University of Baghdad

College of Medicine
2024
• Title: Cryptococcus neoformans
• Grade: 3
• Module: Infectious diseases
• Speaker: Lec. Dr. Basim M. Ibrahim
• Date: 21.03.2024
•
Objectives:
 With the end of this lecture the students will be able to:
1. Define Cryptococcosis and Candidiasis.
2. Demonstrate some important characteristics of Cryptococcus spp.
and Candida spp.
3. State main clinical presentations of the two cases.
4. List laboratory diagnostic steps.
Cryptococcus spp.:
 Classified into the Division: Basidiomycota.
 Encapsulated yeast (surrounded by a large polysaccharide
capsule both in host and on some culture media).
 First case of cryptococcal meningitis was reported in 1905.
 Include 37 species, only Cryptococcus neoformans (C. neoformans)
is pathogenic to human.
 Classified into 4 serotypes according to capsular lipopolysaccharide
antigens; A, B, C and D.
 Capsule importance:
1. Resistance to phagocytosis.
2. Aids in identification.
3. Suppress T-cell function.
 Difference between Yeast and Mold
CCC. Yeast Mold
Definition Microscopic fungus, consisting of Growth form of fungus, which grows in the
a single, oval cell form of multicellular filaments called hyphae

Habitat Common in environment Found in damp, dark or steam-filled areas

Appearance Oval in shape, and is colorless and Fuzzy appearance, and the colors can be
smooth green, orange, black, brown, purple and pink

Energy Converts carbohydrates to alcohol Secretes hydrolytic enzymes to external food

production during fermentation sources and absorbs nutrients

Reproduction Budding Sexual or asexual spores

Uses Baking industry and in the Production of cheese
production of ethanol
Examples Saccharomyces cerevisiae (baking Mucor, Penicillium, Rhizopus, and Aspergillus
yeast) and C. neoformans
Cryptococcus serotypes:
1. C. neoformans var neoformans
 Two serotypes: A and D.
 Found in soil contaminated with pigeon droppings (birds
excreta).
 Causative agent of most common cases of Cryptococcosis,
especially in immunosuppressed individuals.

2. C. neoformans var gattii

 Two serotypes: B and C.
 Found in bark and plant debris under Eucalyptus trees or
decaying wood, not associated with pigeons.
Source of infection??
 Note:
Host’s immune status seems to be more important than
virulence of organism.
Current model of immune response to Cryptococcus spp. in health and disease
1. Inhaled cryptococcal spores are recognized by alveolar macrophages through pattern
recognition receptors (PRR).
2. This stimulates macrophages to release C–C motif chemokine ligand 2 (CCL2) to recruit
monocytes and dendritic cells (DCs) to lung.
3. Recruited DCs are capable of breaking down cryptococcal lifeforms and present Ag to
CD4+ T-cells.
4. Activated Th1 and Th17 secrete IFN-Ɣ, IL-6, IL-10 and granulocyte-macrophage colony
stimulating factor (GM-CSF) to recruit/differentiate classical (M1) macrophages.
5. Exact mechanism of fungicidal activity by M1 macrophages against Cryptococcus spp. is
still unclear; however, they known to upregulate iNOS, CD80 and TLR4 as well as
produce IL-1β, IL-8 and TNF-α.
6. Cytokine/chemokine mileu organize leukocytes to encapsulate/eliminate cryptococcal
organisms within granulomas.
7. Most common association with cryptococcal disease is absence/dysfunction of at least one
aspect of healthy immune response, leads to uncontrolled fungal growth.
8. Some patients develop a skewed hyper-immune response to pathogen, causing
inflammatory damage to host tissue even with fungal clearance.
Cryptococcosis:

 Potentially fatal fungal infection, presenting mainly as

pneumonia or meningitis.
 Clinical presentations:
1. Central nervous system.
2. Pulmonary.
3. Visceral.
4. Cutaneous / Mucocutanous.
1. Cryptococcal meningitis:
 Meningitis/Brain abscess are most common presentations.
 Symptoms including headache, fever, nausea, vomiting, neck
stiffness, vision problems, coma, photophobia and changes in mental
status (confusion or change in behavior).
 Untreated infections are often fatal.

