Fungal

Stefan Zimmerli Institute for infectious diseases University of Bern Friedbühlstrasse 51 3010 Bern Death due to infectious diseases in sub-Saharan Africa

Park BJ. Et al AIDS 2009;23:525 Causes of meningits – Harare, Zimbabwe 1994

200 conscecutive patients with meningitis

Hakim JG. Et al. AIDS 2000;14:1401 Cryptococcal meningitis

Approx. 1 Mio cases/year with 625‘000 deaths 75% of cases and 80% of deaths occur in Sub-Saharan Africa

Park BJ. Et al AIDS 2009;23:525 Kambugu A. et al. CID 2008;46:1694 Fungal meningitis

Rare diseases except for cryptococcal meningitis in HIV

Subacute and chronic meningitis leading presentation

Acute meningitis rare

Complications: abscesses or consequences of vascular occlusion Subacute or chronic meningitis

Yeasts (rare)

Cryptococcus neoformans

Candida Scedosporium/Pseud-

Coccidioidomycosis allescheria

Histoplasmosis

Blastomycosis Parenchymal CNS infections

Infarction and hemorrhagic necrosis due to vascular invasion Aspergillus Agents of

Abscesses Aspergillus Agents of mucormycosis Agents of phaeohyphomycosis Portals of entry

Hematogenous spread from pulmonary focus Local extension from paranasal sinuses Trauma surgery ventricular shunts with injection of drugs head trauma 50 y-o female

Known HIV+ for 24y, no AIDS defining diseases, no treatment, 107 CD4+ cells Increasing headaches for 3 weeks, fatigue Discrete stiff neck, paresis left abducens nerve, hyperreflexia Hb 101 g/l; L 4; T 241; CRP <3

CSF opening pressure 400 mm H2O. CSF WBC 300/mL (100% mononuclear), CSF glucose 1.1 mmol/L (22% of blood glucose) CSF protein 1.4 g/L CT scan normal , disseminated w/meningitis

Cryptococcus neoformans cultured from blood and CSF. Cryptococcus antigen (CRAG) in blood (1:640) and CSF (1:512)

Gomori-methenamine Treatment and evolution

d 1 : RMP, INH, PYR, ETH and Fluconazole 800 mg qd d 4 : AmB + 5FC d 4 : acute deterioration; malresorptive hydrocephalus, ICU, mechanical ventilation, ventricular drainage d16 : Extubation, removal of ventricular drainage, CSF GRAG 1:2, CSF no growth, switch to Fluconazole d 27 : Start cART, no complications Cryptococcal meningitis

In sub-Saharan Africa

the most common fatal CNS infection in patients with AIDS in

20 – 30% of patients with advanced AIDS dye of cryptococcal meningitis

Rate in Uganda = 40/1000 person-years (2x US rate in HIV-infected prior to cART)

median duration of survival = 26 d

Park BJ. Et al AIDS 2009;23:525 Kambugu A. et al. CID 2008;46:1694 Causes of suspected meningits: Harare 1994

Cryptococcal meningitis is a disease of the immunocompromised (HIV+, hematological cancer, solid-organ transplantation.

Rare in the apparently immunocompetent

Hakim JG. Et al. AIDS 2000;14:1401 Cryptococcal meningitis

Primary infection generally pulmonary Hematogenous dissemination Tropism for meninges Meningitis concurrent or years after primary infection

Fever or headache or both for weeks before nausea or vomitus or cerebral nerve palsies or obtundation occur Cryptococcal vs. other meningitis

Hakim JG. Et al. AIDS 2000;14:1401 Clinical characteristics of Cryptococcal vs. other meningitis

Hakim JG. Et al. AIDS 2000;14:1401 Diagnosis of cryptococcal meningitis

In HIV+ blood cultures are positive in ~50%

Serum CRAG has a sensitivity of 96%

CSF opening pressure is often increased

CSF findings may be normal in patients with advanced cellular immunodeficiency

CSF may show mononuclear pleocytosis, elevated protein and decreased glucose levels in less severely immunocompromised Fungicidal treatment effect in cryptococcal meningitis

Combination of AmB + 5FC is more rapidly fungicidal than AmB alone

5FC is prohibitively expensive in most settings where the disease is common

Brouwer, Lancet 2004;363:1764 Treatment of cryptococcal meningitis

Amphotericin B 0.7 - 1mg/kg/d x 14 d + 5-Flucytosine 100 mg/kg/d in 4 divided doses x 14 d

