Cryptococcosis in Transplant Recipients

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EPIDEMIOLOGY

The overall incidence of cryptococcal disease in solid organ transplant recipients is ~2.8% and ranges from 0.3-5% (12). Emerging data show that while the overall incidence of invasive candidiasis and aspergillosis in solid organ transplant recipients has declined, that of cryptococcosis has remained unchanged over the last two decades. Approximately 8% of the invasive fungal infections in solid organ transplant recipients currently are due to cryptococcosis (25). Cryptococcosis is typically a late-occurring infection; the median time to onset usually ranges from 16 to 21 months post-transplantation (12, 25, 36).

Cryptococcal disease in solid organ transplant recipients is considered to represent reactivation of quiescent infection (7, 10). Pre and post-transplant assessment of sera for cryptococcal antibodies using an immunoblot assay showed that a majority of transplant recipients with cryptococcosis exhibited serologic evidence of cryptococcal infection before transplantation (32). Patients with pre-existent cryptococcal antibodies developed cryptococcosis earlier after transplantation than those without these antibodies suggesting that transplant-associated cryptococcosis results largely from reactivation infection (32). Acquisition of primary infection following transplantation has also been documented (17, 23). Transmission from donor allograft and tissue grafts, particularly corneal transplants can also occur (2, 16, 24).

Calcineurin-inhibitors agents have been proposed to have in vitro activity against this yeast. These agents do not appear to influence the incidence, but may affect the extent and severity of cryptococcal disease (12). For example, patients receiving a calcineurin-inhibitor based regimen are less likely to have disseminated disease and more likely to have cryptococcosis limited to the lungs (36). Furthermore, the receipt of calcineurin-inhibitor agents has been independently associated with a lower mortality in solid organ transplant recipients with cryptococcal disease (36). Improved outcomes with the use of calcineurin-inhibitor agents may be attributable in part to their synergistic interactions with antifungal agents (18). T-cell depleting antibodies such as alemtuzumab cause profound and lasting lymphocyte depletion of CD4+T cells. Employment of more than one dose of alemtuzumab or antithymocyte has been associated with an increase in the risk for cryptococcosis (34). The risk of invasive fungal infections appears to be higher when T-cell depleting agents are used as antirejection as opposed to induction therapy (27).

While C. neoformans var grubii (serotype A) that causes most disease in solid organ transplant recipients has no particular geographic predilection (15), C. neoformans var neoformans (serotype D) is prevalent in Northern Europe and preferentially results in cutaneous disease. The ecological niche of C. gattii which until recently was regarded as a tropical and subtropical fungus has now expanded to temperate regions and acquisition of cases within US has been documented, including in solid organ transplant recipients.46 The incubation period of C. gattii disease in Vancouver Island and Pacific Northwest has been documented to be ~6 months (21).

CLINICAL MANIFESTATIONS

Approximately 53-72% of the solid organ transplant recipients with cryptococcosis have disseminated disease or CNS involvement (12, 14, 36, 44). Overall, 61% of the solid organ transplant recipients in one report had disseminated disease, 54% had pulmonary and 8.1% had skin, soft-tissue or osteoarticular cryptococcosi (36). Liver as opposed to other types of solid organ transplant recipients had a 6-fold higher risk for developing disseminated disease. Nearly 33% of the solid organ transplant recipients with cryptococcosis, particularly those with CNS disease may have fungemia (12, 36, 48). In ~ 33% of the solid organ transplant recipients with cryptococcosis is limited to the lungs (36). Pulmonary cryptococcosis may be detected as an incidental finding in asymptomatic patients (22, 36). Pulmonary cryptococcosis manifesting as acute respiratory failure is associated with grave prognosis (3). Cutaneous cryptococcosis can present with papular, nodular, or ulcerative lesions or as cellulitis (8, 11).

Immune Reconstitution Syndrome

Rapid reduction of immunosuppressive therapy in conjunction with initiation of antifungal therapy in solid organ transplant recipients may lead to the development of immune reconstitution inflammatory syndrome (IRIS), the clinical manifestations of which mimic worsening disease due to cryptococcosis (19, 39). The biologic basis of IRS in solid organ transplant recipients is believed to be reversal of a Th2/Treg dominant state to Th1/Th17 proinflammatory response upon withdrawal or reduction of immunosuppression. Employment of potent T cell lymphocyte depleting agents such as alemtuzumab have also been recognized as a risk factor for IRS (13).

