Mini Review - Imaging in Medicine (2023) Volume 15, Issue 3

Multimodal imaging in AIDS-associated cryptococcal disease

Flores Herrera Maria Fernanda*

Department of Ophthalmology, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium


*Corresponding Author:
Flores Herrera Maria Fernanda
Department of Ophthalmology, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium


Received: 1-May-2023, Manuscript No. FMIM-23-92102; Editor assigned: 3-May-2023, Pre QC No. FMIM-23-92102(PQ); Reviewed: 17-May-2023, QC No. FMIM-23-92102; Revised: 22-May-2023, Manuscript No. FMIM-23-92102(R); Published: 29-May-2023; DOI: 10.37532/1755- 5191.2023.15(3).54-56


To report multimodal imaging discoveries in two cases of AIDS-related cryptococcal chorioretinitis related with uveitis and vasculitis. Discoveries on clinical examination, color fundus photography, fluorescein and indocyanine green angiographies, and optical coherence tomography. Both patients were analyzed with Cryptococcus neoformans meningitis within the setting of untreated HIV contamination with CD4+ T cell. Visual appearances happened amid the course of the antifungal treatment for meningitis. In both cases, fundus appeared vitritis. Fluorescein angiography permitted the characterization of vasculitis injuries, and indocyanine green angiography shown choroidal association. In combination with optical coherence tomography, ICG and FA permitted the appraisal of treatment reaction. These two cases uncover the potential of C. neoformans to contaminate nearly all visual structures and the basic role of multimodal imaging in standard assessment and within the follow-up of patients.


Multimodal • Imaging • AIDS • Cryptococcal • Disease


Cryptococcosis is an intrusive mycosis primarily caused by two species: Cryptococcus neoformans and Cryptococcus gattii that can influence both immunocompromised and immunocompetent subjects. C. neoformans may be a major cause of meningitis in HIV-infected patients with progressed immunosuppression and is related with tall dreariness and mortality in resourcelimited settings. C. neoformans spreads hematogenously from the lungs to the central anxious framework causing parasitic meningitis. Ocular manifestations are as often as possible watched amid cryptococcal meningitis in Helps patients. Papilledema, visual misfortune, and cranial nerve paralysis are the foremost visit visual discoveries. Intraocular inclusion, due to hematogenous dispersal or expansion through the leptomeninges, is abnormal and incorporates choroiditis and chorioretinitis [1, 2].

We report two cases of cryptococcal intraocular inclusion in two Helps patients with concomitant cryptococcal meningitis. Fluorescein (FA) and Indo Cyanine Green (ICG) angiographies as well as Optical Coherence Tomography (OCT) discoveries are examined. A 25-year-old man from Sub-Saharan Africa displayed at our ophthalmology office for bothersome ruddy right eye since 3 weeks. The understanding was tainted with HIV taking after vertical transmission and analyzed with HIV disease at the age of 7. The nadir CD4 number was 67/mm3. He was analyzed with cryptococcal meningitis 9 months some time recently. He got a treatment with liposomal amphotericin B and flucytosine taken after by fluconazole auxiliary prophylaxis. After two months, he endured from a backslide after deliberately ceasing his prophylaxis and the same treatment was given [3].


At introduction day in our clinic, the persistent had once more deliberately stopped both antiretroviral treatment (elvitegravir/cobicistat/ emtricitabine/tenofovir) and fluconazole 2 months some time recently. Visual keenness was 1/10 within the right eye and checking fingers within the Cleared out Eye (LE); intraocular weight was typical. Front chamber examination uncovered reciprocal conjunctival hyperemia, in conjunction with granulomatous keratic accelerates. Both eyes fundus shown gentle vitritis beside different yellowish subretinal injuries through the back shaft and midperiphery, with a well-demarcated expansive profound macular injury on the LE. Late-phase Fluorescein Angiography (FA) of the LE appeared vasculitis of expansive venous vessels, hot plate, a few macular hypofluorescent injuries, and with a mellow recoloring of a few injuries. ICG angiography illustrated various hypocyanescent spots, more various than the injuries seen on eye fundus and FA, recommending related broad choroidal injuries. Macular ghastly space Optical Coherence Tomography (SDOCT) illustrated retinal invasion within the second rate portion of the macula with a diffuse thickening. Multimodal imaging discoveries were steady with irresistible two-sided panuveitis with multifocal chorioretinitis, vasculitis, and papillitis. The quiet was conceded, and research facility examinations were performed. C. neoformans developed on products blood societies with positive cryptococcal antigen (Bank). A lumbar cut illustrated Cerebro Spinal Liquid (CSF) lymphocytosis, hypoglycorrhachia, a positive Precipice, and C. neoformans culture. Vitreal culture was not performed. Computed tomography of the brain did not uncover any anomalies, counting signs of cerebral toxoplasmosis. Pneumonic tuberculosis was ruled out: both sputum and broncho alveolar lavage coordinate examination, PCR, and culture were negative for M. tuberculosis. Blood culture was too negative for Mycobacteria sp. Physical examination was striking for papular verrucous skin injuries on the confront. A skin biopsy was performed and PAS, Mucicarmine, and Grocott stainings uncovered moreover the nearness of Cryptococcus. Fringe blood HIV viral stack was 36400 copies/ml, and CD4+ T cells tally was 61/ mm3 (4% of add up to T cells) [4, 5].

