Ophthalmic manifestations of Cryptococcus gattii species complex: a case series and review of the literature

INTRODUCTION

Thecomplex species are spore-forming,soil-dwelling fungi.() was historically considered a variety of().Increased recognition of unique epidemiological,morphological, and clinical features led to its designation as an independent species in 2002. Genotyping identified at least four molecular types or genotypes of(variety gattii; VG), VGI, VGII, VGIII, and VGIV, with each of these genotypes containing subtypes. Based on phylogenetic analysis of genetic loci and genotyping studies Hagendemonstrated significant genetic diversity and proposedbe divided into two species andinto five species. Subsequent published genotypes have revealed greater genetic diversity than is encompassed by the seven species. In an effort to recognise genetic diversity without creating confusion Kwon-Chungproposed the use of“species complex” as a practical solution, rather than creating more species. In this manuscript when “” is used it refers to the “species complex”.

Thoughhas long been established as a cause of endemic infection in the sub-tropics and in Australia, an outbreak in Vancouver Island in 1999 led to spread ofinto the Pacific Northwest region of the United States,with further reports described elsewhere in the United States and in Europe in more recent years. It appears genotype distribution and frequency are dependent on geographic regions. In Australia VGI is the most common genotype of isolates whereas isolates from the outbreak in Canada and the Pacific Northwest region of the United States were the molecular type VGII.

Infections caused byhave classically been associated with immunosuppressed individuals, most frequently HIV/AIDs patients. In contrast,infections have predominantly been documented in healthy and immunocompetent patients. The majority of patients present with central nervous system (CNS) infection, with concurrent or isolated pulmonary infection also common.

A notable observation ofCNS infection is the high rate of visual sequelae, particularly when compared to infections caused byWe present cases from multiple centres that illustrate the diverse ophthalmic manifestations of. We will also review the literature to evaluate ophthalmic manifestations ofinfection,prognosticators of visual outcome, and treatment modalities.To our knowledge this is the first study that has specifically examined ophthalmic manifestations ofinfection.

SUBJECTS AND METHODS

In summary, though many papers examiningmeningitis note ophthalmic signs and symptoms, there is limited data regarding long-term sequelae, and only one study that specifically examined risk factors for visual loss. Reported rates of visual loss varied from 11%-53%, in contrast to studies examining, where visual loss has been reported in 1%-9% of cases.

Four cases ofwere independently identified, including cases from Victoria and Queensland, Australia, and the midwest region of the United States. The ocular and systemic characteristics, treatment, and visual outcomes are reported.A MEDLINE literature search (1990 through 2020) was performed to identify cases ofmeningoencephalitis where ophthalmic manifestations were reported. All reported cases were reviewed and tabulated, together with our series of patients, in this report.

对本科护生进行循证护理理念培养必不可少，将其与真实病人PBL教学相结合，并应用于护生见习环节，有助于提高护生批判性思维能力，提高护生见习参与度，且与传统见习模式相比，其在提高护生自学能力、发现问题和解决问题的能力及团队合作能力方面认可度较高。

RESULTS

A 20-year-old healthy female presented to a tertiary hospital with a 2-month history of frontal headache, night sweats, and blurred vision. Neurological examination was notable for significant nuchal rigidity, visual acuity (VA) was 6/9 right eye and 6/9 left eye, with normal colour vision and no relative afferent pupillary defect (RAPD). Ophthalmoscopy showed bilateral optic nerve swelling (Figure 1). She had not travelled rurally.

Magnetic resonance imaging (MRI) brain showed T1 ringenhancing lesion (Figure 2A) and computed topography (CT)chest showed cavitating lesions in both lungs (Figure 2B).Lumbar puncture (LP) revealed a normal opening pressure(OP), with analysis of cerebrospinal fluid (CSF) demonstrating lymphocytic pleocytosis and Cryptococcal antigen (Crag) titre>1:2560. CSF culture grewwhich was subtyped toVGI using matrix-assisted laser desorption/ionization coupled to time-of-flight spectrometry (MALDI-TOF).Liposomal amphotericin B and flucytosine were initiated. HⅠV testing was negative.

