Essay: Cryptococcosis – cryptococcal disease

Cryptococcosis can be known as cryptococcal disease, is a sever fungal disease. It can be caused by one of two species; Cryptococcus neoformans and Cryptococcus gattii. They were all thought before to be subspecies of C. neoformans but can now been identified as different species. Cryptococcosis can be acquired by inhalation of the infectious spore or propagule from the environment. But its exact nature of the infectious spore or propagule is unknown; the leading hypothesis is that basidiospores can be creating via sexual or asexual reproduction. Cryptococcosis can a defining opportunistic infection for HIVor AIDS and is the second-most-common AIDS-defining illness in Africa. Other diseases that pose an increased risk include lymphoma e.g Hodgkin lymphoma, sarcoidosis, liver cirrhosis, and individual on long-term corticosteroid therapy which suppressive the immune system.  It’s found in soil. The prevalence of cryptococcosis has increases over the past 20 years for these reasons, such as increase in incidence of AIDS and the increasing use of immunosuppressive drugs. C. neoformans causes three types of infections: Wound or cutaneous cryptococcosis, pulmonary cryptococcosis, Cryptococcal meningitis. Cryptococcal Meningitis the infection and inflammation of the meninges, that is inflammation of the membranes that cover the brain and spinal cord which are  pia mater, arachnoid and Dura mater.  This caused the dissemination of the fungus from either an observed or unappreciated pulmonary infection. Sometime there can be silent dissemination throughout the brain when meningitis is present. It is the most common causes of AIDS related mortality worldwide, accounting for 33% – 63% of all cases of adult meningitis in sub-Saharan Africa and 500,000 deaths annually.1
Mode of transmission
Cryptococcus neoformans is a saprophyte found in the environmental. The rarity of its isolation as a human communal and fungal spore is inhaled from environment the fungus cannot spread from person to person.
Transmission suggests that human infection is an accidental dead-end event in its life-cycle. However, the  amongst the thousands of basidiomycete fungi, C.neoformans, can  undergo selective pressure in the environment, and as such  has evolved a number of new character that, perhaps by chance, can enable it to survive within human and other mammalian.2
Symptoms of Cryptococcus Meningitis
Untreated CM can be fatal, especially in people with HIV or AIDS. Symptom onset is often sub acute, progressively worsened over several weeks. The two likely presentations are meningitis (an infection in and around the brain) and pulmonary (lung) infection. Symptoms include:
• Fever
• fatigue
• stiff neck
• body aches
• headaches (often severe)
• nausea/vomiting
• Skin lesions.
• Mental changes,
• including confusion,
• hallucinations, and
• personality changes
• lethargy sensitivity to light
• Vision problems, and possibly seizures.
If it’s left untreated, CM may lead to worst symptoms, such as:
• brain damage
• coma
• hearing loss
• hydrocephalus, which is also called “water on the brain”3
Diagnosis
Firstly clinical presentation (symptom) then   Detection of cryptococcal antigen (capsular material) using   CSF, sputum and urine culture to provides definitive diagnosis rarely Blood cultures can be positive in heavy infections. India ink of the CSF is a traditional microscopic method of diagnosis, 4 the sensitivity can be poor in early infection, and may miss 15-20% of patients with culture-positive cryptococcal meningitis. Cryptococcus antigen found cerebrospinal fluid is the most sensitivity test. Apart from typical method like direct microscopy and culture, rapid diagnostic methods to detect cryptococcal antigen by latex agglutination test.4
Microscopy of cerebrospinal fluid
The CSF white cell count is high, with predominant lymphocytes, in non-HIV-associated infection.  WhiIe n HIV-associated cryptococcal meningitis the CSF white cell count is lower or even be normal. CSF protein is usually high and CSF glucose low. Indian ink examination is positive in 70–90% of AIDS patients but in only ~50% of non-AIDS patient.
Treatment
Antifungal drug
Untreated cryptococcal meningitis is fatal, sometime survival can range from years in those without apparent immunocompromise to only a few weeks in HIV-individual. Amphotericin B is a fungicidal agent that binds to ergosterol in the plasma membrane, causing increasing permeability to protons and monovalent cations like potassium. Antifungal activity can also be due to stimulation of the generation of reactive forms of oxygen in fungal as well as immune cells, but recommended therapy is with amphotericin B and flucytosine. Where flucytosine is not available ( low income countries), fluconazole should be used with amphotericin.3
Prevention
The prevention of cryptococcal is very important as it accounts for 20% of early deaths among HIV-infected patients. WHO recommends cryptococcal antigen screening in HIV-infected persons entering care with CD4<100 cells/Μl, avoid places heavily contaminated with pigeon excreta. Primary prophylaxis can be done by the Treatment of all HIV-infected patients with low CD4 with low-dose fluconazole (200 mg/day) to prevent cryptococcal infection in the future. Patients with previous history of cryptococcal meningitis Ensure that they received adequate maintenance therapy for prior episode as relapse is often common.5
CONCULSION
Disseminated Cryptococcus neoformans infection is a serious opportunistic infection that occurs in individual with suppressive immune system either due to untreated AIDS, lymphoma or long term used of corticosteroids can also infect health individual. It  begins in the lungs, meningitis is the most frequently encountered manifestation of cryptococcosis among those with advanced immumosuppression. Globally, it has been estimated that approximately 957,900 cases of cryptococcal meningoencephalitis occurs each year, resulting in more than 600,000 deaths the vast majority  of cases occur among patients with AIDS  and CD4 count<100cell/microl.the region with  the highest number of estimated cases of 2006 was sub Sahara Africa 720,000 cases; 144,000 to 1.3million6.WHO recommend routine screening of high risk individual and treatment  with Amphotericin B and flucytosine  as a first choice furthermore prophylaxis should be given to these patients with high risk and shown no symptoms the limitation here  Limited improvement in mortality and it is Costly with Concern for widespread fluconazole resistance also Drug toxicity sometime Interaction with other TB and ART drugs. Work has to be done to improve access to antifungal drugs in many areas. While the cost of antiretroviral drugs has reduced markedly in recent years, amphotericin B remains relatively expensive in some countries. Although it is of importance to use of antifungal drugs, studies are also needed to understand the basis of altered mental status in cryptococcal meningitis, given its prognostic significance, and so more controlled trials are needed to direct the management of raised intracranial pressure.6