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Epidemiology of Cryptococcus neoformans.

The concept of the epidemiology of Cryptococcus neoformans as the causative agent of cryptococcosis and as a basidiomycetous yeast is based on the fact that bird manure has been until now its only known habitat but not plant material which likewise harbours various nonpathogenic Cryptococcus species. It could be shown that the possible influence of nutritional factors on the morphology and morphogenesis earns attention not only in view of the epidemiology of C. neoformans but of its perfect states, too.

Animals

In vivo and in vitro studies with an atypical, rhinotropic isolate of Cryptococcus neoformans.

An atypical isolate of Cryptococcus neoformans was investigated because of its consistent and reproducible production of gross nasal pathology following i.v. injection in Swiss albino mice. Dose response to graded concentrations ranging from 1 X 10(2)-1 X 10(7) cells/mouse yielded an LD50 of 1.4 X 10(3) cells/mouse for the atypical rhinotropic strain H140 which was significantly less virulent (p less than 0.01) than our reference strain of Cryptococcus neoformans. There was no significant difference in mortality following the injection of in vitro vs. in vivo passed inoculum. As early as two weeks after inoculation, this strain produced gross nasal enlargement to approximately 2-3 X normal dimensions with granulomatous and ulcerated lesions. The LD60 resulted in the greatest percentage of nasal involvement (85%). C. neoformans was demonstrated by culture and histopathology in the noses, brains, lungs, livers and kidneys. A temperature selection was indicated by findings of a lower temperature minimum for subcultures isolated from the noses relative to those isolated from the brain, and by the fact that the most densely populated organs following intraperitoneal injection were the testes. This route of inoculation resulted in cutaneous nasal involvement in a manner analogous to that following i.v. injection. The atypical isolate was unable to assimilate trehalose or raffinose but otherwise was entirely consistent with identification as C. neoformans and produced characteristic CNS and general organ system disease in addition to the rhinotropic cutaneous manifestations. The model characterized here in normal mice may be of value in studies of fungal dermotropism.

Animals

Growth inhibition of Cryptococcus neoformans by cloned cultured murine macrophages.

Cloned and unselected bone marrow-derived macrophage cell lines were obtained from A/J, AKR/J, BIO.A(5R), CBA/J, DBA/2, HPC, NZW, and [NZB X NZW]F1 mice, and their interactions were studied in vitro with a lightly encapsulated natural serotype A isolate of Cryptococcus neoformans. Growth inhibition of C. neoformans was seen with all of the cell lines, as determined by enumeration of colony-forming units. Inhibition was enhanced by a high concentration (8%) of fresh mouse serum and was the same for serum obtained from AKR/J (C5 deficient) and BIO.A (C5 normal) mice. Macrophage incubation with fresh AKR/J serum which had been absorbed with heat-killed Cryptococcus cells also inhibited C. neoformans growth. Heat-inactivation, EDTA addition or anti-C3 antibody treatment of fresh serum abolished the opsonic activity for C. neoformans, while EGTA addition to fresh serum was without effect on opsonization. In addition, neither IgM nor IgG1 murine monoclonal antibodies specific for C. neoformans enhanced phagocytosis or killing of the yeast by macrophages. These findings are consistent with the interpretation that C3b is an important modulator of interactions between macrophages and C. neoformans.

Animals

An anti-Cryptococcus neoformans monoclonal antibody directed against galactoxylomannan.