网络形式是企业引进新型财务管理模式的中心，且网络支付是创新需要考虑的首要因素。网络环境也并非如想象般安全，潜在的很多不安定因素将会给企业创新带来大量的问题。例如，不完善的网络管理制度，将会给黑客等不法分子提供可乘之机，对网络安全造成极其恶劣的影响。此外，企业网络方面的优秀人才和过硬的软件管理技术的匮乏也将可能提高网络环境的危险程度。更为严重的是，在中国没有制定相应的网络法律条文，在法制时代下，没有法律的约束，企业财务管理所面临的危险将大大提高。所以，企业需要创新网络财务管理制度，着重提高网络技术，雇佣相应的网络技术人才。国家也需要尽快建立专门的网络法律法规约束不法分子，加强对网络的保护。

One week post-initiation of therapy headache continued.Repeat LP revealed an OP of 32 cm HO CSF. Ophthalmic assessment demonstrated dyschromatopsia, right RAPD and worsening of optic disc swelling consistent with grade 5 papilloedemaRepeat MRI brain showed hydrocephalus. She had daily LP until day 20 of admission, when a ventriculoperitoneal (VP) shunt was inserted, resulting in immediate symptomatic improvement. She completed a 6-week induction course of liposomal amphotericin B and flucytosine infusions,followed by a 12mo course of fluconazole to complete consolidation and maintenance therapy. At follow-up 4-months post-discharge her visual acuity was 6/5 in both eyes, with grade 3 papilloedema, and lipid deposits present at the left parafoveal area (Figure 3)

A 61-year-old male presented to an Emergency Department in the mid-west region of the United States, with a 6-month history of headache, vomiting, and 5 kg weight loss. He was immunosuppressed with tacrolimus 2 mg BID, prednisone 10 mg OD, mycophenolate mofetil 250 mg BID following renal transplantation two years prior. The source of infection was not clear. Donor derived transmission ofhas previously been described, however this patient had travelled toendemic regions in the north-western United States. Examination was notable for skin lesions on left forearm (Figure 4A). LP was obtained;OP was 50 cm HO CSF. CSF fungal smear demonstrated. Amphotericin B and flucytosine were initiated and his immunosuppressive regimen was tapered.

The 4 cases presented here, allied with a review of the existing literature, illustrate a number of important principles related to infection with. The first of these is the broad geographical distribution. While previously thought to be a disease of the tropics and sub-tropics,is now recognized as an endemic fungus in the United States, most prevalent in the North-western regions of the country. Host factors also appear to differ significantly when compared to, with infection withobserved more frequently in immunocompetent hosts.

A 41-year old previously well male presented to an Emergency Department in Queensland with a 4-week history of worsening headaches and fever. LP was performed and revealed normal OP with CSF Crag titre of >1:1280 with subsequent culture positive for. CT brain was unremarkable and CT chest demonstrated a pulmonary cryptococcoma in the left lower lobe.

The patient had no visual symptoms but was referred to the ophthalmologist for routine review, with initial VA of 6/4.5 in both eyes. Dilated slit lamp examination was notable for a retinal lesion temporal to the fovea of the left eye, with intra-retinal oedema. Infrared imaging and optical coherence tomography (OCT) and demonstrated a cryptococcoma (Figure 5A, 5B). The optic nerves were normal.

He was treated with amphotericin B and flucytosine infusions.Daily funduscopic examinations showed the retinal lesion reducing in size. After 3wk of inpatient care, he was discharged home after 3wk on oral fluconazole.

The patient returned to the emergency department 5d post discharge with worsening headaches. Repeat MRI demonstrated multiple cerebral cryptococcomas. He was recommenced on amphotericin B and flucytosine infusions and oral fluconazole. The retinal cryptococcoma continued to reduce in size, however the patient developed optic nerve head swelling that continued to worsen on subsequent reviews despite several LPs demonstrating OPs of no higher than 25 cm HO of CSF. He was re-commenced on amphotericin B and flucytosine infusions for 6wk.

