|Year : 2015 | Volume
| Issue : 5 | Page : 148-150
Fatal cryptococcosis involving multiple sites in an immunocompetent child
H Kaur1, K Zaman1, BR Thapa2, SM Rudramurthy1
1 Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||23-May-2014|
|Date of Acceptance||08-Jul-2014|
|Date of Web Publication||6-Feb-2015|
S M Rudramurthy
Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Disseminated cryptococcosis is less common in immunocompetent individuals. Herein, we report a fatal case of cryptococcosis in apparently immunocompetent child with multiple site involvement. The yeast isolated from cerebrospinal fluid, blood, endotracheal, gastric and lymph node aspirate was identified by molecular method as Cryptococcus neoformans var. grubii.
Keywords: Cryptococcus neoformans var. grubii, disseminated cryptococcosis, immunocompetent child
|How to cite this article:|
Kaur H, Zaman K, Thapa B R, Rudramurthy S M. Fatal cryptococcosis involving multiple sites in an immunocompetent child. Indian J Med Microbiol 2015;33, Suppl S1:148-50
|How to cite this URL:|
Kaur H, Zaman K, Thapa B R, Rudramurthy S M. Fatal cryptococcosis involving multiple sites in an immunocompetent child. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 7];33, Suppl S1:148-50. Available from: http://www.ijmm.org/text.asp?2015/33/5/148/150935
| ~ Introduction|| |
Cryptococcus is encapsulated yeast, which is present in environment, especially in soil contaminated with bird excreta. Predominantly, it affects the immunocompromised individuals, especially those infected by human immunodeficiency virus (HIV). The infections of pulmonary and central nervous system (CSI) are the most common among the infections caused by this agent.  However, disseminated infection can occur in immunosuppressed patients. Such disseminated infection is rarely reported in immunocompetent children. ,,,, Herein, we present the first case from India, of an immunocompetent female child, who died due to disseminated infection by Cryptococcus neoformans var grubii.
| ~ Case Report|| |
An 11-year-old female child, resident of Jammu and Kashmir presented with 2 months history of intermittent pain in epigastrium and right hypochondrium and intermittent fever documented up to 102°F associated with vomiting. She had jaundice since 1 month with dark coloured urine, loss of weight and appetite. She was admitted in local hospital for these symptoms but no improvement was seen. When she was presented to our hospital, she had headache in addition to recurrent vomiting since 2 days and had diminished response to stimuli for 1 day. She had raised intracranial pressure and had an episode of seizures with up rolling of eyes. She had no history of pruritis, bleeding from any site, focal neurological deficit or any change in behaviour or trauma, with no history of diabetes mellitus, tuberculosis, malignancy or chronic illness. Her family did not give any history of exposure to bird excreta.
Clinical examination revealed icterus and pallor along with lymphadenopathy. Liver was enlarged with presence of distended veins over the abdomen. Kernig's sign was positive and the fundus showed papilloedema. She had altered sensorium with Glasgow Coma Score (GCS) E2 M4 V2.
Laboratory investigations showed haemoglobin of 7.7 gm, total leucocyte count (TLC) of 18,000 with predominant neutrophils. Other findings included hyperglycaemia, hypokalaemia, hypernatraemia and azotaemia. She was non reactive for HIV. Investigations for cell-mediated, humoural and phagocytic immunity did not show any evidence of immunodeficiency.
Ultrasonography (USG) revealed multiple, enlarged lymph nodes at portal, peri-pancreatic regions and mesentery. Lymph node fine needle aspiration cytology (FNAC) showed presence of yeast cells with capsule on histopathology. Magnetic resonance imaging (MRI) of brain showed multiple, small non-enhancing nodular lesions in bilateral cerebral hemispheres (parietal region, occipital region and putamen) suggestive of cryptococcomas. Contrast-enhanced computed tomography (CECT) head showed dilated third ventricles. Yeast cells with capsule were detected on direct microscopy of Indian ink preparation of cerebrospinal fluid (CSF). Cryptococcal antigen test by latex agglutination (CALAS ® , Meridian Bioscience Inc.) was positive in CSF. Cryptococcus was isolated on Sabouraud dextrose agar and bird seed agar. The same fungus was detected from blood, gastric aspirate, and endotracheal aspirate culture. The isolate was urease positive and there was no colour change on canavanine glycine bromothymol blue (CGB) agar (25°C for 5 days). Antifungal susceptibility testing was performed as per Clinical Laboratories Standard Institute document for broth dilution technique (M 27 A3).