Six monoclonal antibodies (mAb) were produced by immunizing mice with a Cryptococcus neoformans serotype A spheroplast lysate (CNSL). Two mAb were of the IgG1 isotype; the others were IgM. The results obtained with one IgM mAb (CN6) are reported herein. This mAb recognized the four serotypes of C. neoformans and no cross-reactions were observed with extracts from Cryptococcus melibiosum, Candida albicans, Saccharomyces cerevisiae, Torulopsis glabrata or Trichosporon beigelii. Fractionation of the CNSL by gel filtration revealed that mAb CN6 recognized high molecular weight substances as well as a range of smaller molecules. Indirect ELISA inhibition studies showed that this mAb recognized substances in a cryptococcal culture filtrate. Inhibition studies and agglutination tests using latex beads sensitized with purified CN6 showed that CN6 strongly reacted with the C. neoformans serotype A cell envelope galactoxylomannan-mannoprotein complex (GAlXM-MP) and only weakly with the glucuronoxylomannan (GXM) component. These tests also showed that purified galactoxylomannan (GalXM) from C. neoformans serotype A was more reactive than purified mannoprotein (MP). An anti-GalXM mAb might be a useful tool for monitoring the clinical course of cryptococcal infections.

Animals

Survey of Cryptococcus neoformans in the respiratory tract of patients with bronchopulmonary disorders and in the air.

Cryptococcus neoformans was cultured from 9 (1%) of 835 clinical specimens examined from the respiratory tract of patients. These isolations came from 3 (0.4%) of the760 patients; 8 isolates were from sputum and one from urine. The fungus was not demonstrable in the air at a selected site during a 2-year study although other species of Cryptococcus, namely, C. albidus, C. ater, C. flavus, C. laurentii, C. magnus, C. terreus and C. uniguttulatus were isolated. The three C. neoformans positive patients were males, with pulmonary tuberculosis as the primary disease and history of repeated exposure to pigeon excreta in two. None of these patients manifested any overt signs and symptoms specificially attributable to cryptococcosis, nor did they receive any antifungal therapy. Repeated isolations of C. neoformans from sputum, a positive urine culture and demonstration of cryptococcal antibodies in a serum specimen, followed by negative cultures and serology, suggested that patient 1 had spontaneously recovered from an episode of benign, minimal pulmonary cryptococcosis. Patients 2 and 3 probably carried the fungus as a transient resident of the respiratory tract. The results suggest that C. neoformans is of uncommon occurrence in the respiratory tract of patients with bronchopulmonary disorders and that the isolation of the fungus from this site may not necessarily imply an etiologic relationship.

Adult

Failure of the Bactec 460 radiometer to detect Cryptococcus neoformans fungemia in an AIDS patient.

Cryptococcus neoformans fungemia occurred in a patient with the acquired immunodeficiency syndrome (AIDS). The BACTEC 460 radiometer failed to detect Cryptococcus neoformans in eight aerobic BACTEC 6B culture bottles inoculated with the patient's blood. The diagnosis of cryptococcemia was established by terminal (seven-day) subculturing of 6B broth to chocolate agar, which was positive for all eight radiometrically negative blood culture bottles. It appears that radiometric measurement is not optimal for the laboratory detection of cryptococcal fungemia.

Acquired Immunodeficiency Syndrome

Combined activity of amphotericin B and 5-fluorocytosine against Cryptococcus neoformans in vitro and in vivo in mice.

The in vitro and in vivo activities of amphotericin B and 5-fluorocytosine (5-FC) alone and in combination were studied to determine possible drug interactions against two strains of Cryptococcus neoformans, one sensitive to 5-FC and one resistant to 5-FC. In vitro tube dilution studies demonstrated only additive effects with the 5-FC-sensitive organism but antagonism with eth 5-FC-resistant organism. A mouse model of cryptococcal meningitis allowed comparative drug trails in a new model for the detection of drug interactions. Drug combinations were no more effective against meningitis caused by the 5-FC-sensitive organism than the additive effects of the individual drugs. However, meningitis caused by the 5-FC-resistant Cryptococcus responded less to drug combinations than to either drug alone. Serum levels of amphotericin B and 5-FC were comparable in all groups. No evidence of toxicity from the drug combinations was found. No inhibition of development of resistance to 5-FC by the combination with amphotericin B was detected.

Amphotericin B

Canavanine resistance in Cryptococcus neoformans.