The second of these is thatis associated with significant visual sequelae, in particular when associated with intracranial hypertension. While papilloedema is strongly associated with vision loss, it is not present in all cases,and prompt recognition and management of intracranial hypertension with decompressive therapies is critical. Unlike in idiopathic intracranial hypertension, acetazolamide and mannitol are associated with adverse side effects and poor outcomes.Third, these cases highlight the protean ophthalmic and systemic manifestations possible ininfection. Our cases demonstrate thatinfections can cause myriad ophthalmic pathologies including vision loss, papilloedema,and retinal cryptococcomas. While the phenomena of endophthalmitis and retinal cryptococcomas secondary tohave been documented only rarely in the literature, their possibility warrants dilated funduscopic examination. We recommend that all patients diagnosed withmeningitis be referred to an ophthalmologist/neuro-ophthalmologist at presentation and receive long-term follow up during their treatment course to assess for ophthalmic sequelae. Whilst the literature is relatively sparse in this area, there is a suggestion thatis associated with worse visual outcomes than. Whether this is related to differential rates of fungal blockage of CSF, an as yet unidentified mechanism,or a spurious finding, requires further elucidation. Further studies that directly compare the mean ICP and ophthalmic manifestations ofandwould contribute significantly to the literature in this area.

由于杏A注水站停运后将减少注水量约1.21×104m3/d，为保障区域内生产用水需求，需要具备连通性的其他深度注水站提高注水量约1.21×104m3/d。相邻深度注水站生产运行情况见表4，由表中数据可知，杏B注水站、杏C注水站、杏D注水站注入能力可满足杏A注水站停运后的注水量需求。

An independent 58-year-old female from rural Victoria, Australia presented to the local Emergency Department with a cough and lethargy. She had hypertension,obstructive sleep apnoea and migraine.Treatment for community acquired pneumonia was initiated,however 6wk later she returned to the Emergency Department with headaches and confusion associated with photophobia,phonophobia and visual disturbance. Bronchoalveolar lavage with cultures confirmedinfection. MRI brain demonstrated a well circumscribed lesion of the right temporal lobe (Figure 6A). Flucytosine and amphotericin B were prescribed for a 6wk course, followed by consolidation with oral fluconazole. Weekly LPs were performed for chronic headache, with recorded OPs of 26-36 cm HO CSF.Four months following diagnosis she was transferred to our tertiary centre with ongoing postural headaches associated with photophobia, blurred vision, scintillations and new papilloedema. On ophthalmic examination, VA was 6/12 right eye and 6/7.5 left eye. Fundal examination demonstrated grade 2 papilloedema of both eyes (Figure 7). Repeat imaging showed multiple enlarging ring enhancing cryptococcomas with substantial progression of vasogenic oedema in the right supratentorial brain parenchyma (Figure 6B). VP shunt was inserted with improvement in symptoms.

两组患者在治疗前的舒张压、收缩压无明显区别,P>0.05;在治疗后,联合组患者舒张压、收缩压均明显低于对照组,P<0.05。详见表2。

At 1-year follow up, headaches and papilloedema had resolved,however there was further deterioration in VA; 6/12 right eye and 6/15 left eye. Repeat MRI brain demonstrated reduction in size in two of the four cryptococcal lesions. Maintenance therapy with fluconazole was continued for a planned 18mo course.

新时代我国社会主要矛盾变化背景下加强司法行政戒毒工作的思考江西省戒毒管理局课题组（2018年第11期）

DISCUSSION

Fungal cultures of CSF and Grocott’s Methenamine Silver Stain(GMS) staining of skin lesions subsequently demonstrated. The patient had severe headaches with persistent elevation of intracranial pressure (ICP) on serial LPs requiring lumbar drain insertion on hospital day 4. On day 5 the patient developed reduced right VA. VA was counting fingers right eye and 6/15left eye. Funduscopic examination demonstrated bilateral optic nerve oedema. He had limitation of abduction consistent with mild 6nerve palsy in both eyes. MRI brain and orbits revealed generalized mild hydrocephalus and abnormal leptomeningeal enhancement (Figure 4B).Prednisone was switched to dexamethasone for management of optic nerve oedema. Unfortunately, the patient continued to experience profound elevation of ICP with associated encephalopathy despite placement of a VP shunt. A decision was made to pursue hospice cares and the patient died 30d following initial presentation.

