp. molecular types isolated from captive birds&amp;amp;amp;amp;amp... more To evaluate Cryptococcus spp. molecular types isolated from captive birds&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; droppings, an epidemiological survey was carried out in Uberaba, Minas Gerais, Brazil, from December 2006 to September 2008. A total of 253 samples of bird excreta (120 fresh and 133 dry) were collected from pet shop cages and houses in different neighbourhoods. Cryptococcus neoformans was isolated in 19 (14.28%) dry samples and one fresh sample (0.84%). Cryptococcus laurentii was recovered from seven (5.26%) dry samples, but not in the fresh samples. The canavanine-glycine-bromothymol blue test was positive in all but one of the C. laurentii isolates. Cryptococcus neoformans molecular typing was performed using URA5-RFLP and the mating type locus using mating type specific PCR. Nineteen (95.0%) presented genotype VNI and one VNII (5.0%). In addition, all isolates presented mating type α. Thus, the genotype of the environmental C. neoformans isolates observed in this study is in accordance with others already reported around the world and adds information about its distribution in Brazil. Cryptococcus laurentii strains were typed using URA5-RFLP and M13 fingerprinting, which showed similar profiles among them. Thus, despite the low number of C. laurentii isolates analysed, their molecular profile is different from another already reported.
Cryptococcosis is frequently associated to the immune reconstitution inflammatory syndrome (IRIS)... more Cryptococcosis is frequently associated to the immune reconstitution inflammatory syndrome (IRIS) in AIDS patients on highly active antiretroviral therapy (HAART). This study aimed to evaluate clinical and evolutive features of IRIS associated cryptococcosis patients in Uberaba, Brazil. Patients: Eighty-one AIDS individuals admitted at the teaching hospital with cryptococcal meningitis were evaluated and from these, 40 were prospectively followed. Of 40 patients with cryptococcosis, nine (22.5%) presented clinical and laboratory features of IRIS. Six (66.6%) were male, with a mean age of 37.2. Five (55.5%) presented cryptococcosis as first AIDS defining condition. In seven (77.9%) IRIS was characterised as a relapse of meningeal symptoms after 10 weeks, mean time of 72 days, of starting HAART whereas, two asymptomatic patients developed the syndrome as an unmasked cryptococcosis after 10 and 12 weeks on HAART. Lymphadenitis as isolated finding associated with IRIS was evidenced in t...
Background: Although Cryptococcus laurentii has been considered saprophytic and its taxonomy is s... more Background: Although Cryptococcus laurentii has been considered saprophytic and its taxonomy is still being described, several cases of human infections have already reported. This study aimed to evaluate molecular aspects of C. laurentii isolates from Brazil, Botswana, Canada, and the United States. Methods: In this study, 100 phenotypically identified C. laurentii isolates were evaluated by sequencing the 18S nuclear ribosomal small subunit rRNA gene (18S-SSU), D1/D2 region of 28S nuclear ribosomal large subunit rRNA gene (28S-LSU), and the internal transcribed spacer (ITS) of the ribosomal region. Results: BLAST searches using 550-bp, 650-bp, and 550-bp sequenced amplicons obtained from the 18S-SSU, 28S-LSU, and the ITS region led to the identification of 75 C. laurentii strains that shared 99-100% identity with C. laurentii CBS 139. A total of nine isolates shared 99% identity with both Bullera sp. VY-68 and C. laurentii RY1. One isolate shared 99% identity with Cryptococcus rajasthanensis CBS 10406, and eight isolates shared 100% identity with Cryptococcus sp. APSS 862 according to the 28S-LSU and ITS regions and designated as Cryptococcus aspenensis sp. nov. (CBS 13867). While 16 isolates shared 99% identity with Cryptococcus flavescens CBS 942 according to the 18S-SSU sequence, only six were confirmed using the 28S-LSU and ITS region sequences. The remaining 10 shared 99% identity with Cryptococcus terrestris CBS 10810, which was recently described in Brazil. Through concatenated sequence analyses, seven sequence types in C. laurentii, three in C. flavescens, one in C. terrestris, and one in the C. aspenensis sp. nov. were identified. Conclusions: Sequencing permitted the characterization of 75% of the environmental C. laurentii isolates from different geographical areas and the identification of seven haplotypes of this species. Among sequenced regions, the increased variability of the ITS region in comparison to the 18S-SSU and 28S-LSU regions reinforces its applicability as a DNA barcode.
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Papers by Delio J Mora