All of the isolates of Cryptococcus neoformans var. gattii which we tested were resistant to greater than or equal to 3.5 mM canavanine. All of the serotype D isolates and 28% of the serotype A isolates of C. neoformans var. neoformans tested were susceptible to less than or equal to 18 microM canavanine, whereas the remaining 72% of the serotype A isolates were as resistant as the C. neoformans gattii isolates. In the naturally resistant isolates, the mechanism of resistance appeared to be decomposition of canavanine to a nontoxic product. However, in a resistant mutant derived from a naturally susceptible isolate, the mechanism of resistance was an impaired uptake system for canavanine. The toxic effect of canavanine in Cryptococcus results from the incorporation of canavanine into the protein component that is essential for the synthesis of proteins and RNAs.

Arginase

Binding of cryptococcal polysaccharide to Cryptococcus neoformans.

Radioiodinated cryptococcal polysaccharide was used to study binding of the soluble polysaccharide to encapsulated and non-encapsulated cryptoccoci. Binding of polysaccharide to non-encapsulated cryptococci occurred rapidly over a 30-min period and was largely complete after 2 h. Bound, labeled polysaccharide was slowly eluted from Cryptococcus neoformans after the addition of unlabeled polysaccharide, indicating reversibility of binding. Non-encapsulated cryptococci bound polysaccharide in two ways. Specific binding to the yeast was saturable by ca. 82 ng of polysaccharide per 10(6) yeast cells. Nonspecific binding also occurred which was not saturable under the conditions used in our experiments. Phagocytosis of the non-encapsulated yeast strain was inhibited when the specific binding was ca. 50% saturated. Binding of polysaccharide to an encapsulated strain showed nonspecific, nonsaturable binding, but little specific binding occurred. Presumably the specific binding sites were saturated in the encapsulated strain. Polysaccharides obtained from a hypocapsular mutant (A61) and a normally encapsulated strain competed effectively with labeled serotype D polysaccharide for binding sites on non-encapsulated cryptococci and had identical phagocytosis-inhibiting properties. Similarly, polysaccharides from all four cryptococcal serotypes competed effectively with labeled serotype D polysaccharide for binding sites on the non-encapsulated strain, and all four polysaccharides inhibited phagocytosis of non-encapsulated Cryptococcus neoformans. Unmodified, de-O-acetylated, carboxyl-reduced, periodate-oxidized and reduced (polyalcohol), and Smith-degraded polysaccharides competed with labeled polysaccharide for binding sites on the cell. The unmodified, de-O-acetylated and carboxyl-reduced polysaccharides inhibited phagocytosis of non-encapsulated cells, but the polyalcohol and Smith product were unable to inhibit phagocytosis.

Animals

Skin testing of guinea pigs and footpad testing of mice with a new antigen for detecting delayed hypersensitivity to Cryptococcus neoformans.

This study was undertaken to evaluate the potential of a cryptococcal culture filtrate antigen, cryptococcin C184, for detecting delayed hypersensitivity in Cryptococcus neoformans-injected animals. The antigen was tested on guinea pigs which had received saline or C. neoformans and on animals sensitized to Histoplasma capsulatum, Blastomyces dermatitidis, Candida albicans, or Sporothrix schenckii. A delayed-type hypersensitivity response was elicited by cryptococcin C184 in C. neoformans-injected guinea pigs, whereas no indurations or erythemas were seen at 48 h after skin testing of saline controls or heterologously sensitized guinea pigs. Besides being specific for Cryptococcus, the antigen showed a high degree of sensitivity and was reproducible. Footpad tests were conducted with the antigen on mice which had previously received either 10(5) viable C. neoformans cells or saline. Delayed hypersensitivity was indicated in the C. neoformans-injected mice by the increase in thickness of antigen-injected footpads when compared with the saline-injected footpads. In control mice, antigen- and saline-injected footpads were comparable in thickness 24 h after injection. Mice sensitized to B. dermatitidis were footpad tested with C184, and no cross-reactivity was demonstrated.