Center for Food Security and Public Health, Iowa State University, 2012
2. Pulmonary cryptococcosis:
 Either asymptomatic (majority) or symptomatic (self-limiting)
infection.
 After initial infection, spreading to other organs may occur.
 Symptoms include cough, fever, headache, weight loss, dyspnea,
malaise, chest pain and difficulty breathing.
Section of Rt. lung showing apical Distended alveoli filled with
cavity and multiple foci of Cryptococcus spp. (HE stain)
consolidation with a mucoid
appearance
3. Ocular lesions:
 Optic neuritis, chorioretinitis and endophthalmitis.

Conjunictival Cryptococcosis
4. Skin lesions:
 Formation of granulomatous reaction with giant cells.
 Presentations: Papules, vesicles, ulcers, purpura, subcutaneous
tumor-like masses and abscesses.
 Lesions can mimic: Acne, Lipomas and Basal cell carcinoma.

Annular, confluent,
erythematous plaques on
posterior Rt. calf 5 months
after onset of primary
cutaneous cryptococcosis
A. Initial presentation of erythematous and indurated skin.
B. Skin biopsy sample showing yeast forms with mucoid capsules.
C. Progressive ulceration of skin despite antifungal therapy.
D. Slow re-epithelization of skin after surgical debridement and 6 months of
antifungal therapy. Center for Food Security and Public Health, Iowa State University, 2012
5. Cellulitis:
 Common in organ transplant recipients.

Cryptococcal cellulitis on Rt. forearm

Lab. Diagnosis:
1. Specimens: CSF, biopsy, blood, sputum and urine.
2. Slide: Encapsulated (clear halo), round to oval, single cell.

Capsule in tissue section

stained with Meyers-
Mucicarmine stain

India ink preparation of CSF

3. Culture: At 25-37°C for 48-72 hrs. on:
 SDA without cycloheximide: White-creamy to yellowish-brown, soft, fast
growing, glistening, smooth and mucoid.
 Bird seed agar OR Caffeic acid agar: Brown-black colonies (due to
melanin produced).
 Urea agar: +ve.

Bird
seed
agar

-ve / +ve
 SDA medium

Note:
C. neoformans differs from Candida spp. by hydrolyzing urea and
not forming pseudohyphae.
4. Biochemical examination of CSF in addition
to numerous organisms:
5. Serology:
• Not useful in humans as Abs are often found in healthy people.
• Serological tests involve:
1. Latex agglutination test:
• Detect cryptococcal Ags.
• Sensitive and specific.
• In serum, CSF and broncho-alveolar lavage, false-ve results may
exist.
• Patient improves = ↓ titer ; No respond to therapy = ↑ titer.
2. Indirect fluorescent Ab test:
Identifies organism in culture/tissue section, by staining yeast cell wall.
3. Tube agglutination test.
4. ELISA.
Treatment:

 Long-term therapy is required in HIV patients after initial

therapy, as infection respond slowly to treatment.
 Prophylaxis: Fluconazole or itraconazole.
 Rx.: Amphotericin B, 5-Fluorocytosine (both are synergistic),
Fluconazole, Itraconazole, Ketoconazole and Flucytosine.
 Treatment consists of 3 phases:
1. Induction (at least 2 weeks plus clinical improvement).
2. Consolidation (8 weeks or until CSF cultures are sterile).
3. Maintenance therapy (lifelong).
 Prevention and Control: Environmental exposures are difficult to
prevent; avoid pigeon droppings and remove them from the
environment, carefully cleaning of birds cages/handling of infected
animals and avoid eucalyptus trees.
 University of Baghdad
College of Medicine
2024
• Title: Candida albicans
• Grade: 3
• Module: Infectious diseases
• Speaker: Lec. Dr. Basim M. Ibrahim
• Date: 21.03.2024
•
Introduction:

