Cryptococcosis in Nonhuman Immunodeficiency Virus-Infected Children

Between 1991-2006, nine patients below age 18 years, with a microbiologic documentation of Cryptococcus neoformans infection and no evidence of human immunodeficiency virus infection, were identified and treated at Chang Gung Children's Hospital. All exhibited central nervous system involvement. Seven patients were female (age range, 9-16 years; mean age, 13.7 years). Five patients (56%) manifested underlying diseases and were receiving either steroid or immunosuppressant treatment at time of disease onset. Eight patients presented with meningitis. Headache, vomiting, and focal neurologic signs were the most common presentations. Protein and sugar levels in cerebrospinal fluid were within normal range in seven cases, whereas India ink smear and cryptococcal antigen testing were positive in 87% (7/8) and 78% (7/9) of patients, respectively. With prompt antifungal therapy, all survived, but one presented the sequel of blindness. Cryptococcosis is uncommon in the nonhuman immunodeficiency virus-infected pediatric population. Clinicians should take into account a diagnosis of central nervous system cryptococcosis when children present with prolonged headache, vomiting, and focal neurologic signs. Indian ink stain and cryptococcal antigen testing of cerebrospinal fluid should be performed.

Introduction

Cryptococcosis is an invasive infection, usually opportunistic, and attributable to the yeast-like fungus Cryptococcus neoformans. The most common predisposing factor to cryptococcosis worldwide is acquired immune deficiency syndrome [1], [2]. Among pediatric populations, whether human immunodeficiency virus-infected or nonhuman immunodeficiency virus-infected, cryptococcosis is uncommon, for unclear reasons, but its capacity for morbidity and mortality poses a major health problem [3]. Cryptococcosis complicating pediatric acquired immune deficiency syndrome was reviewed previously [4], [5], [6]. To identify the clinical characteristics and outcomes of nonhuman immunodeficiency virus-infected children with cryptococcosis, we retrospectively reviewed these patients in a university-affiliated hospital in northern Taiwan during a 16-year period, from 1991-2006.