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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 29

Ocular cryptococcosis in a HIV-positive patient


Department of Ophthalmology, Pontifical Catholic University of Campinas, Campinas, Brazil

Date of Submission10-Jan-2022
Date of Decision07-Mar-2022
Date of Acceptance08-Mar-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Beatriz Crotti Peixoto
Av John Boyd Dunlop s/n -Jardim Ipaussurama, Postal Code: 13059-900, Campinas
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_4_22

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  Abstract 


We report a rare case of ocular cryptococcosis that presents as chorioretinitis in a patient with acquired immunodeficiency syndrome.

Keywords: Chorioretinitis, cryptococcosis, HIV infection


How to cite this article:
Peixoto BC, Patrus BP, de Souza FB, Rezende CP, Baccega AT, de Andrade Sobrinho MV. Ocular cryptococcosis in a HIV-positive patient. Pan Am J Ophthalmol 2022;4:29

How to cite this URL:
Peixoto BC, Patrus BP, de Souza FB, Rezende CP, Baccega AT, de Andrade Sobrinho MV. Ocular cryptococcosis in a HIV-positive patient. Pan Am J Ophthalmol [serial online] 2022 [cited 2022 Jul 5];4:29. Available from: https://www.thepajo.org/text.asp?2022/4/1/29/348005




  Introduction Top


Eye infections in HIV-positive patients/acquired immunodeficiency syndrome (AIDS) reflect the functionality of the immune system. With the introduction of antiretroviral therapy (ART), intraocular infections such as toxoplasmosis, herpes simplex and herpes zoster virus, and cytomegalovirus (CMV) were greatly reduced. However, these still occur in cases of high viral load and low CD4+ count.[1]

Cryptococcosis is an infection caused by the fungus Cryptococcus neoformans, and Cryptococcus gattii manifests itself mainly in immunocompromised patients but may manifest in immunocompetent individuals. C. neoformans is the main agent of meningitis in patients immunosuppressed by HIV infection and is responsible for a high morbidity and mortality condition. More than 80% of C. neoformans infections are in HIV/AIDS patients when CD4+ count is reduced.[2],[3],[4]

Central and ocular nervous system involvement often occurs in patients with AIDS-related cryptococcosis. The encapsulated organism can be identified in cerebrospinal fluid (CSF) and vitreous fluid.[5]

Treatment with amphotericin B, flucytosine, and fluconazole is recommended for patients who have severe central nervous system infections.[6]


  Case Report Top


The patient, aged 24 years, presented in the emergency room complaining of frontal headache for 1 month. Accompanied by nausea and visual blurring. Personal history of smoking and sporadic consumption of alcohol. HIV-positive patient with irregular use of ART. TCD4 count 29 and viral load: 7869. Serologies: anti HBC: negative, anti-Hbs: positive, Hbs Ag: negative, HCV: negative, toxoplasmosis IgG: positive, CMV IgG: positive, Hepatitis A: negative. Hepatic and renal function without alterations. Computed tomography of the skull without alterations. Magnetic resonance imaging with diffuse meningeal thickening, associated with small ischemic focal in both cerebral hemispheres and reversible cytotoxic edema in the callous body.

The collection of liquor revealed an opening pressure of 78 cmH2O and leukocyte count of 125 (neutrophils 26%, lymphocytes 57%, and monocytes 9%) without erythrocytes, glucose 26 mg, and protein 135 mg. The Chinese ink came back positive. CSF fungal culture grew C. neoformans, which confirmed the diagnosis of cryptococcal meningitis.

On ophthalmological examination, he presented visual acuity in the right eye of 20/80 and in the left eye 20/20. He presented tonometry of 12 mmHg in both eyes. Fundoscopy presented applied retina, posterior pole chorioretinitis, intense vitreitis, and snowballs in the right eye. In the left eye, he had normal fundoscopic examination [Figure 1].
Figure 1: Fundus photograph at the first evaluation

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  Discussion Top


The management was performed with intravenous fluconazole in an attack dose of 800 mg followed by 400 mg per day, using of amphotericin B and ART. In addition, the patient used nystatin for the treatment of oral moniliasis.

