CRYPTOCOCCOSIS ASSOCIATED WITH HIV-NEGATIVE INDIAN PATIENTS AND HIV-POSITIVE INDIAN BLOOD-DONORS

Cryptococcosis, particularly cryptococcal meningitis (CM), has become an increasing problem globally in the AIDS era. In the present investi gation we have made an effort for the first rime to study Indian cases (100) both HIV-positive (23 cases, male, mostly Indian professional b lood donors, PBDs') confirmed by an ELISA test and Western Blot but as ymptomatic for CM and HIV-negative (77: 49 male and 28 female) asympto matic or symptomatic. These subjects were patients from the Lucknow ho spitals admitted during the period between February, 1991 to February 1994, for suspected cryptococcosis or CM. Of those cases, 10% were pos itive for cryptococcosis or CM. Meningoencephalitis was the dominant c linical manifestation in four (HN-negative) cases of CM. CT scanning o f the head of those cases revealed a noncommunicating hydrocephalus du e to aqueductal stenosis (in 2 cases) and a communicating hydrocephalu s with granuloma (by MRI) in another case. The latex agglutination res t (LAT) of the sera was positive for Cryptococcus antigen in 6 (26%) o f the (HIV-positive) patients and 4 (5%), of the HIV-negative cases. I n the cases of Chi, there was a lower antigen titre in CSF than in the pronase-treated sera. The LAT was found to be useful in diagnosis of cryptococcosis, especially in asymptomatic cases. The CSF of CM-positi ve cases revealed low levels of glucose, reduced cell count and high p roteins. Among the HIV-negative cases, the onset of meningitis in 4 ca ses was preceded by the presence of encapsulated budding yeast cells i n CSF India ink smear, or cryptococci in a direct urine smear in one c ase. The CSF culture of 3 cases was positive for mucoid Cryptococcus n eoformans, showing brown colour effect (BCE) on Staib agar (syn. Guizo tia abyssinica creatinine agar, bird seed agar). The isolated yeast st rains were identified as C. neoformans var. neoformans by physiologica l tests. The pathogenicity test of strains revealed virulence to BALB/ c mice evidenced by a high mortality of mice and significantly (p < 0. 05) high CN burden (> 4-5 mean log(10) cfu), in the brain followed by other visceral organs (lung, liver, spleen, kidney and heart). The in- vitro susceptibility (MIG mu gmL(-1)) of strains for 10 antifungals wa s established to draw up guidelines for the management of the disease. Primary therapy of patients with amphotericin B (AMB) alone or combin ed with flucytosine and/or by salvage therapy with fluconazole showed promising results in the management of CM. Our preliminary studies ind icate that association of HIV, notably with PBDs', is an increasingly frequent cause of CN infection.