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Letter to the Editor
Meningeal cryptococcosis in a patient with angioimmunoblastic lymphoma treated with alemtuzumab
Criptococosis meníngea en una paciente con diagnóstico de linfoma T angioinmunoblástico en tratamiento con alemtuzumab
David Cruza,
Corresponding author
, Paula Costab, Miguel Sagüésa
a Servicio de Hematología Clínica, ICO-Girona, Hospital Universitario Dr. Josep Trueta, Girona, Spain
b Servicio de Laboratorio Clínico Territorial ICS Girona, Parque Sanitario Martí Julià, Girona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cryptococcosis is a serious opportunistic fungal disease caused by encapsulated yeasts belonging to the genus <span class="elsevierStyleItalic">Crytococcus</span>&#46; Distribution is worldwide&#46; This genus includes about 50 species&#44; <span class="elsevierStyleItalic">Cryptococcus neoformans</span> and <span class="elsevierStyleItalic">Cryptococcus gattii</span> being the most frequent human pathogens&#46; Depending on its capsular composition&#44; 5 serotypes have been reported&#58; A &#40;<span class="elsevierStyleItalic">C&#46; neoformans var&#46; grubii</span>&#41;&#44; D &#40;<span class="elsevierStyleItalic">C&#46; neoformans var&#46; neoformans</span>&#41; and AD &#40;<span class="elsevierStyleItalic">C&#46; neoformans hybrid</span>&#41; and serotypes B and C &#40;<span class="elsevierStyleItalic">C&#46; gattii</span>&#41;&#46; The main reservoir is soil contaminated with excrement&#44; mostly from birds&#44; bats and organic matter&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> It is acquired mainly by the respiratory route &#40;inhaled&#41;&#44; and rarely by the gastrointestinal tract and skin&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The estimated incidence in our country is 0&#46;5&#47;1&#44;000&#44;000 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main risk factor is cellular immunodeficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The main risk groups include patients with HIV infection&#44; oncohematological patients and transplant recipients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C&#46; gattii</span> has traditionally been associated with the disease in immunocompetent individuals in tropical and subtropical regions&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The most common symptomatology includes headache in up to 75&#37; cases&#44; usually lasting about 2&#8211;4 weeks&#46; Frequently it occurs with fever&#44; nausea&#44; vomiting and seizures&#44; but neck stiffness and typical signs of meningism have been reported in fewer than 25&#37; cases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis is based on the identification of the yeasts in biological fluids&#44; by observing the capsule in the India ink stain&#44; the isolation in cultures or the detection of capsular antigens&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment includes an induction phase with intravenous liposomal amphotericin B and oral flucytosine&#46; After the normalization of cerebrospinal fluid &#40;CSF&#41; results&#44; oral fluconazole is used for maintenance therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Alemtuzumab is a recombinant monoclonal antibody that binds to CD52&#44; present on B and T lymphocytes&#44; monocytes&#44; NK cells and some granulocytes&#46; Lysis of CD52 positive cells occurs by complement activation&#44; antibody-dependent cytotoxicity and apoptosis&#46; It is indicated in the treatment of chronic lymphatic leukemia and other T-cell lymphoproliferative neoplasms&#46; It causes dose-independent lymphopenia and increases the risk of developing opportunistic infections&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">We present a case report of meningeal cryptococcosis in a patient with angioimmunoblastic T-cell lymphoma and treated with alemtuzumab&#44; in January 2016&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A 57-year-old woman diagnosed with angioimmunoblastic T-cell lymphoma in June 2014&#46; She received first-line chemotherapy in accordance with the R-CHOP regimen &#40;rituximab&#44; cyclophosphamide&#44; adriamycin&#44; vincristine and prednisone&#41; for 6 cycles without obtaining a response&#59; subsequently alemtuzumab was administered&#44; which had to be withdrawn due to cytomegalovirus &#40;CMV&#41; infection&#46; She underwent a third-line treatment with ciclosporin until progression and a fourth-line treatment with lenalidomide&#44; without response&#46; Eventually&#44; she restarted treatment with alemtuzumab&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient went to the emergency department due to a 4-day occipital headache&#44; that awakened her at night&#44; and disorientation&#44; with no fever and no further symptoms&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">She was hemodynamically stable&#46; Physical examination revealed a disorientation in time&#44; space and person&#46; She had neck stiffness and positive Kernig and Brudzinski signs&#46; The complete blood count showed&#58; hemoglobin 113<span class="elsevierStyleHsp" style=""></span>g&#47;L&#44; platelets 195<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#44; leukocytes 6&#46;59<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;normal formula&#41;&#46; Plasma coagulation and basic biochemistry were normal&#46; The patient underwent a cranial computed tomography that showed no relevant pathological changes&#46; The CSF study showed&#58; glucose 36<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#91;50&#8211;80&#93; and proteins 81&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#91;15&#8211;45&#93;&#46; Gram staining was negative for bacteria and pneumococcal antigen&#46; The polymerase chain reaction tests for CMV&#44; JC virus&#44; Epstein-Barr virus&#44; herpes simplex virus 1 and 2&#44; varicella-zoster virus and <span class="elsevierStyleItalic">Listeria monocytogenes</span> were all negative&#46; Given the suspicion of opportunistic infection&#44; we used India ink stain which showed capsule yeasts&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C&#46; neoformans var&#46; grubii</span> was isolated in the CSF culture&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The patient underwent treatment with liposomal amphotericin B and flucytosine for 24 days&#44; and she was discharged with maintenance oral fluconazole therapy&#44; completing a 7-month treatment&#46;</p></span>"
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