肺隐球菌病的CT表现及其诊断价值

目的探讨肺隐球菌病的CT表现及其诊断价值。方法回顾性分析经病理确诊的30例肺隐球菌病病人的CT影像资料。结果 CT表现为结节包块影20例,片状渗出影2例,混合型8例。结节包块影均发生于免疫功能正常者,免疫功能低下者主要表现为片状实变影和混合型。结论肺隐球菌病CT表现多样,晕征的出现及病灶的动态变化对本病的临床诊断有极大的参考价值。     

Spread of Cryptococcus gattii into Pacific Northwest Region of the United States

Cryptococcus gattii has emerged as a human and animal pathogen in the Pacific Northwest. First recognized on Vancouver Island, British Columbia, Canada, it now involves mainland British Columbia, and Washington and Oregon in the United States. In Canada, the incidence of disease has been one of the highest worldwide. In the United States, lack of cryptococcal species identification and case surveillance limit our knowledge of C. gattii epidemiology. Infections in the Pacific Northwest are caused by multiple genotypes, but the major strain is genetically novel and may have emerged recently in association with unique mating or environmental changes. C. gattii disease affects immunocompromised and immunocompetent persons, causing substantial illness and death. Successful management requires an aggressive medical and surgical approach and consideration of potentially variable antifungal drug susceptibilities. We summarize the study results of a group of investigators and review current knowledge with the goal of increasing awareness and highlighting areas where further knowledge is required.     

Diagnosis of Cryptococcosis and Monitoring of Chemotherapy

Summary: Despite great variation in the clinical symptoms and routine CSF findings, diagnosis of cryptococcosis of the CNS is quite easy thanks to high reliability of direct microscopy Indian ink and culture of cryptococcosis neoformans in the CSF and of the test for cryptococcal antigen. The crucial point is just to think of cryptococcosis. Monitoring of chemotherapy is more difficult, and this is particularly true for the decision when to discontinue treatment with a minimum risk of relapse. The absolute requirement is a negative CSF culture in 3 consecutive samples taken at weekly intervals. The other parameters such as antigen titer, Indian ink, CSF glucose and cerebral foci in CT, are not reliable taken alone. If, however, 2 or more of the respective findings are still pathological, this must remind us to go beyond the before-mentioned minimum Oeriod. Patients receiving long-acting corticosteroids generally need prolonged treatment only hydrocortisone should be used to combat the “acute” adverse reactions to amphotericin B. The standard period of a given chemotherapy e.g., 6 weeks in the case of the combination of amphotericin B and flucytosine should be considered a rough guide, whilst the actual length must depend on the conditions of the individual patients. Zusammenfassung: Trotz großer Variabilität der klinischen Symptome und der meisten Liquorbefunde ist die Diagnose einer Cryptococcose des Zentralnervensystems verhältnismäßig einfach. Dies dank der hohen Zuverlässigkeit des direktmikroskopischen und kulturellen Befundes von Cryptococcus neoformans im Liquor und des Nachweises von Cryptococcus-Antigen. In den meisten Fällen geht es hauptsächlich darum, an die Möglichkeit einer Cryptococcose zu denken. Die Beurteilung des Heilungsverlaufs unter Chemotherapie, besonders der Behandlungsdauer, ist bedeutend schwieriger. Die Mindestanforderung für ein Absetzen der Behandlung ist ein negativer Kulturbefund in mindestens drei aufeinanderfolgenden, wöchentlichen Liquorproben. Die übrigen Parameter wie Direktmikroskopie, Antigentiter, Liquorzucker und zerebrale Herde in der Computertomographie sind, jeder für sich allein, nicht entscheidend, mahnen aber zu einer Verlängerung der Behandlung, wenn zwei oder mehr der betreffenden Befunde noch pathologisch sind. Patienten, die langwirkende Corticosteroide erhalten haben, benötigen eine verhältnismäßig lange Chemotherapie. Zur Bekämpfung der “akuten” Nebenwirkungen von Amphotericin B sollte ausschließlich Hydrocortison verwendet werden. Die Standarddauer einer gegebenen Chemotherapie z. B. sechs Wochen im Falle der Kombination Amphotericin B plus 5-Fluonytosin sollte eher als Minimum betrachtet werden und nicht als starre Regel.     

