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Infect Dis Clin N Am 16 (2002) 837874

John R. Perfect, MDa,*, Arturo Casadevall, MD, PhDb

Department of Medicine, Division of Infectious Diseases,

Duke University Medical Center, PO Box 3353, Durham, NC 27710, USA
Department of Medicine, Division of Infectious Diseases, Albert Einstein
College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA

Varieties of C. neoformans
Cryptococcus neoformans strains classically have been grouped into two
varieties that included ve serotypes known as C. neoformans variety neoformans (serotypes A, D, and AD) and C. neoformans variety gattii (serotypes
B and C). The serotype dierences between the dierent varieties reect antigenic dierences resulting from dierences in the structure of the capsular
polysaccharide. The serotype classication of a strain is determined using
absorbed rabbit sera [1]. Some monoclonal antibodies are now available
that are useful for typing strains [2,3]. C. neoformans var. neoformans is
found throughout the world in association with excreta from certain birds
including pigeons, canaries, and cockatoos. C. neoformans var. gattii is
found primarily in tropical and subtropical regions and has been associated
with several species of eucalyptus trees.
After many years of stable taxonomic classication the availability of
DNA typing data has shown major dierences between isolates grouped
within a serotype and, as a consequence, there is now considerable uncertainty as to the exact relationship between the varieties and serotypes. The
situation is made more complex by the fact that C. neoformans has a sexual
cycle and that some strains are capable of mating with consequent genetic
recombination. Recently it was proposed to separate serotype A into a
dierent variety known as grubii on account of signicant genetic differences from serotype D [4]. The varietal status for the serotype AD strains

* Corresponding author.
E-mail address: (J.R. Perfect).
The authors are supported by the National Institutes of Health with NIAID grants
AI33774, AI3342, and HL59842 (AC); and AI28388, AI49975, PA 98100, and AI39115 (JRP).
0891-5520/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 8 9 1 - 5 5 2 0 ( 0 2 ) 0 0 0 3 6 - 3


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

is uncertain but there is increasing evidence that these represent diploid

strains, possibly resulting from matings of A and D strains. There is now
a further proposal to abolish the current varietal system and replace it with
two species that contain groupings of genotypes [5]. Given the impending
completion of the C. neoformans genome and rapid advances in the understanding of genetic diversity among fungi it is likely that taxonomic relationship of strains will remain in ux for some time. For clinicians, however, the
standard serotype classication, which has been in use for half a century,
remains a useful method for approaching strain dierences.
Most clinical isolates are serotype A (variety grubii) even in geographic
regions where strains of variety gattii are found in the environment [6,7].
Serotype D is common in certain European countries but constitutes a
minority of isolates in other parts of the world [6,7]. For example, in New
York City serotype D comprises approximately 13% of isolates [8]. From
a clinical viewpoint there has been little emphasis in determining the serotype of clinical strains because all varieties produce similar forms of disease
and there do not seem to be signicant dierences in drug susceptibility
among the various isolates. Hence, strain serotyping is not routinely performed by microbiology laboratories and serotype information is seldom
available to clinicians. There is increasing evidence, however, that the dierent varieties result in dierent clinical manifestations or clinical syndromes.
For example, cryptococcosis caused by C. neoformans var. gattii occurs
primarily in immunologically competent hosts and is associated with the
formation of large granulomas (cryptococcomas) that may require surgical
removal for optimal management [9]. Serotype D strains have been associated with a propensity to cause cutaneous lesions [10].
Pathogenesis and prevalence of human C. neoformans infection
In the 1950s, Baker et al [1113] carried out autopsy studies and documented the existence of a primary infection complex in individuals with and
without a history of cryptococcosis. These studies established that the
pathogenesis of cryptococcosis was similar to that of Mycobacterium tuberculosis and involved an initial pulmonary infection that was contained within the lung by granulomatous inammation. Evidence that latency can
follow an initial infection and reactivate later in life comes from DNA typing studies of C. neoformans isolates from African expatriates who developed cryptococcosis while living in Europe [14]. In this study isolates
from African expatriates were more similar to those from Africa than to the
prevailing European strains [14]. Other evidence consistent with the existence of a latent state is the description of cryptococcosis caused by C. neoformans var. gattii strains in individuals living outside tropical areas with a
history of travel [15]. There is also evidence, however, that initial exposures
to the yeast can lead to symptomatic infection. For example, there are anecdotal reports of cryptococcosis following direct exposure to pigeons and

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


their excreta [16]. Recently, an immunocompromised patient was shown to

have cryptococcosis with a strain that was indistinguishable from an isolate
found in the excreta of a pet bird in the home [17]. Hence, initial acquisition
of C. neoformans from the environment can presumably lead to infection
with at least three outcomes: clearance of infection, development of latent
infection, or acute infection with or without disseminated cryptococcosis.
The outcome of infection is presumably a function of the inoculum, the
immunologic state of the host, and the virulence of the infecting strain.
At this time the interaction of these factors to determine precisely the outcome of infection remains poorly understood but it is believed that most primary C. neoformans infections are asymptomatic.
The prevalence of infection with C. neoformans is believed to be high even
when symptomatic disease is rare. Several methods have been used to study
the prevalence of infection with C. neoformans among individuals without
evidence of cryptococcosis. Skin testing for delayed hypersensitivity to C.
neoformans antigens has shown positive responses in individuals with a history of known exposure to the fungus [18]. The prevalence of positive skin
reactions in individuals with presumed high exposure to C. neoformans, such
as pigeon fanciers and laboratory workers in cryptococcal research laboratories, is high suggesting that asymptomatic infection is common [19]. Serologic studies have consistently provided evidence for widespread infection in
individuals without a history of cryptococcosis. Practically all adults have
serum antibody to C. neoformans antigens [20]. Analysis of sera from children of dierent ages in New York City has shown that the age of seroconversion for most individuals is before the age of 10 [21]. Interestingly, that
study reported one child who presented to the emergency room with vomiting and fever and was positive for serum cryptococcal antigen, which raises
the issue that some childhood infections are accompanied by antigenemia
and may be an early indicator of disseminated infection [21].
Although there are reports of occasional isolation of C. neoformans from
individuals with no signs or symptoms of cryptococcosis [22,23], this fungus
is not generally considered to be a normal constituent of the human microbial ora. The likelihood of recovering C. neoformans from asymptomatic
humans increases, however, in individuals with chronic pulmonary diseases
[24,25]. Hence, isolation of C. neoformans from a human specimen should
prompt consideration of the possibility of chronic infection.
Incidence on human cryptococcosis
Despite strong serologic evidence for widespread infection in certain
human populations, cryptococcosis is a rare disease in individuals without
impaired immunity. Before the AIDS epidemic, cryptococcosis was considered an unusual infection and there was a dearth of robust epidemiologic
studies to provide the true incidence and prevalence of cryptococcosis in the
absence of HIV infection. A retrospective review of the Kaiser-Permanente


