Medical Mycology Case Reports 1 (2012) 91–94
Contents lists available at SciVerse ScienceDirect
Medical Mycology Case Reports journal homepage: www.elsevier.com/locate/mmcr
Rare Cryptococus gattii infection in an immunocompetent dairy goat following a cesarean section Aurora Villarroel n, Tessa R. Maggiulli Department of Clinical Sciences, College of Veterinary Medicine, Oregon State University, 158 Magruder Hall, Corvallis, OR 97331, USA
a r t i c l e i n f o
abstract
Article history: Received 16 September 2012 Received in revised form 22 September 2012 Accepted 25 September 2012
A 5-year-old dairy goat was presented seven weeks post cesarean section for incomplete healing of the incision site. Cytology revealed cryptococcal organisms that were confirmed by the Centers for Disease Control as Cryptococcus gattii type VGIIa. Most cryptococcomas were surgically removed, but some penetrated deep in to the muscular layers and likely into peritoneum. The goat was treated daily with oral fluconazole for 6 months, and had a normal life for almost 2 years. & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved.
Keywords: Cryptococcus gatii Goat Immunocompetent Fluconazole Skin
1. Introduction Infections with Cryptococcus gattii are on the rise in humans and domestic animal species in the western United States [1–3], even among immunocompetent hosts [4,5]. Cryptococcus gattii has been associated mainly to pneumonic involvement [6,7], in contrast with the central nervous infections mainly attributable to Cryptococcus neoformans [5,6]. Cryptococcal infections can successfully be treated with long-term antifungals in humans [4,8] and non-food-producing animals [9,10], however, foodproducing animals such as goats have inherent limitations in therapeutic drugs due to their potential for residues in meat and milk. Most reported cases of cryptococcal infections in goats have proven fatal and were diagnosed on necropsy [7,11]. This case is the first documented case of transabdominal infection and longterm survival of an immunocompetent goat that was infected with Cryptococcus gattii. It was diagnosed in the Northwest part of the United States, and could possibly be related to the current outbreak in this area, although it has no known association with any other positive individuals [1,2].
2. Case A 5-year-old LaMancha doe was presented in June 2010 for a chronic infection in the incision site of a cesarean section (Fig. 1) that had been performed 9 weeks prior, on April 24, 2010 (day 0), and n
Corresponding author. Tel.: þ1 541 737 5853; fax: þ1 541 737 6879. E-mail address: [email protected] (A. Villarroel).
during which a live single male kid was delivered. In spite of daily cleaning and systemic treatment with oxytetracycline for 4 weeks (20 mg/Kg, subcutaneous [SQ], once every 5 days), the infection progressed rapidly, presenting as the main characteristics a massive granulomatous inflammation and draining of a vaseline-like fluid (Fig. 1). Local reaction could be observed to two different types of suture material used during the cesarean section. The doe had a rough and sebaceous coat, but appeared well and was behaving otherwise normally. Cytological evaluation of the draining material revealed cryptococcal organisms with granulomatous inflammation. The State Veterinary Laboratory diagnosed the organism as Cryptococcus gattii, and the Centers for Disease Control typed it as Cryptococcus gattii type VGIIa. 2.1. Treatment After confirmation of the diagnosis (July 2010, month 3), and given the progressive extension of the infection (Fig. 2), surgery was elected to remove as much as possible of the infected tissues. The extensive mycoses involved the left flank subcutis, all muscular layers and likely penetrated into the peritoneum, although this could not be confirmed at the time because the peritoneum was not incised to prevent further dissemination of the organism into the peritoneal cavity. All but four of the visible cryptococcomas were debrided, because they were attached to the peritoneum (Fig. 3). Special care was placed in identifying any possible cause for this infection at the surgical site. A small (1 2 mm) piece of straw was found in the external oblique muscle layer, which was considered a possible culprit for the fungal infection, but it could not be confirmed.
2211-7539/$ - see front matter & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.mmcr.2012.09.005
92
A. Villarroel, T.R. Maggiulli / Medical Mycology Case Reports 1 (2012) 91–94
Fig. 2. Incision site infected with Cryptococcus gattii type VGIIa in a 5-year-old LaMancha goat 9 weeks after undergoing a cesarean section (month 3). The evolution of the granulomatous inflammation is evident in comparison to 2 weeks prior (Fig. 1). Notice the presence of a strand of catgut suture (marked with an arrow) that was used during the cesarean section (day 0).