庄主此话似故作深沉，乍听以为酒徒醉语，细思却也颇入理。凡饮酒者皆成年人也，各有年纪，以酒助兴也罢，借酒浇愁也罢，杯中物不过乃媒介耳，借以回味走过的人生，品评明天的旅程，故而泛在心头的确是时光滋味。

Six weeks later, repeat LP had a normal OP of 19 cm HO CSF,and optic nerve swelling continued to reduce. Repeat infrared imaging and OCT at 4 and 7mo respectively demonstrated improving retinal thickening over the retinal cryptococcoma(Figure 5C, 5D). He was again discharged on oral fluconazole planned for a 12mo course. VA remained stable at 6/4.5 in both eyes.

was thought to be a rare pathogen endemic to the sub-tropics and Australia. Increased laboratory capabilities enabling genotyping of cryptococcal species,with subsequent documentation of cases in North America,South America, Europe, and Asia has led to recognition that this yeast is more widely distributed than previously recognised. In 2014 Baddleyfound thataccounts for approximately 20% of cryptococcal infections.Genotyping identified at least four molecular types or genotypes of, VGI, VGII, VGIII, and VGIV with each of these genotypes containing subtypes. Subsequent published genotypes have revealed greater genetic diversity than is encompassed by the previously delineated taxonomy.As such Kwon-Chungsuggested that “species complex” be used.

[6]Culpeper,Jonathan.Impoliteness and entertainment in the television quiz show:The Weakest Link.Journal of Politeness Research,2005,1:35-72.

VGI and non-outbreak VGII have been associated with particularly severe cases of CNS infection. VGIIa strains reported in outbreak regions of the USA have been associated with higher rates of pulmonary infection, however CNS involvement is common to all types.

In Australia, Chenreport rates of visual loss at 11%, with blindness in 4%. CSF Crag≥1:256 and abnormal neurology at presentation were associated with death and long-term neurological sequela. Speed and Duntcompareandin Victoria during the AIDS epidemic, and suggest that patients withinfection were more likely to have focal CNS features, papilloedema and neurological sequelae and to undergo surgical procedures when compared to, however exact figures are not specified. Studies in the United States have paid minimal attention to visual outcomes with no ophthalmic outcome data reported in either case series.

In contrast with, which is almost universally associated with compromised cell-mediated immunity,(VGI and VGII) appears to have a tropism for immunocompetent hosts. More recent studies have shown an increased risk ofinfection in patients with positive HIV status, solid organ transplant, malignancy, and idiopathic CD4 lymphopenia, particularly in outbreak regions. Male sex has also been positively associated withinfection,although it is likely that this is linked to environmental exposures.

Table 1documents our review of the literature encompassing 331 cases ofCNS infection that ophthalmic manifestations were reported. The majority of patients were immunocompetent. Ophthalmic symptoms reported at presentation ranged from blurred vision, reported at 40%-62%in two case series, and diplopia, reported at 20% in one case series.

These visual symptoms generally occur with headache, nausea and vomiting, and are attributable to papilloedema, the most commonly reported ophthalmic sign, with rates ranging from 43%-50% in earlier studies from Australia and Papua New Guinea (PNG). While LP was not routinely performed to document intracranial hypertension, Seatonreported a rate of optic disc swelling of 81% at presentation in a case series of 82 patients. Notably, they found that rates of optic disc swelling were associated with a significantly longer time from onset of symptoms to presentation, which may account for the lower rates observed in developed countries.More recently Chendocumented a rate of 16% in an Australian study, with associated optic atrophy in 9% of cases.In the United States Harrisreport papilloedema in 10%of cases. Notably, Harrisdifferentiates between outbreak and non-outbreak types: in outbreak types associated with VGIIa infection, papilloedema was observed in 6% of cases,whereas a rate of 22% was observed in infections caused by non-outbreak types.