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

records in Northern California for the years 1971 to 1980 in the pre-AIDS
era yielded only 10 cases with an overall incidence of 0.8 cases per million
persons per year [26]. Extrapolation of these numbers to calculate a rate for
the United States per year would have yielded 176 cases [26], which is not far
o from the estimates of 200 to 300 cases per year made in the 1960s [27]. A
retrospective analysis of the data at the Centers for Disease Control and
Prevention, however, revealed a steady rise in the number of identied cases
through serologic testing from 24 cases in 1965 to 336 in 1976 [27]. Whether
these numbers reected increased awareness of the infection, improvements
in serologic detection, or a true increase in the incidence of cryptococcosis
cannot be discerned from the information available. Nevertheless, it is clear
that in the 1970s there was an increasing recognition of cryptococcal disease,
which may have reected the beginning of the AIDS epidemic, the increasing use of organ transplantation to treat certain incurable diseases, and
progress in cancer therapy resulting in larger numbers of immune-suppressed survivors. A recent population-based study using active surveillance
has documented that the incidence of cryptococcosis in nonHIV-infected
individuals varies with geographic location and ranges from 0.2 to 0.9 per
100,000 in Atlanta and San Francisco, respectively [28]. An active surveillance study in Alabama found an overall annual incidence of 0.84 cases per
100,000 of cryptococcosis in nonHIV-infected individuals [29]. Rates of
cryptococcosis approaching 1 case per 100,000 in patients without HIV
infection are comparable with the incidence rates described for meningococcal meningitis [30].
After the recognition of the AIDS epidemic in 1981 cryptococcosis in
individuals without an obvious cause of immune impairment became an
AIDS-dening diagnosis. Many studies documented a high prevalence of
cryptococcosis in AIDS patients with rates ranging from 2.9% to 13.3%
[3137]. The annual incidence of cryptococcosis in patients with advanced
HIV infection in 1992 to 1994 was 17 and 66 per 1000 persons living with
AIDS in San Francisco and Atlanta, respectively [28]. These incidence numbers predate the introduction of more eective antiretroviral therapy, which
has been associated with a decline in the prevalence of cryptococcosis in this
population (see later).
Two other groups are at signicantly higher risk for cryptococcosis: cancer patients and recipients of organ transplants. Lymphoproliferative disorders were associated with an increased risk for cryptococcosis in the
1950s [38,39]. Subsequent studies have conrmed a continuing association
between cryptococcosis and hematologic malignancies [4042]. Although
prospective population-based incidence data for cryptococcosis in patients
with cancer are not available a retrospective analysis of case records at the
M.D. Anderson Cancer Center (Houston, TX) for the years 1989 to 1999
revealed an incidence of 18 cases per 100,000 admissions. Cryptococcosis
occurred in 2.8% of organ transplant recipients with an overall associated
mortality of 42% [43]. Kidney and liver transplant recipients seemed to be

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at high risk for cryptococcosis and there was a signicantly higher prevalence of C. neoformans infection among organ transplant recipients in the
Northeastern region of the United States [43]. Furthermore, both in corneal
and lung transplantation, the transplanted organ has carried the cryptococcal infection to the host [44,45].
Sources of infection
Cryptococcus neoformans var. gattii (serotype B) is found in several species of eucalyptus trees, whereas C. neoformans varieties neoformans (serotype D) and grubii (serotype A) have been isolated from various sources
including fruits, trees, and avian excreta [46]. There is general agreement
in the eld that most cryptococcal infections are acquired by inhalation of
infectious propagules. The specic source of infection and the form of C.
neoformans responsible for human infection, however, have not been denitively established. Encapsulated yeast cells of the type found in laboratory
cultures and in clinical isolates are thought to be too large to be inhaled eciently. Dehydrated yeast cells or basidiospores (<5 to 10 lm), however, are
suciently small for inhalation and alveolar deposition. Analysis of soils
contaminated with pigeon excreta has shown the presence of large numbers
of propagules with diameters compatible with alveolar deposition [47,48].
Air in sites heavily contaminated with pigeon excreta has also been shown
to contain viable cryptococci. Analysis of the air in a tower in Oklahoma
City contaminated with pigeon excreta revealed an average concentration
of 45 viable cells of C. neoformans cells per 100 L of air with approximately
60% of the cells being less than 5 lm in diameter [49]. Based on these numbers it was estimated that a human exposed to this air for 1 hour would have
41 C. neoformans cells deposited in the lungs [49]. Several studies have
shown that clinical isolates are indistinguishable by molecular typing from
environmental isolates [5052].
Direct evidence for human infection from either eucalyptus trees or
pigeon excreta is not yet available. The nding of viable C. neoformans cells
of size compatible with alveolar deposition in air from sites contaminated
with pigeon excreta and the association of DNA types in clinical- and
excreta-derived isolates, however, provides strong circumstantial evidence
implicating this material as a potential source of infection. There is one
well-documented case that suggests acquisition of C. neoformans infection
from a pet cockatoo [17]. It is advisable that individuals at risk for cryptococcosis avoid sites that are contaminated with pigeon excreta and desist
from having certain birds, such as pigeons, canaries, and cockatoos, as pets.
Although there is not a strong seasonal association for the occurrence of
cryptococcosis, some studies have noted a trend toward higher rates in the
fall and winter [37]. A study from Thailand, however, noted no seasonal
association for C. neoformans infections while demonstrating a strong association for Penicillium marneei infection in the dry season [53].


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Risk factors
Life-threatening cryptococcal disease can occur in apparently normal
individuals but such cases are relatively rare. The likelihood of cryptococcosis rises dramatically, however, in individuals with impaired immunity. Specically, conditions that predispose to impaired cellular immunity have been
associated with a signicantly increased risk of cryptococcosis and these
include advanced HIV infection [32], lymphoproliferative disorders [39], steroid therapy [54], and organ transplantation [55]. Cryptococcosis has also
been associated with hyper-IgM syndrome in children [5658] and HIVnegative CD4+ T lymphopenia in adults [59]. A smoking habit may predispose to C. neoformans infection in certain individuals [28,60]. Populationbased studies have also yielded an association between outdoor activities
and the risk of acquiring cryptococcosis [60].
In patients with HIV infection the incidence of cryptococcosis is inversely
proportional to the CD4 lymphocyte count [61]. In patients with HIV infection the risk of cryptococcosis rises rapidly when the CD4 lymphocyte count
drops below 100/lL [37]. The average CD4 lymphocyte count of HIVinfected patients with cryptococcosis has been measured at 73/lL [61].
Current trends in the epidemiology of cryptococcosis
After rising dramatically until the early 1990s, the prevalence of cryptococcosis in patients with HIV infection began to decline with the introduction of more eective antiretroviral therapy and the widespread use of
uconazole therapy for the treatment of oral candidiasis [28]. Temporal
trends noted a rising incidence of cryptococcosis in HIV-infected patients
from 1985 to 1992 [62], but by the mid-1990s there was evidence for fewer
infections in this population [63]. The introduction of highly active antiretroviral therapy (HAART) reduces viremia and increases CD4 counts,
resulting in an improved immunologic state that is associated with signicantly reduced risk for cryptococcosis. In The Netherlands the number of
patients with HIV infection complicated by C. neoformans infection has
declined by as much as 75% with the introduction of HARRT [64]. Another
important contributor is probably the use of uconazole for the suppression
of oropharyngeal candidiasis in patients with AIDS [65]. In this regard uconazole therapy has been shown to be eective prophylaxis against the
development of cryptococcal meningitis [66,67].
Because HIV infection is currently the major risk factor for cryptococcosis in countries aected by the AIDS epidemic the use of HAART has been
associated with a reduced incidence of cryptococcosis in areas where it is
available. The high cost of HAART and the complicated logistical infrastructure that is necessary for its administration, however, have precluded
its use in less-developed countries of Africa and Asia where the prevalence
of HIV infection and AIDS increased dramatically in the 1990s and so has