 Genus includes approximately 154 species, of which C. albicans is

the most frequently isolated in human infections.
 Candida albicans (C. albicans) is single-celled dimorphic (have 2
forms; yeast in host and mold in environment).
 Endogenous; normal flora of human oral cavity, gut and vagina.
 Frequently recovered from hospitals, medical equipment and food.
 Able to produce blastoconidia, pseudo- and true-hyphae, germ-tube
and chlamydospore by the conversion of hyphal elements.
Virulence Factors:
1. Adhesins (major determinant; MP66, MP-hemed and Ala1p).
2. Enzymes: Proteinase, phospholipase and lipase.
3. Toxins: Gliotoxin and acetaldehyde.
4. Interference with phagocytosis, immune defenses and complement.
5. Mannan: Major antigen of Candida spp.
6. Glucan: Prevent amphotericin B from gaining access to plasma
membrane.
7. Morphogenesis (yeast to filamentous hyphae).
8. Germ tube.
9. Synergism with certain bacteria.
10. Acidic metabolites.
11. Growth rate and undemanding nutrient requirements.
Pathogenesis:
 Most common fungal pathogen worldwide.
 Disease caused by invading human tissue through pseudohyphae
(invasive form), penetrating intracellular cracks.
 Impair immune function by directly/negatively affecting T-
helper:T-suppresser, resulting in unregulated immunoglobulins
production.
 Produce disguising antigens, deterring immune system from
recognizing it as a foreign body, resulting in a non-responsive
condition.
Predisposing factors:
1. Overuse of antibiotics. Because normal flora
2. Oral contraceptives.
3. Steroid hormone medications and corticosteroids.
4. Suppressed immune system: D.M, AIDS, radiation or
chemotherapy.
5. General/invasive surgical procedures, including catheterization.
6. Prolonged hospitalization.
7. Bone-marrow/organ transplantation.
8. Premature low-weight births.
9. Sexual intercourse.
10. Trauma.
11. Pregnancy.
Oropharyngeal Candidiasis (thrush and
Esophagitis):
 Incidence: Infants during their 1st year, elderly persons and D.M
patients.
 Affected areas: Moist surfaces around lips, inside cheeks, tongue and
palate.
 Candidal esophagitis is the most frequent infection among HIV
patients with an incident rate as high as 50-90%.
 Prevention:
1. Treatment of vaginal yeast infection during the last 3 months of
pregnancy.
2. Wash bottles and pacifiers and stop continuous reusing of bottles.
3. Practicing good oral hygiene.
Pseudomembranous
White thick plaques in mouth, tongue, gums,
palate and/or pharynx.

Atrophic
Diffuse erythema affects mainly palate and
tongue and result in soreness, often denture-
induced.

Angular cheilitis
Signs of cracking and inflammation seen at
corners of mouth; painful, burning and
soreness.
Onychomycosis (nail infection):
 Characterized by red swelling around nails, destruction of nail tissue
and loss of nail.
 Difficult to treat, however, oral antifungal medications work best.
Ocular Candidiasis:
 Characterized by cloudy vision and lesions within the eyes.
 Caused by spreading of C. albicans via the bloodstream.
 Treatment: Amphotericin B.
Other presentations:
1. Genital infections.
2. Bloodstream infections.
3. Cutaneous (skin, scalp and nails).
4. Diaper rash in newborn infants.
5. Deep (Invasive).
6. STD.
7. Sepsis.
Blood, swabs, vaginal discharge, urine, feces, nail
clippings, hair, skin scales, respiratory secretions or
material from cutaneous or muco-cutaneous lesions

(Hyphae, spores or yeast cells)

Skin smear C. albicans
 Production of Germ-tube and Chlamydoconidium is a key for
identifying of C. albicans.
C. albicans
Biochemical identification tests:
• API Candida.

Serology/Molecular detection methods:

 Fluorescent in situ hybridization (FISH).
 Amplified TefI gene from C. albicans.
 Serum concentrations of mannan is useful for determining patients
with disseminated Candidiasis.
Antibiotic susceptibility, Treatment and
Prevention:
 Rise in incidence and over prescription of antifungals have
contributed to an increasing resistance.
 Recombinant DNA to create a live vaccine, composed of
conjugated fungal antigens with diphtheria toxoid.
 Prevention procedures: Good personal hygiene; keeping skin clean,
avoid high sugar, starch, and carbohydrates in diet and taking
sufficient amounts of probiotics to repopulate normal flora.
 Vaginal candidiasis: Monistat, Vagistat, Gyne-Lotrimin, Diflucan,
and Amphotericin B.
 Systemic infections: Itraconazole and Fluconazole.
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