Cranial nerve (CN) palsies have also been documented in 20% of patients reported by Lallooin PNG and 18%in Australia by Chen. CN VI was involved most frequently in both cases series. Whether CN palsies are a result of direct invasion byor secondary to increased ICP has not been determined. We found one further case of endogenous endophthalmitis secondary to, diagnosed on PET scan and confirmed with vitreous biopsy. Prior to our case series, there has also been only one previous case of retinal cryptococcomas secondary toreported in the literature. Interestingly in both cases there did not appear to be loss of VA. Whether this is truly a rare phenomenon, or rather due to lack of routine dilated eye examination is unclear.In PNG, Seatonstudied 82 patients withmeningitis and found that 51% of patients had developed “varying degrees of visual loss” and 31%became blind during the course of their illness. Visual loss was significantly associated with CN VI palsy, and serum and CSF Cryptococcus antigen (Crag) titres ≥1:1024 Ⅰt isunclear whether patients in this case series received ICP lowering therapies, which may have a profound impact on visual outcomes.

The primary environmental factor associated with infection appears to be exposure to decayed tree hollows.has been isolated from over 50 tree species, with eucalypt trees in particular linked to the higher rates of infection seen in Australia. In the USA,favourable biogeoclimatic zones in the Pacific Northwest are thought to be responsible for the development of an ecological niche;has consistently been recovered from native trees, soil and freshwater in this region.

Approval for the study was obtainedthe Institutional Review Boards at the Royal Melbourne Hospital and at Mayo Clinic respectively. All research activities were in accordance with the Declaration of Helsinki.

establishes infection in the lunginhalation of spores. From this point it enters the blood-stream and traverses the blood-brain barrier before entering the CSF. The prototypic finding of cryptococcal meningitis (CM) is intracranial hypertension, often in the absence of significant inflammation. While the underlying mechanism of elevated ICP is likely multi-factorial, the theory given most weight in the literature is fungal blockage of CSF at the level of the arachnoid villi. Occasionally obstructive hydrocephalus occurs, often secondary to a mass effect in the presence of cryptococcomas. However, the presence of intracranial hypertension in the absence of radiological hydrocephalus is also frequently observed and has been attributed to equivalent pressures between intraventricular fluid and CSF surrounding the brain and the paucity of intraventricular fungal elements, preventing ventricular dilation.

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Papilloedema is defined as optic nerve swelling secondary to intracranial hypertension and is the most frequently cited mechanism for visual loss in CM, with direct fungal invasion or compression of the optic nerve cited as other mechanisms for visual loss. One recent study found that intracranial hypertension and increased fungal burden are independently associated with severe visual loss. It is notable that even though papilloedema was observed to be a risk factor for visual sequelae in our review, it has not universally been observed on funduscopic examination, and optic nerve sheath dilatation or inflammation has not been consistently visualized on MRI.

This has led to the proposal of optic nerve sheath compartment syndrome (ONSCS) as a possible mechanism of visual loss in. infections by Moodley. Plugging of the peri-optic space at the mid-orbital level of the optic sheath by cryptococcal fungal elements is theorised to cause a large pressure gradient between the intracranial sub-arachnoid space and the proximal peri-optic CSF space. In their studies this is demonstrated by enlargement of peri-optic space and loss of peri-optic CSF signal during phases of elevated CSF pressure on T2 weighted MRI, with return following lowering of CSF pressure. ONSCS follows during the initial phase, causing optic nerve compression, axoplasmic stasis, and ischaemia.Optic nerve dysfunction may ensue with visual blurring and visual loss.

Ophthalmic manifestations ofoccur in the context of CNS infection and treatment modalities focus on anti-fungal therapies for pathogen eradication, and ICP-lowering therapies for prevention of neuro-ophthalmic sequelae. Infectious Disease Society of America (IDSA)treatment guidelines do not differentiate betweenandinfection, but do outline therapeutic approaches based on host status and complications of cryptococcosis.In the immunocompetent host, induction therapy with amphotericin B and flucytosine for 4-6wk is recommended;with the longer induction regimen reserved for patients with neuro-ophthalmic symptoms at baseline. CSF should be examined every second week for clearance during the induction phase. Induction therapy should be prolonged in two weeks cycles until fungal clearance is demonstrated. High dose fluconazole is then suggested for a further 8wk, followed by maintenance therapy with low dose fluconazole for a further 6-12mo, or longer dependent on clinical response. Patients with renal impairment at baseline should receive liposomal amphotericin B. For patients co-infected with HIV specialist advice should be sought regarding 1) timing of antifungal therapy and initiation of antiretroviral therapy, and 2) the duration of antifungal therapy.