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cryptococcosis. For example, in Asia a prospective study of bloodstream

infections in patients hospitalized at a Bangkok hospital revealed that C.
neoformans was the most common pathogen recovered in culture [68]. The
net result of these epidemiologic trends has been an explosion in the incidence of cryptococcosis in Africa, Thailand [68], and India [69], whereas the
number of cases in Europe and the United States has declined.
Several reports early in the AIDS epidemic suggested that cryptococcosis
was more prevalent in Africa than in other geographic regions [70,71]. Currently, cryptococcal meningitis is the leading cause of culture-positive meningitis in Zimbabwe, constituting 45% of all cases and easily outnumbering
the cases of pyogenic (16%) or tuberculous (12%) meningitis [72]. A similar
situation exists in Malawi where C. neoformans is the most common cause of
meningitis having surpassed both Neisseria meningitidis and Streptococcus
pneumoniae in this role [69]. The mortality in African patients is high, averaging over 40%, and the mean duration of symptoms before hospitalization
is only 4.8 days [69]. The exact reason for the apparently higher prevalence
of cryptococcosis in African patients with HIV infection is not known.
There is some evidence that the incidence of cryptococcosis in Africa has
been increasing for decades possibly as a consequence of the developing
HIV epidemic in that continent [73]. Interestingly, a population analysis
of AIDS-dening illnesses in Australia revealed that birth in Africa was
associated with an odds ratio for developing cryptococcal meningitis that
was 2.43 times that observed for individuals born in Australia or other
industrialized nations [74]. The authors speculate that the higher likelihood
of cryptococcal disease in African expatriates may be a result of greater
exposure and lower rates of antifungal prophylaxis [74]. It is also possible,
however, that host genetic and nutritional dierences, possibly combined
with C. neoformans strain dierences, are responsible for the greater prevalence of cryptococcosis in sub-Saharan patients with AIDS.
Host defense and immune response
There is evidence that C. neoformans infections are common in the general population based on serologic [21] and skin hypersensitivity [75,76]
studies. Because the prevalence of infection in the general population seems
to be very high yet the incidence of cryptococcosis is relatively low, one must
conclude that normal host defense mechanisms are highly eective at containing and preventing disease. Nevertheless, the reality of reactivation disease in many cases of human cryptococcosis [14] strongly suggests that the
establishment of latent infection in granulomas may be a relatively common
event following acute infection in normal individuals. C. neoformans
presents the paradox that normal immune mechanisms must be highly eective at containing infection but may be unable to eradicate the organism
once established in tissue in many immunocompetent hosts. The immune
response to C. neoformans has been studied extensively in humans and


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

experimental animals and is relatively well understood. The mechanisms by

which C. neoformans subverts the immune system to establish chronic infections are only beginning to be unraveled.
Eective immune response
Most cryptococcal infections are associated with conditions whereby cellmediated immunity is compromised [77]. This observation strongly suggests
an important requirement of cell-mediated immunity in host defense against
C. neoformans and there is general agreement that a strong cellular immune
response producing granulomatous inammation is essential for containment of C. neoformans infection [7881]. In humans, containment of cryptococcal infection in the lung is associated with the formation of a primary
complex, which consists of a granulomatous subpleural nodule [11]. In brain
tissue a granulomatous response is associated with control of infection in
both humans [82] and rats [82,83]. Experimental cryptococcal infection in
immunocompetent rats reveals that control of infection with diminution
of fungal burden is temporally associated with a granulomatous tissue reaction [78]. Similarly, normal rabbits infected with C. neoformans mount a
strong cellular immune response in the meninges that is associated with containment of an intracisternal infection [84]. Because granuloma formation is
a result of a Th1-polarized response, there is a requirement for the production of Th1-associated cytokines, such as interferon-c and interleukin (IL)-2,
and eective host responses to C. neoformans infection [85,86].
The macrophage is generally considered to be the central eector cell
against C. neoformans [8789]. Alveolar macrophages are probably the rst
immune eector cell encountered by inhaled cryptococcal cells [90,91]. The
macrophage functions in defense against cryptococcosis by ingesting and
killing yeast cells and by producing proinammatory cytokines, such as
IL-12. Chemokines, such as MCP-1 and MIP-1a, are important for recruitment of inammatory cells to sites of cryptococcal infection [92]. Histologic
examination of infected tissue reveals that macrophages are closely associated with cryptococci [87]. T cells are believed to contribute to host defense
by providing cytokines that activate macrophage fungicidal activity, such as
interferon-c [93], and by promoting the transformation of alveolar macrophages into giant cells capable of ingesting large encapsulated yeast cells
[94]. Natural killer cells, neutrophils, eosinophils, and certain types of lymphocytes have each been reported to mediate direct antifungal eects in vitro
suggesting that they contribute to host defense [46].
There is evidence that humoral immunity contributes to protection
against C. neoformans [95]. Four independent research groups have shown
that passive administration of certain monoclonal antibodies to the polysaccharide capsule can prolong survival or reduce fungal burden [9699]. A polysaccharide-tetanus toxoid conjugate vaccine was shown to elicit high titers
of antibody to the capsule that protected against an intravenous infection in

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


mice [100]. The availability of specic antibody can help the host response
by providing opsonins for ecient phagocytosis, enhancing natural killer
cell function, and clearing capsular polysaccharide [101]. Antibodies to glucosylceramide [102] and melanin [103] in the cell wall have been shown to
modify the course of infection suggesting the existence of other targets for
humoral immunity in addition to the polysaccharide capsule. Serologic studies in patients at risk for infection suggest qualitative and quantitative dierences in the types of immunoglobulins present that may predispose to
disseminated disease [104].
Intracellular pathogenesis
Histologic examination of C. neoformansinfected tissue can reveal
diverse inammatory responses ranging from the virtual absence of tissue
reaction to intense granulomatous inammation resembling caseous
necrosis [79]. The budding index of C. neoformans in tissue is inversely proportional to the intensity of the granulomatous reaction which is consistent
with the view that strong cell-mediated tissue responses are required to contain infection [79]. The protean nature of tissue responses to this fungus
seems to be a function of both the immunologic status of the host and certain yet undened characteristics of C. neoformans. For example, switch variants of a single C. neoformans strain can elicit diverse inammatory
responses in rats ranging from minimal inammation to caseous necrosis
[105]. There is evidence that the size of the capsule aects the type of
response. In this regard, infection with small capsule variants often elicits
intense inammatory responses that have been confused with Histoplasma
capsulatum [106]. This phenomenon is believed to represent interference of
capsular polysaccharide during infection with these well-encapsulated
strains and the inammatory response (see later).
The location of C. neoformans vis-a`-vis inammatory cells is also a function of the inammatory response. Although the capsular polysaccharide
is antiphagocytic in vitro in conditions where there are no complement or
antibody opsonins, the fungus is rapidly ingested by alveolar macrophages
after experimental infection [107]. Granulomatous responses are associated
with a predominance of intracellular forms, whereas in the absence of inammation cryptococci can grow as extracellular fungal masses, which are
grossly visible in tissue and can give a soap suds appearance [79]. There is
increasing evidence, however, that C. neoformans can survive in macrophages for prolonged periods of time [89]. Studies on the course of C. neoformans infection in immunocompetent mice have shown that C. neoformans
can replicate inside alveolar macrophages resulting in host cell lysis [107].
At the initial stages of infection, before the immune response is established,
most of the replication occurs in the intracellular compartment. C. neoformans has a unique strategy of intracellular replication in macrophages
whereby capsular polysaccharide is secreted into vesicles resulting in


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

disruption of the vesicular network, which presumably leads to cytotoxicity [108].