Follow-up therapy with oral fluconazole 400 mg/d for at least 10 weeks

Mainenance therapy in HIV+ until CD4+ cells >100/µl under successful cART large-volume lumbar punctures or ventricular drainage or ventriculo- peritoneal shunting often needed to reduce increased intracranial pressure. Do not use adjunctive corticosteroids. Survival after cryprococcal meningitis: Uganda

Treatment with AmB for all

2006 survival rate 6 months after diagnosis was 41%; all under ART

Kambugu A. et al. CID 2008;46:1694 Cryptococcal meningitis and IRIS

Immune reconstitution inflammatory syndrome

(inflammation ≠ infection)

Paradoxical worsening of symptoms under cART (in about 30%) or with reduced immunosuppressive therapy

DD symptomatic relapse

IRIS with higher opening pressure, CSF glucose and WBC counts 39 y-o man advanced liver disease due to hepatitis C and high alcohol intake. ICU due to pneumococcal pneumonia, sepsis and multi-organ failure. Death on ICU d12 despite adequate antibiotic treatment. Meningitis was not diagnosed during life Candida Meningitis Cerebral microabscesses with Candida Candida meningitis

Rare

Mostly associated with neurosurgery and ventricular drainage

Prolonged candidemia rarely leads to meningitis (often associated with microabscesses)

Mostly subacute evolution over 2-4 weeks : fever, headache, diminished consciousness, lethargy, and confusion. Meningeal signs may be present. Candida meningitis

CSF findings can be indistinguishable from bacterial meningitis although monocytic predominance reported in ~40% Culture from large-volume CSF samples needed for diagnosis Mortality in ventriculostomy-associated cases is 11% Invasion of vessels predominately at the base of the brain may produce infarcts Recommended treatment is amphotericin B 0.6 –1 mg/kg/d + 5 fluorocytosine 25mg/kg/d in 4 divided doses for a minimum of 4 weeks over the resolution of all signs and symptoms CNS infections due to Aspergillus

Disease of immunocompromised patients – hematological malignancy undergoing chemotherapy an or bone marrow transplantation

Lung is primary focus of infection

Hematological dissemination to CNS in 14 – 40% Invasive pulmonary hemorrhage

ischemic necrosis Cerebral aspergillosis - ischemic necrosis Aspergillus meningitis

Very rare Disease of the immunocompetent Extension of sinusitis through skull base into meninges Spinal anesthesia with contaminated syringes Granulomatous inflammation progression over weeks Signs of meningeal irritation unususal Invasion and thrombotic occlusion of vessels at the base of the brain leds to ischemia or hemorrhage Aspergillus meningitis Aspergillus meningitis

Lumbar puncture may initially yield normal resuslts

Diagnosis may be established by PCR and/or galactomannan

determination from CSF

Treatment includes surgical débridement of sinus and adjacent bone

and voriconazole Rat model of cerebral aspergillosis

Intracisternal injection of Aspergillus conidia in non-immunosuppressed 11 d old rats Perivascular inflammation, vascular invasion and thrombosis Evaluation

> Survival studies

> Monitoring disease progression: - Study animals on day 2, 3, 5 & 11 - Quantitative fungal cultures - Galactomannan determinations by double-antibody-sandwich ELISA - Cytokine determinations by flow-cytometry based assay (Luminex) - MMP-2 & -9 determinations by gelatine zymography - Histopathological evaluation with periodic acid Shiff and Grocott‘s methenamine silver stainings

36 Survival of rats with cerebral aspergillosis

p = <0.0001 100

75 )

(% Caspofungin (n = 21) 50 Combination CAS + L-AmB (n = 21) * Voriconazole (n = 20)

survival Liposomal Amphotericin B (n = 21) Controls (n = 21) 25

0 0 2 4 6 8 10 12 days post-infection

37 Brain drug levels

Resistance testing - Caspofungin: 0.016 mg/l 1.5 - Amphotericin B: 0.500 mg/l

1.0 g k / mg 0.5

Caspofungin (n = 23 + 21) 0.0 Amphotericin B (n = 21 + 21)

2 3 5 1 y y 1 a ay y d da d da

38 Summary

Fungal meningitis is rare except for Cryptococcal meningitis

Commonly presents as subacute or chronic meningitis

Diagnosis is straightforward for Cryptococcal meningitis and may be difficult for other causative organisms

Fungicidal drugs should be used in the initial treatment phase

39