An estimated 5-11% of the solid organ transplant recipients with cryptococcal disease may develop IRS typically between 4-6 weeks after initiation of antifungal therapy (37, 39). IRS developers are more likely to have received potent immunosuppression comprising a combination of tacrolimus, mycophenolate mofetil, and prednisone. Additionally, cases with IRS versus those without it were more likely to have disseminated cryptococcosis (38). IRIS may present as lymphadenitis, cellulitis, aseptic meningitis, cerebral mass lesions, hydrocephalus or pulmonary nodules (19, 39). Development of IRS may be temporally associated with allograft loss (38).

LABORATORY DIAGNOSIS

Transplant recipients with suspected or documented cryptococcosis should have a complete evaluation, including a lumbar puncture, blood and urine cultures. CSF opening pressure should be routinely recorded, and the CSF should be for Gram stain, cell count, protein, glucose, and cryptococcal antigen (9, 31, 40). CSF cryptococcal antigen is more sensitive and specific than India ink staining or fungal cultures of the CSF and titers are higher with leptomeningeal than intraparenchymal brain lesions (12, 36, 48). Cryptococcal antigen from the serum is also very reliable (90%) for the initial diagnosis of disease, however the titers are typically lower (usually <1:1024) than in HIV-associated cryptococcal disease (47, 48). Serum cryptococcal antigen titers are higher in disseminated and CNS disease than isolated pulmonary disease (26, 35, 40). Titers generally decrease with appropriate therapy (12, 31, 48) blood cultures for Cryptococcus may be positive up to 45% of the patients with neurological disease (40).

A CT scan of the head may be performed prior to lumbar puncture to determine if there is a mass lesion or hydrocephalus present (31). Up to 33% of the patients may have cryptococcomas on presentation and MRI is more sensitive than CT imaging for detecting these lesions. Mortality rate is generally higher for patients with intraparenchymal lesions than with meningeal disease alone (4, 40). Pulmonary cryptococcosis has been detected as asymptomatic disease typically in the late posttransplant period in patients are on lower dose immunosuppression (36). Pulmonary disease often presents as nodular opacities on chest x-ray and CT scan, and less often as effusions or consolidations (22, 26, 35). Diagnosis is frequently made by the detection of the yeast in BAL. Positive cryptococcal antigen has been documented in 83% of the patients with any pulmonary involvement in solid organ transplant recipients (35). Patients with cryptococcosis limited to the lungs are less likely to have a positive antigen than those with concomitant extrapulmonary disease (35).

While there are no laboratory markers or clinical criteria that can reliably diagnose IRS or distinguish this entity from worsening cryptococcosis (4). IRS may be considered based on suggestive criteria discussed in the chapter entitled “ Immune reconstitution syndrome”.

TREATMENT

In patients with CNS and disseminated cryptococcosis, and severe respiratory cryptococcosis a lipid formulation of amphotericin B and flucytosine are recommended (5, 6). The use of a lipid formulation of amphotericin B is preferred over amphotericin B deoxycholate, not only because of a lower nephrotoxic potential, but superior efficacy with the former (20, 29, 40, 45). A recent study has documented that lipid formulations of amphotericin B were independently associated with an improved 90 days survival rate compared to amphotericin B deoxycholate even when controlled for other factors associated with increased mortality i.e., renal failure at baseline and fungemia (41). Additionally, compared with amphotericin B, both liposomal amphotericin B and amphotericin B lipid complex were associated with lower mortality. Mortality did not differ in patients receiving a lipid formulation of amphotericin B with or without flucytosine.

We recommend induction therapy (Table 1) with liposomal amphotericin B (3-4 mg/kg/day) or amphotericin B lipid complex (5 mg/kg/day) plus flucytosine (100 mg/kg/day in 4 equally divided doses every 6 hours based on creatinine clearance) in patients with CNS disease, disseminated disease and severe pulmonary disease for 14 days followed by consolidation with fluconazole (400-800 mg/day) for 8 weeks and, finally suppression with fluconazole (200-400 mg/day) for 6 to 12 months. Persistently positive CSF cultures at 2 weeks portend a poor outcome and continuation of induction therapy until CSF sterilization is appropriate in these patients.

For patients with focal pulmonary and incidentally detected asymptomatic pulmonary disease fluconazole 400 mg/day for 6-12 months is acceptable. C. neoformans-positive cultures from even non-sterile sites such as sputum warrant treatment even if the patient is asymptomatic. This is particularly relevant in lung transplant recipients where the Cryptococcus may be colonizing the donor allograft and may become invasive in the presence of immunosuppression (16).

The relapse rate of cryptococcosis after 6 months of fluconazole maintenance is very uncommon based on available data and thus the recommendations are for 6-12 months of therapy (39). Given the drug interaction between fluconazole and calcineurin inhibitor agents, careful monitoring of calcineurin inhibitor levels is prudent. The use of extended-spectrum azoles such as voriconazole, itraconazole and posaconazole have shown not to offer any extra benefit over fluconazole, are more expensive, have significantly more drug interactions with immunosuppressive agents and data in HIV-infected patients showed that itraconazole was inferior to fluconazole in the clearance and maintenance phases (1, 28, 30). An exception may be C. gattii which appears to have reduced susceptibility to fluconazole and in-vitro data suggest that the extended-spectrum azoles have excellent activity against this species.

