Cryptococcosis associated with HIV negative Indian patients and HIV positive Indian blood donors

Abstract

Cryptococcosis, particularly cryptococcal meningitis (CM), has become an increasing problem globally in the AIDS era.In the present investigation we have made an effort for the first time to study Indian cases (100) both HIV positive (23 cases, male, mostly Indian professional blood donors, PBDs') confirmed by an ELISA test and Western Blot but asymptomatic for CM and HIV-negative (77: 49 male and 28 female) asymptomatic or symptomatic.These subjects were patients from the Lucknow hospitals admitted during the period between February, 1991 to February, 1994, for suspected cryptococcosis or CM.Of those cases, 10% were positive for cryptococcosis or CM.Meningoencephalitis was the dominant clinical manifestation in four (HIV-negative) cases of CM.CT scanning of the head of those cases revealed a noncommunicating hydrocephalus due to aqueductal stenosis (in 2 cases) and a communicating hydrocephalus with granuloma (by MRI) in another case.The latex agglutination test (LAT) of the sera was positive for Cryptococcus antigen in 6 (26%) of the (HIV-positive) patients and 4 (5%), of the HIV-negative cases.In the cases of CM, there was a lower antigen titre in CSF than in the pronase-treated sera.The LAT was found to be useful in diagnosis of cryptococcosis, especially in asymptomatic cases.The CSF of CM-positive cases revealed low levels of glucose, reduced cell count and high proteins.Among the HIV-negative cases, the onset of meningitis in 4 cases was preceded by the presence of encapsulated budding yeast cells in CSF India ink smear, or cryptococci in a direct urine smear in one case.The CSF culture of 3 cases was positive for mucoid Cryptococcus neoformans, showing brown colour effect (BCE) on Staib agar (syn.Guizotia abyssinica creatinine agar, bird seed agar).The isolated yeast strains were identified as C.neoformans var.neoformans by physiological tests.The pathogenicity test of strains revealed virulence to BALB/c mice evidenced by a high mortality of mice and significantly (p < 0.05) high CN burden (> 4–5 mean loglo cfu), in the brain followed by other visceral organs (lung, liver, spleen, kidney and heart).The in-vitro susceptibility (MIC [μmL-1) of strains for 10 antifungals was established to draw up guidelines for the management of the disease.Primary therapy of patients with amphotericin B (AMB) alone or combined with flucytosine and/or by salvage therapy with fluconazole showed promising results in the management of CM.Our preliminary studies indicate that association of HIV, notably with PBDs', is an increasingly frequent cause of CN infection.