Cryptococcus neoformans in the Seminal Fluid of an AIDS Patient. A Contribution to the Clinical Course of Cryptococcosis: Cryptococcus neofomans im Sperma eines AIDS-Patienten. Ein Beitrag zum Minischen Verlauf der Cryptococcose

In a 33-year-old HIV-positive homosexual male suffering from unexplained headache, cryptococcosis was diagnosed in a progressive secondary stage. After treatment with the standard combination therapy of amphotericin B + flucytosine for 34 d, the patient was clinically symptom-free and discharged, upon his own request, from the hospital. He remained under ambulatory mycological control. After an interval of 65 d during which the urine had been free from Cryptococcus neoformans (Cr.n.), the fungus could not be isolated from urine but 3 X 10(5) CFUs/ml were found in the seminal fluid. Andrologically, teratospermia and hyposemia were present. There were no clinical signs in the genitourinary tract including the prostate. The significance of ecological niches for Cr.n. colonization of the genitourinary tract after antimycotic therapy is discussed. In such cases, in addition to cultural examination of urine for Cr.n. by the membrane filtration technique (MFT) and Staib agar, an additional cultural examination of seminal fluid is recommended. It is also proposed to pay more attention to Cr.n. in andrological examinations. Special regard should be given to a possible occurrence of Cr.n. in the seminal fluid of AIDS patients. In cytology of the seminal fluid, use of the Giemsa stain is unsuitable for the purpose of Cr.n. detection. For this reason, it should be supplemented by PAS staining.     

Isolated cerebral cryptococcosis

Summary A case of cerebral infection with cryptococcus neoformans whose symptoms simulated those of an intracranial space-occupying lesion is described. Differential diagnosis is a problem because of the aspecificity of the clinical and neuroradiological features of this grave fungal infection.     

Cellulitis Revealing a Cryptococcosis-Related Immune Reconstitution Inflammatory Syndrome in a Renal Allograft Recipient

Immune reconstitution inflammatory syndrome (IRIS) has rarely been described in the course of disseminated cryptococcosis in solid organ transplant recipients. We report here the case of a renal transplant recipient who developed severe cellulitis in the context of Cryptococcus neoformans-associated IRIS while undergoing reduction of his immunosuppressive therapy. IRIS appeared concomitantly with a dramatic increase of blood CD4+ T cells (94-460/mm(3)) and required the administration of a short-term steroid therapy to resolve.     

Acquired immunodeficiency syndrome manifested as disseminated cryptococcosis

A 32-year-old male homosexual presented to the emergency department (ED) with the clinical picture of a nonspecific illness. While in the ED, he experienced a first-time seizure. Computed tomography (CT) showed an enhancing mass lesion. Antibacterial therapy was started and continued until a second lumbar puncture (LP), 36 hours after admission, showed distinct yeast forms. Subsequent institution of appropriate therapy did not prevent the patient's death. The cause of death was disseminated cryptococcosis secondary to acquired immunodeficiency syndrome (AIDS).     

Necrotising cryptococcal vasculitis in an HIV-negative woman

An 84-year-old woman with a past medical history significant for haemolytic anaemia necessitating chronic steroid therapy presented with skin induration and erythema initially thought to be cellulitis. After a rapid progression of symptoms and failure to respond to antibiotics, a clinical diagnosis of necrotising vasculitis was made. Necrotising cryptococcal vasculitis was confirmed by histopathology and culture.     

Computed tomography (CT) and positron emission tomography with [F]fluoro-2-deoxy-d-glucose (FDG-PET) images of pulmonary cryptococcosis mimicking lung cancer

BACKGROUND: The objective of this study was to clarify the clinical features of pulmonary cryptococcosis using chest computed tomography (CT) and positron emission tomography with [18F]fluoro-2-deoxy-D-glucose (FDG-PET), with a view to developing appropriate treatment. METHODS: We analyzed the clinical features, and chest CT and FDG-PET characteristics of six cases of pulmonary cryptococcosis that were treated by surgery. The patients comprised four males and two females, ranging in age from 28 to 79 years. RESULTS: All the patients were asymptomatic and had no extrapulmonary involvement. In all cases, chest CT showed nodular shadows. Spiculation and convergence of peripheral vessels were demonstrated in three cases, and pleural indentation in two cases. FDG-PET was performed in four of the cases, and showed accumulation of FDG in all of them. The standard uptake value (SUV) ranged from 0.93 to 4.85. Chest CT findings and accumulation of FDG made it difficult to distinguish pulmonary cryptococcosis from malignancies. Segmentectomy or wedge resection was performed in all cases for pathological diagnosis, and this revealed Cryptococcus fungal bodies. After surgical resection, no sign of relapse has been seen in any of the patients. CONCLUSIONS: Surgical resection is recommended for both diagnosis and treatment of pulmonary cryptococcosis.