Fig. 1. Incision site infected with Cryptococcus gattii type VGIIa in a 5-year-old LaMancha goat 7 weeks after undergoing a cesarean section. Granulomatous inflammation and a vaseline-like fluid were the most notable characteristics at presentation (month 2).
Long-term treatment with oral fluconazole was established at 5 mg/Kg/day PO for 6 months (July 2010 through January 2011, month 3 through month 9). The doe also received an immunostimulant agent twice, in July (month 3) and August 2010 (month 4) (Immunoboost [Bioniche Animal Health USA, Inc., Bogart, GA], 1 ml, SQ) at the time of follow-up visits. During these visits, local reaction was noticed to the surgical material used at the debridement intervention, which was purposefully changed from that used during the cesarean section due to the initial reaction. Milk production increased gradually to approximately 50% of the normal amount in previous lactations (none of the milk was used for human consumption). After 6 months of daily antifungal treatment (January 2011, month 9), the goat appeared normal and had recovered a normal hair coat. Evaluation of a blood sample at this time indicated possible presence of chronic inflammation (serum TP¼8.9 mg/dl). For this reason, an ultrasonographic evaluation of the incision site and abdomen was performed, which revealed three deep muscular masses, resembling fibrous tissue in the same areas where the non-debrided cryptococcomas were localized. No other abnormalities were diagnosed.
Fig. 3. Incision site infected with Cryptococcus gattii type VGIIa in a 5-year-old LaMancha goat during debridement surgery (month 3). Notice the various muscular layers that have been debrided, and the presence of several round cryptococcomas along the incision line, the most evident being the one in the center of the picture (ventral).
A. Villarroel, T.R. Maggiulli / Medical Mycology Case Reports 1 (2012) 91–94
Fig. 4. Intraperitoneal cryptococcoma of Cryptococcus gattii type VGIIa organisms in a LaMancha goat 16 months post-debridement surgery (month 19). Notice the large cryptococcoma (15 cm diameter) embedded in the omentum.
Serology titers against Cryptococcus spp. were first measured at the time of initiation of treatment with fluconazole at 1:4096 and they progressively decreased over time to 1:2048 during treatment, and later increased to 1:8192 immediately after treatment (January 2011, month 9). Titers never decreased beyond 1:2048 when monitored during the following 6 months (through July 2011, month 15). 2.2. Follow up The doe remained in good condition after surgical debridement. Milk production remained at the same level and estrus cycles were regular, although conception failed despite multiple attempts. In November 2011 (month 19) the doe presented to the veterinary hospital with a complaint of acute hemoglobinuria. Abdominal ultrasound showed a round mass in the caudal abdomen that was approximately 15 cm in diameter and presumed to be at that time the uterine body filled with purulent material. Exploratory laparotomy revealed the mass was a peritoneal cryptococcoma (confirmed by cytology) not associated with the uterus, but embedded in the omentum and measured 15 cm in diameter (Fig. 4). After the cryptococcoma and adjacent omentum were surgically removed, the doe recovered well from anesthesia but general health declined over the next 2 days, at which point humane euthanasia was elected. The final diagnosis was immune-mediated hemolytic anemia with secondary renal failure. No post-mortem exam could be performed.