From a clinical viewpoint the occurrence of intracellular parasitism in C.
neoformans infection is signicant because it suggests that ecient eradication of infection requires antifungal agents capable of host cell penetration
and that are active in phagolysosomes.
Immunomodulation by C. neoformans and its products
There is considerable evidence that C. neoformans infection is able to
modulate the host immune response through various fungal products. C.
neoformans infection elicits suppressor responses in experimental animals,
which presumably down-regulate the cellular immune response to infection
[109,110]. In rats, the maintenance of chronic infection is associated with
down-regulation of both humoral and cellular immune responses [89]. The
best characterized immunomodulator is the capsular polysaccharide, which
has been shown to interfere with a variety of immunologic functions [111].
C. neoformans sheds capsular polysaccharide into tissue during infection,
which presumably results in both local and global inhibition of the immune
response [111]. Locally, shed polysaccharide may interfere with leukocyte
migration, cytokine production, and phagocytosis, whereas globally this
antigen is believed to elicit a state of immunologic unresponsiveness such
that aected hosts seldom mount signicant antibody responses [112].
In addition to exopolysaccharides, C. neoformans synthesizes three other
products that can aect the immune response: (1) mannitol, (2) melanin, and
(3) prostaglandins. C. neoformans produces mannitol in tissue [113], which
can interfere with oxidative killing by phagocytic cells [114]. C. neoformans
has a laccase that can synthesize melanin from phenolic precursors [115].
Melanin production in tissue has been documented during both human and
rodent experimental infection [116,117]. Melanin is believed to contribute to
virulence by protecting the fungal cell against oxidative and nonoxidative
fungicidal mechanisms of host immune eector cells [118]. Melanin may also
act as an immunomodulator by down-regulating the cellular immune
response in the lung [119]. C. neoformans has recently been shown to produce prostaglandins in vitro that could modulate the immune response if
they are produced in vivo [120].
Clinical manifestations
There are two primary sites of infection with C. neoformans: the lung and
the central nervous system (CNS). In a recent review of nonHIV-infected
patients, there were 109 (36%) with only pulmonary involvement and 157
(51%) with CNS disease and the rest with other or multiple sites [121]. Three
other sites of infection (the skin, prostate, and eye) have particular clinical features that require some specic clinical attention. It should be

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


emphasized, however, that C. neoformans can infect any organ in the body
[122]. There are also a few dierences that distinguish cryptococcosis in
patients with or without HIV infection, such as more CNS and extrapulmonary involvement, higher rate of positive India ink examinations, positive
blood cultures, and fewer cerebrospinal uid (CSF) inammatory cells. This
is primarily a distinction of severity of immunosuppression and burden of
yeast and not a specic feature or tropism between HIV and the fungus.
This organ is the most common portal of entry for infection and symptoms range from asymptomatic colonization [123] to life-threatening pneumonias [124]. Although at least a third of normal hosts are asymptomatic
and infection is found by an abnormal chest radiograph, patients may
present with evidence of acute infection, such as fever, chest pain, cough,
weight loss, and sputum production [125,126]. There are also a series of
unusual presentations of pulmonary cryptococcus, such as allergic cryptococcal pneumonia [127], pseudo-Pancoasts tumor [128], bronchiolitis
obliterans with organizing pneumonia [129], and superior vena cava syndrome [130,131]. It is also possible to have simultaneous infection with
other pathogens, such as tuberculosis, Nocardia, and Echinococcus [132135].
The chest radiographs in apparently normal hosts range from well-dened,
noncalcied, single or multiple lung nodules; indistinct mass-like inltrates;
hilar lymphadenopathy; pleural eusions; and lung cavitation [136]. There is
no characteristic radiograph, although single or multiple nodules are most
common and may radiographically mimic a malignant tumor. If the infection is limited to the lung, the serum cryptococcal antigen is generally negative and in the authors opinion a positive cryptococcal serum antigen is a
sign that the yeast may have disseminated from the lung to other body sites.
Patients with C. neoformans isolated from the lung and with an underlying
immunosuppressive risk factor for invasive infection should probably be
considered for lumbar puncture to rule out simultaneous CNS infection
with or without symptoms. In the apparently normal, asymptomatic patient
with C. neoformans isolated from the lung, however, the yield of positive
ndings with lumbar puncture is so low that it does not need to be performed routinely.
In the severely immunocompromised host, cryptococcal pneumonia can
progress more rapidly; the ability to disseminate outside the primary lung
focus to the CNS allows patients to present with a meningeal rather than
a pulmonary syndrome [137]. Patients can, however, develop an over
whelming cryptococcal pneumonia with features of adult respiratory distress
syndrome [138140] without CNS involvement. Unlike immunocompetent patients, most immunosuppressed patients have constitutional
symptoms, such as fever, malaise, chest pain, cough, dyspnea, weight
loss, or headaches. Chest radiographs are similar in spectrum to


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

nonimmunocompromised hosts except that alveolar and interstitial inltrates may be more common and can potentially be confused with other
pathogens, such as Pneumocystis carinii. In AIDS patients, cryptococcal
pneumonia is primarily symptomatic and over 90% already have concomitant CNS infection at clinical presentation [124]. This observation reects
the extreme nature of the immunodeciency in these patients at the time
of cryptococcosis in which CD4 counts have generally fallen under 100
cells/lL. It should also be noted that all severely immunocompromised
patients with pulmonary cryptococcosis may present with other concomitant opportunistic pulmonary and disseminated infections, such as
typical or atypical mycobacteria, cytomegalovirus, Nocardia, and P. carinii
Central nervous system
Most patients with cryptococcal meningitis present with signs and symptoms of subacute meningitis or meningoencephalitis, such as headaches,
fever, lethargy, coma, or memory loss over 2 to 4 weeks. Patients may not
have classic symptoms, however, and present with acute (several days)
symptoms of severe headaches, intermittent headaches, or no headaches
with altered mental status. It is dicult to separate AIDS patients from
others in their presentation except to point out that symptoms may be
shorter; there is a greater chance of nding a secondary site of infection; a
greater likelihood of having a second CNS event with either infections, such
as Toxoplasma gondii, or lymphoma; and a higher burden of yeasts. A recent
new cryptococcal syndrome associated with HAART and partial immune
reconstitution has been described during HIV infection. Several patients
after starting or changing HAART developed acute symptoms of cryptococcal meningitis or pain and swelling in tissues [141]. It is hypothesized
that with an improved immune system produced by HAART, a silent or
latent cryptococcal infection was then clinically made apparent as an inammatory reaction was mobilized to the clinically silent yeast cells or polysaccharide antigen [141].
There are little data that relate the severity of CNS disease to the infecting
strain of C. neoformans and it is generally considered that the state of
host defenses primarily determines clinical manifestations. There are some
suggestions, however, that certain strains can inuence clinical presentation. For instance, in Australia, which attends to infections with both
C. neoformans var. neoformans-grubii and C. neoformans var. gattii, cerebral
cryptococcomas or hydrocephalus with pulmonary mass lesions in immunocompetent host, were generally found with the variety gattii infections [142].
In general, infection with this variety has longer survival rates than those
with variety neoformans-grubii. In a subgroup of patients with variety gattii
infection, however, there are more brain-enhancing lesions by scan, complications of hydrocephalus, cranial nerve palsies, and elevated intracranial