Agglutination Tests

Pigment production by Cryptococcus neoformans from para- and ortho-Diphenols: effect of the nitrogen source.

Cryptococcus neoformans produced pigments when p-diphenols were substrates in a glucose-amino acid-salts medium. The best substrates were 2.5-dihydroxybenzoic acid and 2,5-dihydroxybenzenesulfonic acid. In contrast to the cellular pigment production from o-diphenols (hydroxyl groups in the 2,3- or 3,4-position of phenyl ring), the p-diphenols (1,4- or 2,5-positions for the hydroxyl groups) produced large amounts of soluble pigments that diffused into the medium. When an optimal source of nitrogen (glutamine, glycine, and asparagine) was used, 89% of the C. neoformans strains produced pigments from p-diphenols. In contrast, 0 to 67% of the strains produced pigments when a suboptimal nitrogen source (proline, ammonium sulfate, ornithine, and methionine) was used. When glutamine-glycine-asparagine was the nitrogen source, 100% of the C. neoformans strains produced pigments from o0diphenols, whereas 77 to 100% of the strains produced pigment when proline-ammonium sulfate-ornithine-methionine was the nitrogen source. Cryptococcus species other than C. neoformans and all tested Candida species failed to produce pigments from any of the substrates except when hydroquinone was used. A combination of glutamine-glycine-asparagine and 3,4-dihydroxyphenylalanine allowed differentiation of colonies of C. neoformans from C. albicans in 3 to 6 days. These data showed that pigment production from o- and p-diphenols served as an excellent biochemical test for the identification of C. neoformans.

Asparagine

Antigenic characterization of Cryptococcus neoformans serotypes and its application to serotyping of clinical isolates.

Antigenic analysis of the four serotypes of Cryptococcus neoformans was carried out by slide agglutination with reciprocal adsorption methods. With this procedure the antigenic patterns of the serotypes were established. Serotypes A and D had antigenic factors 1, 2, 3, 7 and 1, 2, 3, 8, respectively. Serotypes B and C were found to have antigenic factors 1, 2, 4, 5 and 1, 4, 6, respectively. Factor sera, prepared according to the antigenic patterns demonstrated by adsorption studies, proved to be useful for rapidly and accurately identifying C. neoformans serotypes. Some patterns similar to those of the C. neoformans serotypes were observed in five other Cryptococcus species and two Candida species. The proton magnetic resonance spectra of polysaccharides from the C. neoformans serotypes correlated well with their antigenic characteristics. Phenol oxidase test reactions and growth at 37 degrees C were useful criteria for determining which yeasts should be chosen for clinical application of factor sera for serotyping of C. neoformans. Sixty-two Japanese isolates of C. neoformans were serotyped. Fifty-eight of these isolates were serotype A, three were serotype A-D, and one was serotype D.

Agglutination Tests

Normally saprobic cryptococci isolated from Cryptococcus neoformans infections.

We report two cases in which Cryptococcus laurentii was isolated from surgically resected pulmonary lesions but the cryptococcal cells is tissue reacted positively with a specific fluorescent antibody (FA) conjugate for Cryptococcus neoformans. Both patients had no apparent host defense defects. In both cases, multiple cryptococcal isolates were obtained from tissue, and yeastlike cells consistent with C. neoformans were seen in direct histology. The isolates were identified by assimilation patterns and standard procedures including phenoloxidase reactions. Since C. laurentii was consistently isolated by using stringent procedures, it was considered unlikely that the fungus represented surgical or laboratory contamination. Its presence may be the result of dual infection not detected by FA, but other possible explanations exist. The results show the value of the FA test in diagnostic mycology and call into question previous reports of cryptococci other than C. neoformans as agents of infection.

Adult

Rapid presumptive identification of Cryptococcus neoformans.