93
The fact that the doe had reacted to three different types of suture material used during the two surgeries (cesarean section and debridement surgery) suggests some kind of immune system aggravation. However, it should not be considered as immunodeficiency, as the immune system was fighting extraneous material. The small piece of straw found in the external oblique muscle layer, which was considered a possible culprit for the fungal infection, was likely acquired post-operatively, because the cesarean section had been performed in a veterinary hospital under sterile conditions. The animal was returned home immediately after surgery, as it is common with these types of interventions in food-animals. Therefore, it was hypothesized that the piece of straw resulted from postoperative contamination in the normal environment of the goat, and therefore had to penetrate the wound from outside of the skin. No other animals in the same premises have shown any signs consistent with cryptococcal infection. The decision for the dose and length of treatment with oral fluconazole was established based on available literature in horses, cats and dogs [9,10,14] because no reports of treatment in foodanimals could be found. Although goats are ruminants, and therefore the bioavailability of oral medications usually varies from that in monogastric animals, oral administration was considered as the only viable option in this case. Intravenous administration would have been preferred, but it proved impossible to maintain an intact catheter in place for longer than 12 h in this goat, and intravenous administration had to be performed over a period of 30 min which would have been untenable over a period of 6 months. Bioavailability of oral fluconazole could not be established. However, the positive clinical changes observed in the doe without any other treatment seemed to support the idea of its effectiveness. Possible explanations for the intraperitoneal cryptococcoma found during the exploratory laparotomy in November are (a) local dissemination of a cryptococcoma that had already penetrated the peritoneal cavity prior to surgical debridement, (b) hematogenous dissemination of one of the partially-debrided cryptococcomas during the surgery of June 2010, or (c) it could have already been present intraperitoneally at the time of the debridement surgery, but was not observed because the peritoneum was not incised during debridement. The massive size of this cryptococcoma suggests a long-term presence. The persistence of the intraperitoneal cryptococcoma despite antifungal treatment could be explained by two things. Cryptococcus gattii, especially VGII isolates, has been shown to have variable susceptibility to fluconazole [15,16]. This is not very likely in this case, as all other cryptococcomas completely disappeared during the treatment period. The most likely reason is due to the encapsulated nature of the cryptococcoma and the location in the omentum, embedded in low-perfusion tissue (Fig. 4) that may have limited the access of antifungal drugs and the immune system to the infection site. However, this encapsulation may not have prevented the massive release of cryptococcal antigen when Cryptococcus gattii is extruded out of the phagolysosomes [17], which would explain the immunemediated hemolytic anemia diagnosed in this animal.
3. Discussion To our knowledge, this is the first report of cutaneous cryptococcosis in a goat, as well as the first report of long-term survival of a goat infected with Cryptococcus gattii. Cutaneous cryptococcosis has been reported in humans [12] and cats [13] with varying results. Most patients recovered from the infection with either antifungal treatment alone or combined with surgical debridement. The goat presented in this case was treated similarly, with a combination of debridement and long-term antifungal administration.
Conflict of interest There are none.
Acknowledgments We would like to thank Dr. Erica McKenzie, Associate Professor of Internal Medicine, and the members of the clinical pathology
94
A. Villarroel, T.R. Maggiulli / Medical Mycology Case Reports 1 (2012) 91–94
section of the Veterinary Diagnostic Laboratory at Oregon State University for their insight and help during this study. References [1] Datta K, Bartlett KH, Baer R, Byrnes E, Galanis E, Heitman J, et al. Spread of Cryptococcus gattii into Pacific Northwest region of the United States. Emerging Infectious Disease 2009;15(8):1185–1191. [2] Debess E, Cieslak PR, Marsden-Haug N, Goldoft M, Wohrle R, Free C, et al. Emergence of Cryptococcus gattii—Pacific Northwest, 2004–2010. MMWR— Morbidity and Mortalility Weekly Report 2010;59(28):865–868. [3] Marr KA. Cryptococcus gattii as an important fungal pathogen of western North America. Expert Review of Anti-Infective Therapy 2012;10(6): 637–643. [4] Okamoto K, Hatakeyama S, Itoyama S, Nukui Y, Yoshino Y, Kitazawa T, et al. Cryptococcus gattii genotype VGIIa infection in man, Japan, 2007. Emerging Infectious Disease 2010;16(7):1155–1157. [5] Byrnes III EJ, Marr KA. The Outbreak of Cryptococcus gattii in Western North America: epidemiology and clinical issues. Current Infectious Disease Reports 2011;13(3):256–261. [6] Ngamskulrungroj P, Chang Y, Sionov E, Kwon-Chung KJ. The primary target organ of Cryptococcus gattii is different from that of Cryptococcus neoformans in a murine model. MBio 2012;3(3):e00103–e00112. [7] Torres-Rodriguez JM, Baro T, Morera Y, Alia C, Lopez O, Hermoso dM. Molecular characterization of Cryptococcus neoformans var. gattii causing epidemic outbreaks of cryptococcosis in goats. Caracterization molecular de Cryptococcus neoformans var. gattii causante de brotes epidemicos de criptococosis en cabras. Revista Iberoamericana Micologia 1999;16:164–165. [8] Harris JR, Lockhart SR, Debess E, Marsden-Haug N, Goldoft M, Wohrle R, et al. Cryptococcus gattii in the United States: clinical aspects of infection with an emerging pathogen. Clinical Infectious Disease 2011;53(12):1188–1195.
