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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusion
 ~ Acknowledgment
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 31  |  Issue : 1  |  Page : 75-77
 

Cryptococcus laurentii Fungemia


1 Department of Microbiology, GB Pant Hospital, Delhi, India
2 Department of Cardiology, GB Pant Hospital, Delhi, India

Date of Submission09-Aug-2012
Date of Acceptance26-Oct-2012
Date of Web Publication15-Mar-2013

Correspondence Address:
M Haider
Department of Microbiology, GB Pant Hospital, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.108731

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 ~ Abstract 

In the last few years there has been an increasing incidence of infection due to non-neoformans Cryptococcus spp. especially in immunocompromised host. Cryptococcus laurentii is a non-neoformans Cryptococcus which has rarely been known to cause bacteremia and pulmonary infection in humans. Here we report a case of fungemia due to Cryptococcus laurentii.


Keywords: Cryptococcus, fungemia, infection, sepsis


How to cite this article:
Banerjee P, Haider M, Trehan V, Mishra B, Thakur A, Dogra V, Loomba P. Cryptococcus laurentii Fungemia. Indian J Med Microbiol 2013;31:75-7

How to cite this URL:
Banerjee P, Haider M, Trehan V, Mishra B, Thakur A, Dogra V, Loomba P. Cryptococcus laurentii Fungemia. Indian J Med Microbiol [serial online] 2013 [cited 2019 Aug 22];31:75-7. Available from: http://www.ijmm.org/text.asp?2013/31/1/75/108731



 ~ Introduction Top


Cryptococcus laurentii is one of the several nonneoformans cryptococcus that has rarely been associated with human infection. However, in recent years there has been an increasing incidence of opportunistic infections associated with Cryptococcus laurentii, Cryptococcus albidus, Cryptococcus curvatus, Cryptococcus humicolus and Cryptococcus uniguttulatus. 15 C laurentii, a basidiomycetous encapsulated yeast, is present in the droppings and cloacal samples of feral pigeons. It is responsible for both deep seated infections, such as fungemia and meningitis, and superficial infections such as keratitis. 13,[6] Most of the cases of fungemia with C laurentii have been seen in immunocompromised host. We report a case of fungemia caused by C laurentii in a postsurgical patient with complete clinical resolution occurring after Amphotericin B administration. The organism was isolated twice from blood cultures drawn 2 days apart.


 ~ Case Report Top


A 76 year old male patient was transferred from another tertiary health care facility to our hospital, with complains of dyspnoea and swelling of both lower limbs for 7 days. The patient was a known hypertensive on regular medication and had under gone aneurysmal clipping for haemorrhagic cerebrovascular aneurysm 34 years ago. He was treated medically for myocardial infarction 23 years back. Patient was a vegetarian and did not have any significant history of travel. He was apparently well 3 months prior to admission, when he developed mild cough and dyspnoea for which he had to be nebulized at home. On examination patient was hypotensive and drowsy with biphasic crepitation on auscultation. Initial laboratory investigations reported random blood glucose of 108 mg/dl, haemoglobin of 11.4 gm% and total leukocyte count of 9800/mm cu. Chest X ray showed features of pulmonary oedema. On Echocardiogram there was LV dilation, severe mitral valve regurgitation, Type II diastolic dysfunction and global hypokinesia with ejection fraction of 1520%. Cardiac electrophysiological study showed infrahisian AV conduction block. Patient was empirically put on Amoxicillinclavulanate and was operated for cardiomyopathy on fifth day of admission. Patient was implanted with Combodevice (Cardiac resynchronization therapydefibrillator) in left infra clavicular fossa using a subcutaneous pocket. Postoperatively, Amikacin and Teicoplanin were added to the antibiotic regime. On second postoperative day patient began to get spikes of fever.  Pseudomonas aeruginosa Scientific Name Search s isolated from blood culture on the third day of operation. As per the antibiogram, antibiotics were changed to Meropenem, Piperacillintazobactam and Linezolid. On the eleventh postop day patient was intubated due to respiratory failure and septicaemia. Total parenteral nutrition was also initiated.

Patient continued to have fever and unstable vitals inspite of administration of broad spectrum antibiotics. Two weeks after surgery blood culture (Brain Heart Infusion Broth) grew cream coloured, smooth colonies of 12 mm in diameter on both blood agar and Sabouraud's Dextrose agar after an incubation of 48 hours. Blood culture after a gap of 2 days grew same colonies [Figure 1].
Figure 1: Isolation of C. laurentii on SDA – Cream colored smooth colonies after 48 hours of incubation

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Gram stained smear of the colonies revealed gram positive spherical budding yeast cells. India ink preparation showed narrow capsules surrounding the yeast cells. Urease production was noted.

Subsequent identification and sensitivity of both the isolates on automated Vitek II card gave a report of C. laurentii sensitive to Fluconazole, Amphotericin B, Voriconazole and with MIC of 2, ≤0.25 and ≤0.12 mg/l respectively. Flucytosine was resistant with an MIC of ≥64 mg/l. The isolates were further confirmed by biochemical and sugar assimilation tests.

C. laurentii was identified by the utilization of inositol and melibiose. A negative caffeic acid test and absence of Nitrate utilization reliably differentiated this species from C. neoformans and C. albidus. Culture from other sites like endotracheal tube secretion, central line tip and urine did not yield any yeast. Liposomal Amphotericin B was started (5 mg/kg) after the first report of Cryptococcus isolation and continued for two weeks. Patient became afebrile after 48 hours of treatment and two paired blood culture taken on day 10th and 18th after initiation of Amphotericin B treatment was sterile. Patient was shifted to oral antifungal therapy (fluconazole 150 mg BD) for another 2 weeks. The patient was weaned off ventilator support. He showed considerable improvement of other comorbid conditions and was finally discharged on oral antibiotics.