Antifungal Susceptibility Testing

Routine antifungal susceptibility testing for cryptococcal disease is neither recommended nor feasible. However, patients experiencing a relapse on therapy, particularly those receiving fluconazole or those with a documented C. gattii disease should have the isolates submitted to a specialty laboratory for azole antifungal susceptibility testing (9, 42, 43).

Immunomodulatory Approaches

Interferon-γ (IFN- γ) has been utilized as an adjunct to antifungal therapies in HIV patients, however other than one case report there is no large randomized clinical trial data and can not be recommended due to concerns that it may induce organ rejection in this population (36).

Management of Immunosuppression

An important consideration in the treatment of cryptococcosis is the management of the immunosuppression. Whenever possible, a reduction in the net state of immunosuppression should be reduced during therapy. However, a rapid reduction in immunosuppression may predispose to IRS or lead to allograft rejection. The goal is to gradually taper immunosuppression with consideration given to decreasing corticosteroids first and then calcineurin inhibitor agent. Our preference based on clinical experience is not to decrease the dose of tacrolimus by more than 50% upfront.

Immune Reconstitution Syndrome (IRIS)

There is no proven therapy for IRIS. Minor manifestations may resolve spontaneously within few weeks. Modifications in antifungal therapy are not warranted unless viable yeasts are documented in culture. Anti-inflammatory drugs such as corticosteroids have been employed anecdotally with success in Cryptococcus-associated IRS in solid organ transplant recipients (19, 37). Corticosteroids in doses equivalent to 0.5 to 1 mg/kg of prednisone may be considered for major complications related to inflammation in the CNS and severe manifestations of pulmonary or other sites.19 The efficacy of thalidomide and other non-steroidal anti-inflammatory agents remains unproven.

Elevated Intracranial Pressure Management

Elevated of intracranial pressure in CNS cryptococcosis can lead to hydrocephalus, blindness, deafness and death (9). Initial opening pressure must be recorded and if > 25 mmHg, a large volume tap should be performed to reduce the intracranial pressure to < 20 mmHg. If the initial opening pressure is > 25 mmHg, lumbar pressure should be performed daily until opening pressure is < 25 mmHg. If the intracranial pressure remains high, either a lumbar peritoneal or external ventricular drain can be placed to monitor CSF and ensure clearance of organisms until a ventriculo-peritoneal shunt can be placed (9, 33).

ANTIFUNGAL PROPHYLAXIS

Primary Prophylaxis

We do not currently recommend that solid organ transplant recipients receive routine antifungal prophylaxis against cryptococcosis, as there is no specific high-risk group that has been identified.

Secondary Prophylaxis

For solid organ transplant recipients who experience graft failure after cryptococcosis, timing of retransplantation is unknown. However in kidney transplant recipients in whom there is the possibility of a hemodialysis bridge, it is reasonable to consider retransplantation in this population if they have received ~a year of antifungal therapy, have no signs or symptoms attributable to active cryptococcal disease and have negative cultures from the original site of infection. In those solid organ transplant populations where there is no bridging option available, we recommend that induction therapy is completed, all sites that yielded positive cultures have cleared and the cryptococcal antigen titer should be optimally declining before retransplantation. In these cases, secondary fluconazole prophylaxis should be considered for at least a one year period (35). The optimal timing of transplantation in patients with cryptococcosis during transplant candidacy is not known. However, liver transplantation has been successfully performed under the umbrella of fluconazole therapy after clinical disease was controlled, and cultures for Cryptococcus were rendered negative in patients with endstage liver disease and cryptococcosis (Singh N. unpublished observation).

REFERENCES

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Table 1: Management of Cryptococcal Disease in Solid Organ Transplant Recipients

Meningoencephalitis, disseminated disease or severe pulmonary disease
Induction	Duration
Liposomal amphotericin B 3-4 mg/kg/d or amphotericin B lipid complex 5 mg/kg/d plus 5 flucytosine 100 mg/kg/d (adjusted for renal dysfunction) OR	2 weeks
Liposomal amphotericin B 3-4 mg/kg/d or amphotericin B lipid complex 5 mg/kg/d	4 weeks
Consolidation
Fluconazole 400-800 mg/d	8 weeks
Maintenance
Fluconazole 200 mg/d	6-12 months
Isolated pulmonary cryptococcosis
Fluconazole 400 mg/d	6-12 months