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


pressures, and a poor prognosis is noted [142,143]. Although these ndings

may relate to the distribution of infection in normal hosts and their degree
of immune suppression [9], it is possible that there may be an intrinsic pathobiologic varietal dierence, particularly in the propensity to invade the
brain parenchyma.
Cryptococcus neoformans has been reported to produce almost any
type of human skin lesion [144147]. Skin manifestations include acneiform
lesions, purpura, papules, vesicles, nodules, tumors, abscesses, ulcers,
supercial granulomas, plaques, sinus tracts, and herpetiformis- [148] and
molluscum contagiosumlike lesions [149,150]. Even cellulitis around an
intravenous catheter, which resembles a bacterial infection, may be caused
by C. neoformans in a high-risk patient [151,152]. The variety of skin presentations make it essential that a biopsy with culture is obtained and histopathology is performed on any new skin lesions in immunocompromised hosts.
These skin lesions can be a sentinel nding for disseminated cryptococcosis.
In fact, except for occasional clinical, laboratory accidents [153,154] and
direct trauma, cutaneous cryptococcosis generally represents disseminated
disease and it may occur simultaneously on the skin with other systemic
mycoses in severely immunocompromised hosts [155]. A recent observation
in a cohort of solid organ transplant recipients suggests that the type of primary immunosuppressive agent used for rejection of transplanted organs
can inuence clinical manifestations of cryptococcosis. In this report, transplant patients with cryptococcosis receiving tacrolimus were signicantly
less likely to develop CNS disease and more likely to have skin, soft tissue,
and osteoarticular involvement compared with patients receiving a nontacrolimus-based immunosuppressive regimen [43]. Tacrolimus has anticryptococcal activity at high temperatures (37 to 39C) but loses activity as the
environmental temperatures decrease [156]. This observation might explain
the more frequent skin involvement with its lower body temperatures.
The prostate gland has been recognized as a potential clinical site for
sanctuary of this yeast from antifungal treatment [157]. In fact, a silent C.
neoformans infection has been spread into the blood during urologic surgery
on the prostate [158]. It has been shown during careful follow-up of patients
with cryptococcosis and HIV infection that cultures of urine with or without
prostatic massage and seminal uid were frequently positive at the end of
initial therapy [159,160]. This site may represent a major reservoir for
relapse of infection in all patients, although this site is less well-studied in
non-AIDS patients with cryptococcosis. Despite reports of a penile ulcer
[161] and a vulvar lesion with C. neoformans [162], there have been no
reports of conjugal spread of this yeast.


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Before the HIV pandemic, ocular signs and symptoms could be found in
45% of patients with cryptococcal meningitis [163]. Manifestations can
range from ocular palsies to retinal involvement. Ocular infections can occur
simultaneously with other pathogens, such as HIV or cytomegalovirus [164
166]. In one fourth of cases, eye involvement may occur before the diagnosis
of meningoencephalitis [165]. Ocular cryptococcosis may lead to visual loss.
In fact, most cases of cryptococcal endophthalmitis lead to blindness with
only an occasional case successfully managed [167]. There have also been
reports of catastrophic loss of vision in patients without evidence of endophthalmitis [168,169]. Two pathogenic processes have been hypothesized.
First, rapid visual loss associated with optic neuritis caused by inltration
of the optic nerve with yeasts. There are few therapeutic options for successful therapy of this form of visual loss. On the other hand, a second group of
patients presents with slower visual loss and later in therapy or during the
follow-up period. In this group, symptoms may be related to increased intracranial pressure and treatment with ventricular shunts or optic nerve fenestrations may halt progression of visual loss. Most eye infections are from an
endogenous source, such as the CNS and blood, but occasionally the yeast
can be introduced directly into the eye from outside sources, including
trauma and transplantation of human tissue [44,170].
Other Body Sites
Cryptococcus neoformans has been described to infect most areas of the
body. The previous ve sites and their clinical manifestations are the most
common. Cryptococcemia, bone and joint, and cryptococcal peritonitis,
however, have been reported enough not to be considered rare infections.
Cryptococcemia occurs in advanced HIV infection or during periods of high
amounts of immunosuppression from either the underlying disease or drug
treatments, such as corticosteroids. It generally reects a high burden of
yeasts in tissue but it can occur without an apparent secondary site of
involvement. Cryptococcemia rarely causes vascular instability (ie, shock
or endocarditis) but these conditions have been reported. Bone and joint
involvement is an occasional extraneural site. Before the HIV epidemic, it
had been reported that up to 5% of disseminated cases of cryptococcosis
showed bone and joint involvement [171]. Osteoarticular cryptococcosis can
occur in both immunocompromised and nonimmunocompromised hosts
and the only clinical link with infection is the suggestion that sarcoidosis
is a common underlying disease with this site of infection. In AIDS patients,
it might be found in a random bone marrow biopsy without any radiographic evidence of disease. Cryptococcal peritonitis is an occasional clinical
occurrence and generally presents in two groups of patients: patients on
chronic ambulatory peritoneal dialysis; and patients with severe underlying

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illnesses, such as cirrhosis [172]. The following body sites are considered rare
manifestations of cryptococcosis because less than a dozen cases per site
have been presented in the literature: genitourinary tract (pyelonephritis and
genital lesions); muscle (myositis); heart (native and prosthetic endocarditis,
mycotic aortitis or aneurysm, myocarditis, pericarditis, and vascular foreign
body); thyroid (thyroiditis and mass); adrenal gland (adrenal insuciency
and excess); head and neck (gingivitis, sinusitis, salivary gland involvement,
larynx, and neck mass); gastrointestinal (esophagitis, biliary tract, enteritis,
and hepatitis); breast (mastitis and mass); and lymph node (lymphadenopathy) [46].

Laboratory diagnosis
Direct microscopic examination
Clinical specimens from the CSF to aspirates of cutaneous lesions can be
examined by India ink examination for the 5 to 10 lm in diameter yeast cells
with capsules. Approximately 80% of AIDS patients and 50% of non-AIDS
patients with cryptococcal meningitis reveal the yeast with this simple and
immediate test. For a routine positive India ink test from CSF, it is estimated that the specimen needs to contain greater than 103 CFU/mL of CSF
(personal observations). Although calcouor white is not specic for C. neoformans, this solution can be used on tissue aspirates with a uorescent
microscope to nd these yeasts quickly when they are in a reduced number
within a specimen. In tissue sections, the encapsulated yeasts may be surrounded by empty spaces because the capsule does not routinely stain with
many of the standard histologic stains, such as hematoxylin and eosin. The
appearance of the polysaccharide capsule can be identied with specic
stains, such as mucicarmine and alcian blue. The Gomori methenamine silver stain for fungi identies C. neoformans as a yeast but it is not specic for
this yeast and the Fontana-Masson stain, which identies melanin, selectively stains these yeasts in tissue. Most clinical isolates in both tissue and
uids have evidence of a capsule, although occasionally there are reported
hypocapsular strains in which the capsule is dicult to observe histologically [173].
Cryptococcus neoformans can be isolated on most routine mycologic or
bacteriologic media. Standard blood culture methods, including radiometric
methods, now routinely detect cryptococcemia. In fact, one study using a
lysis-centrifugation procedure showed over 70% sensitivity of detecting
cryptococcemia in AIDS patients with cryptococcosis [174]. Most C. neoformans isolates can be detected in culture between 3 and 7 days after the specimen has been placed into or on media.