Carbohydrate-containing extracts were prepared from mature yeast colonies grown on Sabouraud dextrose agar by mixing a 0.001-ml loopful of yeast cells for 30 s in phenolized saline and removing the cells by centrifugation. Extracts were prepared from 54 Cryptococcus neoformans isolates, 29 isolates of other Cryptococcus species, 16 isolates of Candida species, 2 Rhodotorula, 2 Torulopsis, and 1 Saccharomyces species. Initially the carbohydrate content of each extract was estimated (Molisch method) and adjusted to 1, 5, and 10 microgram/ml. Twofold dilutions of each extract were tested for reactivity with the cryptococcal latex agglutination reagent of Bloomfield et al. (N. Bloomfield, M.A. Gordon, and D.F. Elmendorf, Jr., Proc. Soc. Exp. Biol. Med. 114:64-67, 1963). All 54 C. neoformans extracts gave strong agglutinations (3+ to 4+) in dilutions of 1:4 or greater. None of the other yeasts produced any agglutination, except for 1 of 15 C. laurentii isolates, which showed a 1+ reaction that disappeared at a dilution of 1:4 and above. Subsequent testing established that a single extract made from 0.001 ml of yeast cells in 6 ml of phenolized saline contained less than 5 microgram of carbohydrate per ml, was suitable for a single rapid screening dilution, and eliminated any cross-reaction from the C. laurentii isolates. In our hands this method has provided a reliable differentiation of C. neoformans from other unknown yeast colonies in less than 20 min exclusive of a Molisch determination.

Candida

Utilization by yeasts of D-glucarate, galactarate, and L-tartarate is uncommon and occurs in strains of Cryptococcus and Trichosporon.

In 38 yeast genera tested, utilization of D-glucarate was uncommon, occurring with only 10 strains out of 373. The ability was prominent among Cryptococcus strains, with 8 out of 8 tested being positive, including the pathogen Cryptococcus neoformans. The ability was present also in Trichosporon where 2 out of the 4 strains tested were positive. There was a correlation between ability to utilize D-glucarate, galactarate, L-tartarate, and D-glucuronate. Use of L-ascorbate occurred in more genera than use of D-glucarate, but all strains that grew on D-glucarate grew on L-ascorbate. The utilization of certain hydroxylated carboxylates by strains, mainly found in two genera, is of interest in identifying the catabolic pathways involved, in taxonomic studies, and in developing rapid methods of yeast identification.

Ascorbic Acid

Cytologic detection of Cryptococcus neoformans in cerebrospinal fluid. Rapid screening methods.

Yeasts of Cryptococcus neoformans in cerebrospinal fluid (CSF) were studied using polarized light and fluorescence microscopy. Ultraviolet-induced fluorescence of wet-fixed, Papanicolaou-stained smears and polarization of air-dried, Diff-Quik or Leishman-stained preparations are complementary methods that allow for rapid screening for and immediate identification of Cryptococcus in cytologic preparations of CSF.

Birefringence

Isolation of Cryptococcus neoformans, Candida albicans and other yeasts from pigeon droppings in Egypt.

Two hundred pigeon droppings, unmixed with soil, and collected from various provinces in lower Egypt (Delta) were cultured to detect yeasts. Yeasts were isolated from 53.5% of the samples; Cryptococcus neoformans was recovered from 30 samples and Candida albicans from 19 samples. Other Cryptococcus and Candida species as well as species of Torulopsis and Rhodotorula were also encountered. Aspergillus fumigatus was isolated on 13 occasions.

Animals

Six-hour pigmentation test for the identification of Cryptococcus neoformans.

Cryptococcus neoformans colonies can be identified within 6 h using paper disks containing caffeic acid and ferric citrate. Indentification is based on the development of a dark brown pigment. Saprophytic Cryptococcus species and common clinically isolated yeasts do not develop the brown color. The concentration of the reagents and the method of storage of the impregnated paper disks are critical for the rapid and specific development of the pigment.

Caffeic Acids