The minimum inhibitory concentration (MIC) of isolate was: Amphotericin B-0.25 μg/ml; fluconazole-1.0 μg/ml; itraconazole-0.03 μg/ml; voriconazole-0.03 μg/ml; caspofungin-2.0 μg/ml; anidulafungin-2.0 μg/ml; micafungin-2.0 μg/ml.
The growth of Cryptococcus was used to extract the deoxyribose nucleic acid (DNA) and was amplified using ITS 1, 4 and 26S rRNA primers. It was then subjected to sequencing by Big Dye Terminator Cycle Sequencing Kit, Version 3.1 (Applied Biosystems, Foster city, CA, USA) and analysed by ABI 3130 Genetic Analyser (Applied Biosystems).  The sequence obtained was compared with GenBank DNA database. The strain showed 100% similarity with standard strain of Cryptococcus neoformans var. grubii (CBS 8710, GenBank accession FJ534879). The isolate was deposited at the National Culture Collection of Pathogenic Fungi (NCCPF), Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India with accession NCCPF 250472. The nucleotide sequence is deposited in GenBank with accession KJ777814.
Urine sample showed growth of Escherichia More Details coli. Acid-fast stain for gastric aspirate, sputum and lymph node aspirate were negative.
Initially, anti-tubercular therapy (ATT) was given for three days as the symptoms were quite suggestive of tuberculosis. However, after FNAC for lymph node demonstrated Cryptococcus, patient was started on liposomal amphotericin B (6 mg/kg/day) and 5 flucytosine (100 mg/kg/day in four divided doses). Two days later, liposomal formulation was replaced by conventional amphotericin B (1 mg/kg/day), which led to the development of hypokalaemia, for which she was given potassium supplements. She was given mannitol, 3% hypertonic saline, and glycerol for decreasing intracranial tension. She also developed hyperglycaemia (central diabetes insipidus) and was started on insulin and vasopressin therapy. Phenytoin (5 mg/kg/day) was given for epileptic seizure. She went into shock with persistent fever spikes and intermittent episodes of hyperventilation and was started on dopamine. She was also given antibiotics including vancomycin and meropenem. She progressed to ventricular tachycardia, multiorgan dysfunction syndrome, pulmonary haemorrhage and finally refractory septic shock, after which she could not be revived.
| ~ Discussion|| |
Cryptococcus neoformans causes infection most commonly in immunocompromised patients including HIV positive, solid organ transplant and haematology malignancy.  Disseminated infection is defined by a positive culture from at least two different sites or a positive blood culture.  In the present case, positive cultures have been obtained from multiple sites (CSF, endotracheal aspirate, gastric aspirate, and lymph node aspirate) and from blood (cryptococcaemia) as well. Cirrhosis and liver disease have been found to be an important risk factors for disseminated infection. , In this case as well, liver involvement was present as shown by jaundice and dark-coloured urine. However, liver disease could not be investigated. The most commonly infected organ system in disseminated disease is central nervous system (CNS) followed by lung. This child had involvement of both CNS and lung.
In this case, the presentation of the disease was insidious and chronic, as the child had complaints of vomiting and headache since two months.  Though amphotericin B and 5 flucytosine were started immediately after diagnosis, it was too late as the infection had spread to multiple organs. Cryptococcosis in non-HIV patients has high mortality, possibly due to low suspicion of infection and delay in diagnosis. 
Cryptococcus neoformans var. neoformans and Cryptococcus neoformans var. grubii cause infection generally in immunocompromised individuals, whereas Cryptococcus gattii is responsible for disease in immunocompetent hosts.  Disseminated infection in immunocompetent children in earlier reports was caused by Cryptococcus neoformans var. neoformans and Cryptococcus neoformans var. humicolus, both of which showed remission after treatment. , In the present case, the isolate was identified to be C. neoformans var. grubii, which has been rarely reported to cause disseminated infection in immunocompetent hosts, especially children.  The present case highlights the importance of suspecting this aetiologic agent in immunocompetent children with liver failure presenting with complaints that are similar to this case. The major challenge in such cases is the differential diagnosis of tuberculosis, which produces similar symptoms. It is very important to initiate treatment after prompt diagnosis is made, so as to reduce mortality due to disseminated cryptococcosis in immunocompetent hosts, especially children.
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