山洪具有突发性、水量集中、破坏力大等特点，对局部地区的经济和人民生命财产造成极大的危害，甚至是毁灭性的灾害。如1999年9月4日，永嘉县受9909号热带风暴倒槽东风波扰动影响，小流域山洪暴发导致两座小型水库垮坝，直接经济损失7.35亿元；2004年8月13日，第14号台风（云娜）登陆后引发乐清市的龙西乡上山村一处特大泥石流山洪灾害；2005年9月3日晚，临安市遭遇罕见短历时特大暴雨袭击，02省道接官岭地段发生泥石流，直接经济损失3亿元，等等。据不完全统计，自进入21世纪，全省发生较严重的山洪灾害共有31次，平均每年3次，直接经济损失达410亿元。

Management of intracranial hypertension is a critical component of therapy. IDSA guidelines recommend baseline LP with measurement of OP, with target closing pressure<20 cm CSF or <50% of OP. If symptoms and signs of intracranial hypertension persist, daily LP should be performed. In refractory cases, CSF diversion procedures should be considered. The role of CSF diversion versus medical management has yet to be studied in a clinical trial,however optic nerve fenestration for management of visual loss associated with papilloedema has been performed in individual cases with good visual outcomes. Unlike in cases of idiopathic intra-cranial hypertension and other causes of intracranial hypertension, mannitol and acetazolamide have not shown effectiveness in management ofCM. The use of acetazolamide showed increased rates of metabolic acidosis and more-frequent serious adverse events than subjects who received placebo. Metabolic acidosis is thought to be related to the combination of acetazolamide and amphotericin.

在我国，考试既是测量学生学业水平的重要工具，也是评价教师教学能力的重要手段。在过去，考试的整个流程主要包含教师网络搜题组卷或自行编辑试题组卷、学生使用纸质化试卷答题、教师手工阅卷、人工统计分数、机械化讲评试卷。而在数字化时代的今天，智学网等网络平台为教师提供组卷、阅卷、分析成绩与试卷的功能。这在很大程度上使教师提高阅卷工作效率、直观了解班级学情、明确班级优劣科目，同时让学生最大限度地了解自身优势与不足，明确自己的考试成绩、优势科目、薄弱科目、知识点漏洞。

区块链要发挥其战略价值，必须要能提供商业上切实可行的解决方案，并且这种解决方案是可规模化的。按照标准与合规、技术、资产、生态四个关键因素。逐一评估目前已经发现了超过90个潜在可能的应用，区块链在各行业应用的可行性取决于四个因素：资产类型、技术成熟度、法规与监管以及生态系统构建，其中最主要的是共同标准的建立。目前，制约区块链技术大规模应用的最主要因素是缺乏共同标准和清晰的法规监管。

The role of steroids in the management of CM-induced intracranial/optic nerve oedema has proved controversial. Seatondemonstrated a significant improvement in rates of visual deterioration in patients withmeningitis treated with corticosteroids (12.5%70%,=0.007) in a case series of 26 patients in PNG in 1997. A subsequent randomized,double-blind, placebo-controlled trial assigned patients to dexamethasone plus standard cares versus standard cares alone..was not identified, and all patients in the study had HIV. Mortality rates in the steroid group trended higher, without any noted improvement in visual outcomes,and a significantly higher rate of adverse clinical events.In conclusion, these cases illustrate the diverse and potentially devastating systemic and ophthalmic manifestations ofinfections and highlights the key role ophthalmologists can play in the diagnosis and management of this emerging infection.

The authors would like to thank Kayla Morris PhD for her assistance with the provision of images for the case report number three.

Campbell TG received support from the Hector Maclean Scholarship through the Centre for Eye Research Australia and Department of Surgery, University of Melbourne,Australia.

receives salary support from Bayer Pharmaceuticals through a unrestricted educational grant to the Centre for Eye Research Australia;None;None;None;None;None.