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

All Cryptococcus species are nonfermentative and produce extracellular

starch and urease. C. neoformans is unique among Cryptococcal species in
its ability routinely to grow at 37C. It also produces a phenoloxidase. These
features have allowed for the rapid identication of C. neoformans by the
use of a rapid urease test or the use of Staibs birdseed agar, DOPA, or caffeic acid media to detect the brown or black colonies as the phenoloxidase
breaks the diphenolic compounds in the media down into melanin [175
177]. Isolates can also be identied by several commercial systems based
on biochemical reactions [178,179] or the use of DNA-based methods
The two varieties of C. neoformans can be dierentiated by a color reaction when grown on concanavine-glycine thymol blue agar [182] and a serotype commercial kit using monoclonal antibodies is available [183,184].
Finally, specic strains can be ngerprinted or biotyped using DNA-based
or enzymatic methods, respectively [185188], and these DNA methods can
identify specic varietal genotypes.
The serologic test for the detection of cryptococcal polysaccharide and
the diagnosis of invasive cryptococcosis is both specic and sensitive
(90%). The most commonly used method of antigen detection is the latex
agglutination test, but the enzyme immunoassay is occasionally used in
some medical centers. A positive test at titers of greater than or equal to
1:4 in a biologic uid strongly suggests infection. In fact, every positive test,
no matter what the titer, should be considered carefully within the clinical
context of the patient. Many kits can now detect as little as 10 ng/mL of polysaccharide in specimens. With proper treatment of specimens, such as elimination of rheumatoid factor by boiling and pronase or 2-mercaptoethanol
treatment, there are few false-positives. One rare false-positive occurs when
there is a cross-reactive antigen, such as the polysaccharide of Trichosporon
beigelii, in the specimen or another microorganism [189191]. False-negative
results, however, are also rare. These false-negative tests may be caused by
low titers, early infection, presence of immune complexes, prozone eect of
high titers, or poorly encapsulated strains with low production of polysaccharide. The antigen detection system has its most clinical experience with
CSF and serum specimens, but it has been used to detect polysaccharide
antigen in urine or bronchoalveolar lavage uid [192].
In diagnosis, cryptococcal antigen tests should be part of the standard
analysis on CSF specimens in immunocompromised hosts with meningitis.
They may also be used to screen serum in febrile, very high-risk patients,
such as those with HIV infection in areas where there is a known high rate
of cryptococcal infection [193]. The detection of cryptococcal polysaccharide is the leading example of a useful test for serologic diagnosis of an invasive fungal infection and it may even be positive before detection of the

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


organism by culture. Despite its excellence as a diagnostic test, it is more difcult to use as a treatment barometer except as a general prognostic feature.
High titers (1:1024) generally reect high burden of yeasts, a poor host
immune response, and a greater likelihood of therapeutic failure. Cryptococcal antigen titers have been less useful to make specic clinical treatment
decisions. For instance, the use of serial antigen titers to develop a treatment
algorithm remains imprecise and not validated by clinical trials.
Antibodies to C. neoformans may not be detected or are at low levels during active infection because many patients are severely immunosuppressed,
but they may rise during clinical recovery. They are not useful, however, for
diagnosis or treatment decisions.
Chest radiograph
The chest radiograph of pulmonary cryptococcosis in the immunocompetent host can show a variety of features including nodules, inltrates, hilar
lymphadenopathy, or pleural eusions [136,194198]. In AIDS patients the
radiograph may reveal either diuse or focal interstitial inltrates with or
without lymphadenopathy [124,199,200]. This radiograph may be confused
with P. carinii infection or represent co-infection with it or another
CT and MRI
CT and MRI are frequently used in the diagnosis and management of
cryptococcal meningitis. CT scan ndings in non-AIDS patients with meningitis can reveal hydrocephalus; gyral enhancement; or multiple nodules,
which may be enhancing or nonenhancing [201]. Cryptococcomas can be
either single or multiple and occur in up to 25% of patients [202,203].
Approximately one half of CT scans, however, are normal in cryptococcal
meningitis. In patients with HIV infection, the scans are similar to nonAIDS patients except approximately one third of patients have cortical atrophy from their underlying HIV infection [204].
The MRIs are more sensitive than CT scan for detecting abnormalities.
MRI ndings include numerous clustered foci that are hyperintense on
T2-weighted images and nonenhancing on postcontrast T1-weighted images
within basal ganglia and mid-brain, which represent Virchow-Robin spaces.
There may also be the multiple miliary enhancing parenchymal and leptomeningeal nodules with gadopentetate dimeglumine [205].
It should be emphasized that there is no pathognomonic radiographic
picture for cryptococcal meningitis. It may present simply as an idiopathic
hydrocephalus identied by CT or MRI [206]. In AIDS patients, however,
a scan may identify a parenchymal lesion, which represents a second CNS
disease process, such as toxoplasmosis or lymphoma. Finally, the use of
CT or MRI in follow-up of cryptococcal meningitis may show worsening


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

(enlargement or new lesions) or persistence of the cryptococcomas [207]

while the patient continues to improve clinically or is stable. This nding
may simply represent enhancement by inammatory cells within granulomas as microscopic infectious foci are being eliminated; it is not necessarily
a criteria for treatment failure.

The management of cryptococcosis has been extremely well-studied and
although all aspects of treatment are not consistently successful or uniformly agreed on, there is substantial evidence-based data to make recommendations. A group of experts have attempted to collate the therapeutic
evidence into a series of guidelines for therapy of cryptococcosis [208]; these
guidelines are excellent starting points for therapeutic decisions, but this discussion adds the authors own insights and opinions. The breadth of decisions to be made in cases of cryptococcosis can be quite diverse. For
instance, it is clear that some individuals with asymptomatic isolation of
C. neoformans from respiratory secretions have been untreated without clinical compromise. A recent review of this issue suggested that approximately
20% of patients with positive pulmonary cultures received no treatment
[121]. Cryptococcal meningitis, however, is uniformly fatal without antifungal treatment. Before availability of antifungal agents, there were cases that
survived for years with this chronic CNS condition before succumbing. The
rapidity of progression to death for the natural history of this infection with
severe immune suppression, however, such as HIV infection, is illustrated
in the comprehensive report on meningitis in HIV-infected patients in
Zimbabwe [72]. Of 406 patients, 45% had cryptococcal meningitis and
almost 40% of those with this infection died during the initial hospitalization
without treatment. Therapeutic decisions do have a wide range of options
and consequences in the management of cryptococcosis.
In vitro susceptibility testing
Methods for testing C. neoformans isolates in vitro for minimum
inhibitory concentrations (MICs) have been standardized and modied for
media, inoculum, and end point determinations [209,210]. Most initial
isolates of C. neoformans have low MICs to amphotericin B, ucytosine, and
azoles [211,212]. Initial resistance to ucytosine is low [213] but rising MICs
occur during therapy with this agent and correlate with clinical relapse
[137,214,215]. There has been identied, however, only an occasional
C. neoformans isolate resistant to in vitro amphotericin B [216], and
most relapse isolates remain fully susceptible to this polyene. During the
HIV epidemic and before HAART the widespread use of azoles in severely

