First Case of Human Cryptococcosis Due to Cryptococcus neoformans var. gattii in Spain

Abstract

We report the first case of human cryptococcosis due to Cryptococcus neoformans var. gattii described in our country, which was presented as brain cryptococcoma in an immunocompetent patient. An extensive sampling of the patient's environment was carried out to find the source of infection. CASE REPORTA 60-year-old heterosexual Spanish farmer came to the Hospital General de Alicante in July 2003, having suffered for several days from cephalalgia and somnolence. He had never traveled abroad. A diabetes mellitus type 2 identified 2 years previously was the only clinical antecedent of interest. Human immunodeficiency virus serology was investigated with repeated negative results. General and neurological exploration included computerized tomography scanning, which disclosed a brain mass lesion in basal ganglions. Capsulated yeasts were seen in a stereotaxic brain puncture sample, and Cryptococcus neoformans was suspected to be the causative agent. C. neoformans capsular antigen was detected in blood and cerebrospinal fluid (CSF) several times during the process (maximum values detected, 1/256 and 1/32, respectively). The yeast was cultured from a surgical drainage sample of the brain abscess. Species identification was carried out on the basis of microscopic morphology, growth at 37°C, a urease test, phenoloxydase production, and the carbohydrate assimilation pattern (Auxacolor; Bio-Rad). Further testing such as canavanina glycine bromothimol blue agar growth, serotype determination (Cryptocheck test; Iatron), and genotype analysis revealed that the strain was C. neoformans var. gatti serotype B. The strain identification and serotype were confirmed in another mycology laboratory (IMIM, Barcelona, Spain). Two antifungal drug sensitivity tests were performed (Sensititre and Etest). Both tests showed low amphotericin B (AMB) and ketoconazole MICs but different results with fluconazole (MIC sensititre , 8 g/ml; MIC Etest , 64 g/ml) and 5-flucytosine (MIC sensititre , 2 g/ml; MIC Etest , 32 g/ml). Voriconazole was only tested with the Sensititre test (MIC sensititre , 12 g/ml). Genotype analysis consisted of the study of five molecular DNA targets: internal transcribed spacer-5.8S rRNA gene sequence analysis (36), 5S rRNA gene and URA5 gene restriction fragment length polymorphism (RFLP) analysis (24), and amplification patterns of two highly repeated minisatellite sequences (M13 and GACA 4 ) (14, 24). Nucleotide sequence analysis of the internal transcribed spacer-5.8S rRNA gene confirmed the identification at a species level by comparing it to ribosomal sequence databases (EMBL and GenBank). RFLP of the URA5 gene showed a VGI molecular type (Fig. 1) which is characteristic of C. neoformans var. gattii. RFLP 5S rRNA gene and minisatellite amplification of M13 and GACA 4 also displayed molecular patterns attributable to C. neoformans var. gattii strains (14, 24).Some different antifungal therapies were followed, depending on the clinical evolution and the antigen levels (serum and CSF). Intravenous AMB at 200 mg/day (A...

Cryptococcus gattii Infections

“…Decomposing wood in tree hollows has been identified as an environmental source (22,105). Eucalypts are in fact only one of Ͼ50 different species of tree that can provide an ecological niche for C. gattii (106)(107)(108)(109)(110). Environmental isolates have been obtained from Africa (33,(110)(111)(112), Asia (76,77,108), Australia (26,110,(113)(114)(115)(116)(117)(118), Europe (110,119,120), North America (38,110,121), and South America (122).…”

“…Single cases of infection have also been reported in the United States, including New England (85,243,247), New Mexico (272), and Florida (253); Europe (91,95,106,245); Asia, including Japan and Singapore (227,246,249); and South America (223,256). Most recently, Harris et al reported 25 cases, inclusive of previously described patients (247,253) diagnosed between 2009 and 2012, from Montana, Alabama, California, Hawaii, and Michigan; none of these patients had traveled to areas of C. gattii endemicity (251).…”

Cerebellar cryptococcoma due to Cryptococcus gattii VGI; a rare and first report from India

“…During our literature review we found only seven Englishlanguage case reports of cerebellar cryptococcoma caused by C. gattii (Li et al, 2010;Colom et al 2005;Velamakanni et al, 2014). Among them, three cases were treated with only antifungal drugs and four received surgical intervention along with antifungal treatment.…”

“…Among the reports of CNS cryptococcoma caused by C. gattii, molecular characterization was performed for only three isolates, two of which were VGI (USA, Spain) (Colom et al 2005;Trilles et al, 2004) and one was VGIIa (Japan) (Okamoto et al, 2010). Our isolate was also analysed to determine the molecular subtype, hence these data will contribute to the epidemiology of C. gattii in India.…”

Identification ofCryptococcus gattiiby Use ofl-Canavanine Glycine Bromothymol Blue Medium and DNA Sequencing

“…gattii) differs from the closely related C. neoformans in several ways, including a contrasting host profile and a reduced susceptibility to certain antifungal agents (19,20). Cryptococcus gattii has traditionally been thought to be geographically restricted to tropical and subtropical climates, although recent reports indicate that it can be found worldwide, including in regions with distinctly nontropical climates, like the Pacific Northwest (2,4,8,12,14,17,19). Clinically, the majority of cryptococcosis cases that occur in AIDS patients and other immunocompromised hosts are caused by C. neoformans var.…”