 ~ Discussion Top


Cryptococci generally occurs in soil contaminated with pigeon faeces and are transmitted to humans primarily through inhaled fomites. NonC neoformans species have generally been regarded as nonpathogenic saprophytes. But due to a growing population of immunosuppressed patients there are an increasing number of invasive fungal infections by nonneoformans Cryptococci. Cryptococcus laurentii and Cryptococcus albidus, together are seen to be responsible for 80% of reported cases. [7] Impaired cellmediated immunity and presence of invasive devices are important risk factors, the latter being significantly associated with Cryptococcus laurentii infection. [7]

The natural habitat of C. laurentii is unknown. Potential sources for fungemia include dissemination from a pulmonary source or transmission along intravenous catheters. It has been described as a cause of pulmonary infection. [8] Thus, acquisition of the organism by inhalation is possible. After the initial pulmonary infection, it may spread to other organ systems, particularly in immunosuppressed patients. The organism can disseminate even if the pulmonary infection is asymptomatic. In many patients, the first sign of cryptococcosis is disseminated disease. This could have been the mode of infection in the present case. Risk factors associated with C. laurentii infection are invasive devices, prior steroid exposure, prior immunosuppressant exposure, prior azole exposure, low CD4 count, exposure to pigeon excreta and neutropenia. [7] According to previous studies, blood stream infection is the most common clinical manifestation. [8] A recent case report of Primary cutaneous cryptococcosis due to C. laurentii in a renal transplant recipient has been described from India.[9] Although in the present case the exact source of infection could not be determined but the patient had risk factors like old age, prior operative procedure, in situ invasive devise and total parenteral nutrition. Generally C. laurentii infection clinically presents with febrile illness and some cases presented with hemodynamic changes in the form of hypotension; both the features were present in our case. However, neurological and cutaneous manifestations were absent. Isolation of the organism from blood is considered as diagnostic in cases of fungemia. The sensitivity pattern of our isolate is similar to other studies where clinical isolates of nonneoformans Cryptococci were susceptible to amphotericin B and fluconazole. [1]

There is no validated standard treatment for C. laurentii infection. Studies correlating in vitro antifungal susceptibility test results and treatment outcomes do not exist. Amphotericin B alone was used for treatment of fungemia for 2 weeks. The patient improved and was shifted to oral fluconazole for further 2 weeks. There are studies stating poor activity of fluconazole and flucytosine against non neoformans Cryptococci, however invivo susceptibility has been observed as patients have tolerated and responded to oral fluconazole. [1],[10]


 ~ Conclusion Top


To the best of our knowledge the present report is the first to describe Cryptococcus laurentii fungemia from the India. Generally immunocompromised patient are known to be at risk, but infection in immunocompetent patients cannot be overruled. Non neoformans Cryptococci are easy to miss, so a high degree of clinical suspicion, improved culture and identification techniques can contribute to the diagnosis of unusual fungal infections.


 ~ Acknowledgment Top


We would like to acknowledge the help of Dr Malini Kapoor (Mycology Division, Dept of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital) in identification of Cryptococcus laurentii.

 
 ~ References Top

1.Johnson LB, Bradley SF, Kauffmann CA. Fungaemia due to Cryptococcus laurentii and a review of nonneoformans cryptococcaemia. Mycoses 1998;41:27780.  Back to cited text no. 1
    
2.Kordossis T, Avlami A, Velegrakis A, Stefanou I, Georgakopoulos G, Papalambrou C, et al. First report of Cryptococcus laurentii meningitis and a fatal case of Cryptococcus albidus cryptococcaemia in AIDS patients. Med Mycol 1998;36:3359.  Back to cited text no. 2
    
3.Ritterband DC, Seedor JA, Shah MK, Waheed S, Schorr I. A unique case of Cryptococcus laurentii keratitis spread by a rigid gas permeable contact lens in a patient with onychomycosis. Cornea 1998;17:1158.  Back to cited text no. 3
[PUBMED]    
4.Velez A, FernandezRoldan JC, Linares M, Casal M. Melanonychia due to Candida humicola. Br J Dermatol 1996;134:3756.  Back to cited text no. 4
    
5.McCurdy LH, Mor0row JD. Ventriculitis due to Cryptococcus uniguttulatus. South Med J 2001;94:656.  Back to cited text no. 5
    
6.Mattsson R, Haemig PD, Olsen B. Feral pigeons as carriers of Cryptococcus laurentii, Cryptococcus uniguttulatus and Debaryomyces hansenii. Med Mycol 1999;37:3679.  Back to cited text no. 6
[PUBMED]    
7.Khawcharoenporn T, Apisarnthanark A. Mundy LM. Nonneoformans Crytococcal Infections: A systemic review. Infection 2007;35:518.  Back to cited text no. 7
    
8.Lynch JP, Schaberg DR, Kissner DG, Kauffman CA. Cryptococcus laurentii lung abscess. Am Rev Respir Dis 1981;123:1358.  Back to cited text no. 8
    
9.Kulkarni A, Sinha M, Anandh U. Primary cutaneous cryptococcosis due to Cryptococcous laurentii in a renal transplant recipient. Saudi J Kidney Dis Transpl 2012;23:1025.  Back to cited text no. 9
    
10.Shankar EM, Kumarasamy N, Bela D, Srinivasan R, Hayath K, Salomon S, et al. Pneumonia and pleural effusion due to Cryptococcus laurentii in a clinically proven case of AIDS. Can Respir J 2006;13:2758.  Back to cited text no. 10
    


    Figures

  [Figure 1]

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