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


immunocompromised host showed an increase in lumenal infections with

azole-resistant Candida albicans. Although there have been some apparently
azole-resistant C. neoformans strains isolated from patients, azole resistance
probably runs less than 5% of initial isolates [217]. In fact, when secondary
isolates are examined, it seems through molecular typing methods that these
are relapse isolates rather than reinfection [218] and most have a similar (susceptible) MIC as the primary isolates [219]. There are cases of increasing uconazole MICs during treatment [220], however, and present animal data
suggest a correlation between in vitro susceptibility testing and in vivo outcome [221]. It is not certain what the precise breakpoint is for uconazole susceptibility in cryptococcosis treatment. MICs, however, of greater than or
equal to 16 lg/mL from both pharmacodynamic studies in vitro [222] and
some experience with isolates from relapsed patients with prior azole exposure [223] should make the clinician consider very high dosing of drug or the
possibility of using another agent. It is possible that more azole-resistant C.
neoformans with its heteroresistant phenotypes [224] may be observed in the
future. At this time with the low incidence of primary azole-resistant isolates
it is probably not necessary to check MICs before treatment if patients had
not received prior azole therapy. All initial isolates should be saved and compared with relapse isolates, however, to determine if drug resistance is a possible factor for treatment failure. A general overview of in vitro and in vivo
reports suggests that there is a positive interaction against C. neoformans for
the following drug combinations: amphotericin B and ucytosine; amphotericin B and azole; amphotericin B and rifampin; ucytosine and azole; and triple combination of amphotericin B, ucytosine, and azole [225227].
Treatment strategies
It should be emphasized that success rates from any study depend primarily on study denitions and the patients prognostic factors. These factors always need to be taken into account when reviewing the published
data and treating the individual patient.
Amphotericin B therapy converted cryptococcal meningitis from a uniformly fatal infection to one that is curable. Amphotericin B successes
before the AIDS epidemic were reported at 60% to 70% [146,228]. A 10week course of amphotericin B at 0.4 mg/kg/d for 10 weeks recorded a success rate of 68% in non-AIDS patients [228]. In AIDS patients at 0.5 mg/kg/
d of amphotericin B, the success rate dropped to 40% [229]. Recent studies
have suggested that a higher daily dose of amphotericin B may be more
eective [230,231] and this strategy has been more commonly adopted. Furthermore, amphotericin B can now be given in higher doses with reduced
toxicity in lipid preparations if toxicities develop with standard amphotericin B. Ambisome at 4 mg/kg/d has the most clinical experience [3] and
includes a comparative trial in which it performed similar to amphotericin
B [232]. It is probably the best alternative polyene preparation for treatment


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

after standard amphotericin B deoxycholate, although ABLC has shown

some treatment success in cryptococcal meningitis [233].
Flucytosine was initially used alone in the treatment of cryptococcal meningitis [214,234], but development of resistance on therapy reduced enthusiasm for monotherapy. Several studies used the combination of amphotericin
B (0.3 mg/kg/d) and ucytosine (150 mg/kg/d) to reduce the course of treatment to 6 weeks and the toxicity of amphotericin B [228,235,236]. In some
cases, with good prognostic signs there was success with 4 weeks of treatment [236]. Furthermore, in a small number of AIDS patients, the combination therapy was found to be superior to uconazole [237] and itraconazole
alone [238]. The combination regimen reproducibly sterilizes CSF at 2 weeks
in most patients including those with AIDS and there are several studies that
support less relapses with an amphotericin B plus ucytosine treatment regimen [239,240]. This led to a denitive study using higher doses of amphotericin B (0.7 mg/kg/d) and lower doses of ucytosine (100 mg/kg/d) for a
2-week induction period of treatment and then switching to uconazole
(400 mg/d) alone for 8 weeks and completion of initial therapy [241]. This
strategy has become a primary modality in AIDS patients and frequently
chosen now for non-AIDS patients with cryptococcal meningitis [121] and
in the authors opinion represents the initial regimen of choice for treatment
of cryptococcal meningitis.
Fluconazole has been studied in cryptococcal meningitis because of its
excellent pharmacokinetics within the CNS. In a comparative trial with
amphotericin B in AIDS patients, the success rate was similar to amphotericin B alone but sterilization of the CSF took longer with the azole therapy
[229]. Fluconazole may have its most dicult time in controlling infection
when the burden of yeasts is high and infection is well-established
[242,243]. In initial therapy of cryptococcal meningitis it may be less useful.
Fluconazole has also been used as salvage therapy with higher doses [244].
Furthermore, it has been used successfully with ucytosine in treatment of
an animal model [245] and humans [246]. It has also been used in successful
suppressive therapy for AIDS patients [247,248] and may be useful for prolonged initial therapy in non-AIDS patients. Although optimal dosing for
initial stages of meningitis treatment is not precise, doses of 400 to 800
mg/d are likely to give the best results.
Itraconazole, despite its poor penetration into CSF, has been used in the
successful management of cryptococcal meningitis [249251]. Direct comparison for initial treatment of cryptococcal meningitis with uconazole has
not been made. For suppressive therapy in AIDS patients, however, uconazole has been shown to have a distinct advantage over itraconazole [239].
Miconazole has rarely been used in cryptococcal infection and with
mixed results [252254]. Ketoconazole has not been successful in treatment
of cryptococcal meningitis [255], but it is likely to be eective in non-CNS
infections [256]. Voriconazole and posaconazole have excellent in vitro
activity against C. neoformans and animal studies support their potential

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


in this infection [257,258]. Present trials for these drugs in cryptococcosis

have generally used them as therapy for patients who failed standard regimens. Successes in this unique population of patients run from 30% to
70% [259,260]. At present, the new b-glucan synthase inhibitors, such as caspofungin, micafungin, and anidulafungin, do not have clinical activity for
treatment of C. neoformans. There are a series of concepts in treatment of
cryptococcosis that require further explanation.

Site of infection
In pulmonary cryptococcosis, there are few comparative studies to determine which drugs are the best when treatment is indicated. Azoles, however,
such as uconazole, at 200 to 400 mg/d for 3 to 6 months, are safe and easy
to administer and generally form the primary treatment strategy [261,262],
unless the patient is severely ill, in which case amphotericin B should be
used. In the authors opinion, it is clear that both symptomatic and asymptomatic immunosuppressed patients with C. neoformans isolated from lung
must be treated because dissemination from this site is a distinct possibility
[137]. In fact, the authors recommend that most patients irrespective of
immune status should probably be treated when C. neoformans is isolated
from nonsterile respiratory secretions with or without symptoms. Most CNS
cryptococcomas can be treated and although length of therapy is not
dened, the authors treat patients sometimes with 2 years of uconazole.
As previously mentioned, serial scans may not be helpful and complete resolution radiographically may take years. Surgery has been recommended for
large CNS lesions (>3 cm) [263], but in the authors opinion its use needs to
be individualized, with it rarely needed with present medical management.

Immune status of host

Every attempt to improve immunity of the host during treatment needs to
be made. This may mean reducing corticosteroid treatment and it is recommended that a dose of prednisone less than or equal to 20 mg/d be achieved
during therapy. More studies on cytokines as adjunct therapy are needed
(see later). The published results of these studies are awaited to attempt to
put cytokine treatment in proper perspective. Unfortunately, in AIDS
patients who generally develop C. neoformans with less than 100 CD4
cells/lL, immune augmentation had been dicult until the age of HAART
and continuous azole suppressive therapy had been required to prevent a
high rate of relapse (50% to 60%) if antifungals were stopped, but this strategy may be changing (see later). In HIV-infected patients with cryptococcal
meningitis, it may be reasonable rst to treat the fungal infection aggressively and attempt to sterilize CSF with antifungal drugs before starting
HAART to avoid a rapid inammatory process return and development


