MISSED DIAGNOSIS OF CRYPTOCOCCUS NEOFORMANS – It was a uncommon infection in the past From its humble beginnings as a single case report in 1895 to its worldwide explosion of disease with a million cases per year as the HIV epidemic peaked (Park et al., 2009), Cryptococcus has achieved a major place in clinical mycology. We are all much trained that if on has HIV/AIDS are linked with cryptococcal meningitis, I always wished that all specimens of CSF should along with Gram stain and culturing should never forget to an India ink preparation. The diagnosis of cryptococcosis, after 100 years of experience, is relatively facile with multiple methods and improved diagnostic strategies however it certainly need a qualified microbiologists patience and competence we can do better, as happened a 24 years young person’s CSF ( HIV negative by Rapid dot method ) a CSF specimen was sent to the Microbiology Laboratory with a persistent head ache qualified in post-graduation too do not care much and matters are left to technicians a sterile culture report sent after, for bacteriological work up, as the case of treated as Viral meningitis with antiviral drugs and lower doses of steroid patient becomes top moribund and a MRI was done and Radio logical opinion suggests possible cryptococcal Meningitis ? need Microbiology reviews and I happened to see the slide at emergency hour and happen to observe the CSF flooded with many capsulated with India ink preparation as it is one and only we can do in the critical hour, and patient dies after 3 days after aggressive anti fungal therapy with Ketoconazole , has some legal and litigation into this case, and we are helpless on many matters, and as many specimens are totally not evaluated as it is a dedicated workup and expensive, It is unfortunate still we may be missing many cases of Cryptococcus with lack of laboratory facilities . certainly need better methods as the techniques include direct examination of the fungus in body fluids with India ink examination, histopathology of infected tissue with specific stains to identify capsule (mucicarmine and alcian blue) or presence of melanin (Fontana-Masson), serology from body fluids and culture of fluids and/or tissues, Certainly we miss with India ink preparation the sensitivity is poorer than many other emerging tests as Polysaccharide antigen testing has two other important principles. First, a baseline high titer of polysaccharide antigen in serum or CSF carries prognostic significance, in that a high titer (>1:1024) is associated with a large burden of yeasts and a high viable quantitative yeast count in CSF is a predictor of death during systemic anti fungal therapy (Jarvis et al., 2014)
Not forgetting cryptococcosis is in a state of evolution, from the organism, to the host, to the guidelines for diagnosis and treatment. We know a lot but still not enough! The sugar-coated yeast still sickens and we need better technologies and dedicated diagnostic microbiology to manage it better. As many patients treated assuming as bacterial infection and many die and Cryptococcus are missed as we too primitive in approaches to diagnosis
Not to forget any patient After organ transplantation heavy doses of corticosteroid therapy are potential medications to treat rheumatoid arthritis, or other medications that weaken the immune system. and there are many surprises that without any established predisposing conditions can infected with Cryptococcal infections in any organ of the body
Photo courtesy CDC 1 and 2
Ref Cryptococcosis diagnosis and treatment: What do we know now Author John R. Perfecta Fungal Genetics and Biology Science Direct
Formulated by Dr.T.V.Rao MD