A conclusion of systemic and visual cryptococcal disease was hence made, and combination treatment with liposomal amphotericin B (250 mg/24 h) and flucytosine (1750 mg/6 h) was restarted for add up to of 14 days. The quiet was discharged with fluconazole 800 mg together with antiretroviral treatment. At 10-month follow-up, fringe blood HIV viral stack was imperceptible (< 20 copies/ml) and CD4 check was 144/mm3. The quiet was still taking fluconazole auxiliary prophylaxis. Visual sharpness was, individually, 10/10 and 4/10 and there was no sign of aggravation on the opening light. The eye fundus examination illustrated numerous reciprocal fringe dormant injuries and a macular scar on the LE [6].

Late-phase FA appeared relapse of the vasculitis, remaining late dissemination of the optic nerve, and recoloring of the macular and fringe cicatricial retinal injuries. Late-phase ICGA illustrated extreme enhancement with perseverance of a few discrete hypocyanescent spots likely comparing to the cicatricial injuries seen on eye fundus and FA. A 32-year-old man was conceded for disarray and misfortune of awareness. HIV-1 testing was positive. CSF examination uncovered positive Precipice and Indian ink examination. Both CSF culture and blood societies developed for C. neoformans. Brain MRI did not uncover signs of cerebral toxoplasmosis. Aspiratory tuberculosis was ruled out both sputum and bronch oalveolar lavage coordinate examination, PCR, and culture were negative for M. tuberculosis. Fringe blood HIV-1 viral stack was 8,00,000 copies/ml, and CD4+ T cell tally was 12/mm3. On the third day of hospitalization, combination treatment by liposomal amphotericin B (350 mg/24 h) and flucytosine (100 mg/kg/24 h) was started and was halted after 18 days since of intense kidney disappointment conceivably related to liposomal amphotericin B and thrombocytopenia conceivably related to flucytosine [7, 8].


Auxiliary prophylaxis by fluconazole 400 mg was started. In any case, on the 30th day of hospitalization, fever backslid went with with cerebral pains. Lumbar cut investigation uncovered positive Indian ink examination but negative C. neoformans culture. Subsequently, liposomal amphotericin B treatment was reinitiated for likely backslide of cryptococcal meningitis. On the fifth day of hospitalization, the understanding, complaining of floaters, was alluded to the ophthalmology office. The visual sharpness was 10/10 on both eyes. Opening light examination uncovered few cells within the front chamber with no keratic accelerates or synechia. Fundus examination appeared mellow vitritis in both eyes related to reciprocally numerous dab and smudge hemorrhages, cotton fleece spots, products profound yellowish injuries, and huge whitish fringe retinal ranges. Vitreal culture was not performed. FA appeared hilter kilter papillitis and occlusive vasculitis in both eyes. ICGA illustrated numerous hypocyanescent spots all through the back shaft and the midperiphery. Upgraded Profundity Imaging-OCT (EDIOCT) performed on a superotemporal hypocyanescent spot within the cleared out eye uncovered a well-delineated injury involving all the choroidal space and considered as a cryptococcal granuloma, associated with a little serous retinal separation which may be related to auxiliary incendiary reaction to the fundamental choroidal injury [9, 10].



Conflict of Interest



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