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

of new symptoms. HAART can probably be started at 2 to 3 months after

initiation of specic anticryptococcal therapy.
Suppressive therapy
Relapse rates in AIDS patients with cryptococcal meningitis before
HAART approached 50% to 60% when antifungal therapy was stopped.
Studies showed that daily uconazole can reduce relapse rates to less than
5% [248,264]. Fluconazole has been shown to be more eective than weekly
intravenous amphotericin B dosing [248] and itraconazole [239] and it has
become standard clinical practice to prescribe indenite uconazole suppressive therapy in AIDS patients. Recent data in several small studies,
however, suggest that with HAART and its immune reconstitution (rising
CD4 counts and lowering HIV loads), antifungal suppressive therapy can
be stopped at 1 year with little chance for relapse in the next year [265
267]. A large study of stopping the suppressive azole regimen is beginning
in Europe and it is hoped this study will bring more certainty to this strategy. There are no guidelines for suppressive therapy in non-AIDS patients
with cryptococcal meningitis who can relapse in the rst year at a 10% to
15% rate with standard regimens. With the use of safe and oral azoles, a
common practice has been to extend therapy with uconazole at 200 mg/d
for 6 months to a year to cover this highest relapse period.
Role of intracranial pressure
Patients with high burden of yeasts and antigen can develop increased
intracranial pressure both before treatment, during early treatment, and
with the chronic phase of treatment and monitoring. With high intracranial
pressures during early management of infection, these patients develop
symptoms, such as systemic hypertension, decreased sensorium, cranial neuropathies, visual loss, or increased headaches. It has been postulated that the
elevated subarachnoid pressures are caused by reduced CSF resorption
because of increased outow resistance possibly from yeasts and polysaccharide plugging the arachnoid villi and the antigen contributing to brain
edema [268]. Clinical response to therapies is better in those patients with
pretreatment CSF opening pressures less than or equal to 250 mm H2O
or those with stable or decreased (>10 mm H2O) lumbar CSF pressures
at 2 weeks [269]. Control of increased intracranial pressures with techniques
of external drainage, such as repeated lumbar punctures or lumbar drains,
may be necessary during the early treatment phase. Unfortunately, the general preciseness of methods and goals remains elusive and generally is based
on individual patient responses. In contrast to early treatment pressure
problems, ventricular shunts are successful for long-term pressure control
in those with classic obstructive hydrocephalus, which may occur months
after start of treatment and must be watched for during follow-up visits.
A shunt can be placed successfully while cryptococcal meningitis is being

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


eectively treated. In cases of cryptococcal meningitis in which the shunt has

already been in place for treatment of hydrocephalus before anticryptococcal treatment, however, it needs to be removed for cure [206]. The patient
can then be started on adequate treatment and when CSF is sterile another
shunt can be placed if clinically indicated.
Antigen titers
Cerebrospinal uid polysaccharide antigen titers generally reect the burden of organisms at the initial diagnosis and high antigen titers predict a
poor prognosis. The use of specic antigen titers to predict individual outcome and direct therapy, however, is generally not helpful [270]. Polysaccharide antigen may persist for long periods of time despite adequate
therapy. Changing or xed titers are not reliable indicators of treatment outcome in individual patients. During the AIDS epidemic, isolated cases of
serum cryptococcal polysaccharidemia in HIV-infected patients with negative cultures have occurred [271]. Management of these cases is dicult but
empiric therapy may be wise in these high-risk patients because many eventually develop cryptococcosis.
Cytokines and monoclonal antibodies
Disseminated cryptococcosis generally occurs during an episode of
immunosuppression. There are in vitro studies and animal models that indicate that biologic response modiers or antibodies can have a positive eect
on outcome of cryptococcosis (see host factors). Granulocyte-macrophage
colonystimulating factor, macrophage colonystimulating factor, IL-2,
IL-12, and interferon-c can positively interact with host cells to inhibit or
kill C. neoformans. Granulocyte-macrophage colonystimulating factor has
been used in an open trial [272] and results of an adjunct trial of interferonc, which was supported by encouraging results in animals, are awaited [273].
It is not yet clear whether these cytokines help or exactly how to optimize
their use. Specic monoclonal antibodies and serum therapy have a positive
eect on the prevention and treatment of experimental cryptococcosis [274
276]. A monoclonal antibody is now being studied in early phase I trials in
HIV-infected patients with stable cryptococcal disease but persistent polysaccharide antigenemia. There remain little denitive human clinical trials,
however, into immune modulation therapy. It is clear that future studies
with these biologic enhancers are needed as further strategies are developed
for management in an infection, which can still have 10% to 25% acute mortality rates during early treatment in medically advanced countries.
The most important prognostic factor for the success and treatment
of cryptococcal meningitis is the ability to control the patients underlying


J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874

disease. It has been shown that cancer victims have a shorter survival than
AIDS patients because of their underlying disease state [277]. Another major
risk group is solid organ transplant recipients and recent data and prognosis
in this group are conicting. In one study the prognosis of cryptococcosis in
solid organ transplant was similar to patients without an underlying disease
[121] but in a second study there was a death rate of 42% [43]. More studies
are needed in this area. Two other prognostic ndings are burden of organisms at presentation and the level of patients sensorium. A poor prognosis is
found with a heavily positive India ink examination; high polysaccharide
antigen titers (1:1024); and a poor inammatory response in the CSF
(<20 cells/ll). Patients on presentation who have a lucid sensorium have a
better prognosis than those stuporous or in coma [236].
Specic factors have predicted outcome and generally relate to the three
factors previously described. On amphotericin B therapy, Diamond and
Bennett [278] found more than three decades ago that patients who died
during therapy were more likely to have: (1) an initial positive India ink
examination, (2) high CSF opening pressure, (3) low CSF glucose, (4) low
CSF leukocytes, (5) cryptococci isolated from extraneural site, (6) absence of
anticryptococcal antibody, (7) initial CSF or serum antigen titer of greater
than 32, and (8) corticosteroid therapy or lymphoreticular malignancy.
Patients who relapsed after treatment were characterized by: (1) abnormal
CSF glucose for greater than or equal to 4 weeks of therapy, (2) low initial
CSF leukocytes, (3) cryptococci isolated from extraneural sites, (4) absence
of anticryptococcal antibody, (5) posttreatment CSF or serum cryptococcal
antigen titer greater than or equal to 8, (6) no signicant decrease in CSF
and serum antigen titer during therapy, and (7) daily dose of corticosteroid
therapy equivalent to 20 mg of prednisone or more after therapy. These
insights may still help to predict failures today. Recent studies with amphotericin B and ucytosine treatment in non-AIDS patients indicated a better
prognosis if there was a normal mental status, headache on presentation,
and a CSF leukocyte count greater than 20 WBCs/lL [236]. In AIDS
patients during treatment with amphotericin B or uconazole, important
positive pretreatment predictors for death during treatment were abnormal
mental status, a CSF antigen titer greater than 1:1024, and CSF leukocyte
count less than 20 WBC/lL [241]. Identication of these high-risk patients
for failure and relapse should allow the clinician to design specic antifungal
regimens for these subsets of patients.
There are at least four methods for approaching high-risk patients to prevent cryptococcosis. First, antifungal prophylaxis for AIDS patients has
been eective in reducing the incidence of cryptococcosis with the use of uconazole [67,279]. Both HAART and concerns about widespread exposure
to azoles worked together, however, to reduce enthusiasm for its general

J.R. Perfect, A. Casadevall / Infect Dis Clin N Am 16 (2002) 837874


use. Second, active immunization with a vaccine for high-risk patients is

possible. A cryptococcal GXM-tetanus toxoid conjugate vaccine has been
developed which elicits protective antibodies in mice [280] and an initial
paradigm has been completed. It or other vaccine candidates, however,
await clinical trials in humans. Third, the ability to produce protective
humanized or murine monoclonal antibodies could be given to high-risk
patients as passive prophylactic therapy, but protection requires repeated
continuous administration over the risk period. Finally, high-risk patients
can attempt to avoid high-risk environments, such as bird droppings, which
contain yeasts to be aerosolized and inhaled.
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