After 1 week of treatment, there was a significant improvement in systemic and ocular symptoms. On ophthalmological examination, his uncorrected visual acuity in the right eye went from 20/80 to 20/40. He presented 12 mmHg tonometry in both eyes. At fundoscopy, he presented applied retina, reduction of posterior pole chorioretinitis, reduction of vitreitis, and snowballs in the right eye. In the left eye, he had normal fundoscopic examination [Figure 2].
Figure 2: Fundus photograph after 1 week of treatment

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Intravenous antifungals were meant to be continued for 2 weeks followed by oral fluconazole for 8 weeks (400 mg per day) and maintained at a prophylactic dose of 200 mg per day. However, the patient refused to continue treatment with antifungals and ART, escaping from the hospital and not returning to service.

Common ocular manifestations of cryptococcosis include neuro-ophthalmic lesions such as cranial nerve paralysis, arachnoiditis, and papilledema in association with increased intracranial pressure, commonly resulting in neuropathy and/or optic nerve atrophy. Intraocular involvement in the form of coroiditis or endophthalmitis has also been reported.[4],[7],[8]

Most ophthalmologic cases are related to a picture of cryptococcal meningitis by disseminate hematologic or proximity to leptomeninges.[4],[8]

The detection of the organism in the CSF and vitreous fluid serves both for diagnosis and follow-up of treatment.[5]

Cryptococcosis coroiditis is a challenging and difficult case to diagnose due to the similarity of the condition with infections with Toxoplasma gondii, CMV, and herpes virus infections that can also present with reduction of visual acuity, posterior pole chorioretinitis, vitreitis, and snowballs.[8]

Depression is the most common neuropsychiatric complication in HIV-infected patients, and the prevalence is about 42%. Such a disease has negative impact by reducing treatment adherence and the patient's quality of life.[9]


  Conclusion Top


Ocular cryptococcosis is a rare entity and should always be remembered as a differential diagnosis of chorioretinitis in HIV/AIDS patients. Thus, this patient should be investigated for better treatment.

In addition to treatment with antifungics and ART, psychological/psychiatric follow-up is necessary because depression is a prevalent disease in patients with HIV/AIDS that reduces treatment adherence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hassoun, A., & Mehrotra, N. (2018). Disseminated cryptococcosis in HIV negative patient. BMJ Case Reports, bcr–2017–223500. doi:10.1136/bcr-2017-223500.  Back to cited text no. 1
    
2.
Flores Herrera MF, Dauby N, Maillart E, Libois A, Papaleo A, El Ouardighi H, et al. Multimodal imaging in AIDS-related ocular cryptococcosis. Case Rep Ophthalmol Med 2021;2021:8894075.  Back to cited text no. 2
    
3.
Chayakulkeeree M, Perfect JR. Cryptococcosis. Infect Dis Clin North Am 2006;20:507-44, v-vi.  Back to cited text no. 3
    
4.
Chai SM, Teoh SC. Ocular cryptococcosis as a presenting manifestation of cryptococcal meningitis in a patient with HIV. Int J STD AIDS 2012;23:377-8.  Back to cited text no. 4
    
5.
Peng CH, Chen SJ, Ho CK, Ku HH, Lin HW, Chen SS, et al. Detection of HIV RNA levels in intraocular and cerebrospinal fluids in patients with AIDS-related cryptococcosis. Ophthalmologica 2005;219:101-6.  Back to cited text no. 5
    
6.
Amphornphruet A, Silpa-Archa S, Preble JM, Foster CS. Endogenous cryptococcal endophthalmitis in immunocompetent host: Case report and review of multimodal imaging findings and treatment. Ocul Immunol Inflamm 2018;26:518-22.  Back to cited text no. 6
    
7.
Jabs DA. Ocular manifestations of HIV infection. Trans Am Ophthalmol Soc 1995;93:623-83.  Back to cited text no. 7
    
8.
Heitor DF, Mora DJ, Damasceno-Escoura AH, Micheletti AM, Garcia Torres R, Castro Gazotto F, et al. Choroiditis in a HIV-infected patient with disseminated cryptococcal infection: A case report and literature review. Rev Iberoam Micol 2019;36:155-9.  Back to cited text no. 8
    
9.
Nanni MG, Caruso R, Mitchell AJ, Meggiolaro E, Grassi L. Depression in HIV infected patients: A review. Curr Psychiatry Rep 2015;17:530.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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