[9] Graves TK, Barger AM, Adams B, Krockenberger MB. Diagnosis of systemic cryptococcosis by fecal cytology in a dog. Veterinary Clinical Pathology 2005;34(4):409–412. [10] O’Brien CR, Krockenberger MB, Martin P, Wigney DI, Malik R. Long-term outcome of therapy for 59 cats and 11 dogs with cryptococcosis. Australian Veterinary Journal 2006;84(11):384–392. [11] Chapman HM, Robinson WF, Bolton JR, Robertson JP. Cryptococcus neoformans infection in goats. Australian Veterinary Journal 1990;67:263–265. [12] Marques SA, Bastazini Jr. I, Martins AL, Barreto JA, Barbieri D’Elia MP, Lastoria JC, et al. Primary cutaneous cryptococcosis in Brazil: report of 11 cases in immunocompetent and immunosuppressed patients. International Journal of Dermatology 2012;51(7):780–784. [13] Medleau L, Hall EJ, Goldschmidt MH, Irby N. Cutaneous cryptococcosis in three cats. Journal of the American Veterinary Medical Association 1985;187: 169–170. [14] Hart KA, Flaminio MJ, LeRoy BE, Williams CO, Dietrich UM, Barton MH. Successful resolution of cryptococcal meningitis and optic neuritis in an adult horse with oral fluconazole. Journal of Veterinary Internal Medicine 2008;22(6):1436–1440. [15] Varma A, Kwon-Chung KJ. Heteroresistance of Cryptococcus gattii to fluconazole. Antimicrobial Agents and Chemotherapy 2010;54(6):2303–2311. [16] Hagen F, Illnait-Zaragozi MT, Bartlett KH, Swinne D, Geertsen E, Klaassen CH, et al. In vitro antifungal susceptibilities and amplified fragment length polymorphism genotyping of a worldwide collection of 350 clinical, veterinary, and environmental Cryptococcus gattii isolates. Antimicrobial Agents and Chemotherapy 2010;54(12):5139–5145. [17] Alvarez M, Saylor C, Casadevall A. Antibody action after phagocytosis promotes Cryptococcus neoformans and Cryptococcus gattii macrophage exocytosis with biofilm-like microcolony formation. Cell Microbiol 2008;10(8): 1622–1633.
Contents lists available at SciVerse ScienceDirect
Medical Mycology Case Reports journal homepage: www.elsevier.com/locate/mmcr
Rare Cryptococus gattii infection in an immunocompetent dairy goat following a cesarean section Aurora Villarroel n, Tessa R. Maggiulli Department of Clinical Sciences, College of Veterinary Medicine, Oregon State University, 158 Magruder Hall, Corvallis, OR 97331, USA
a r t i c l e i n f o
abstract
Article history: Received 16 September 2012 Received in revised form 22 September 2012 Accepted 25 September 2012
A 5-year-old dairy goat was presented seven weeks post cesarean section for incomplete healing of the incision site. Cytology revealed cryptococcal organisms that were confirmed by the Centers for Disease Control as Cryptococcus gattii type VGIIa. Most cryptococcomas were surgically removed, but some penetrated deep in to the muscular layers and likely into peritoneum. The goat was treated daily with oral fluconazole for 6 months, and had a normal life for almost 2 years. & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved.
Keywords: Cryptococcus gatii Goat Immunocompetent Fluconazole Skin
1. Introduction Infections with Cryptococcus gattii are on the rise in humans and domestic animal species in the western United States [1–3], even among immunocompetent hosts [4,5]. Cryptococcus gattii has been associated mainly to pneumonic involvement [6,7], in contrast with the central nervous infections mainly attributable to Cryptococcus neoformans [5,6]. Cryptococcal infections can successfully be treated with long-term antifungals in humans [4,8] and non-food-producing animals [9,10], however, foodproducing animals such as goats have inherent limitations in therapeutic drugs due to their potential for residues in meat and milk. Most reported cases of cryptococcal infections in goats have proven fatal and were diagnosed on necropsy [7,11]. This case is the first documented case of transabdominal infection and longterm survival of an immunocompetent goat that was infected with Cryptococcus gattii. It was diagnosed in the Northwest part of the United States, and could possibly be related to the current outbreak in this area, although it has no known association with any other positive individuals [1,2].
2. Case A 5-year-old LaMancha doe was presented in June 2010 for a chronic infection in the incision site of a cesarean section (Fig. 1) that had been performed 9 weeks prior, on April 24, 2010 (day 0), and n
Corresponding author. Tel.: þ1 541 737 5853; fax: þ1 541 737 6879. E-mail address: [email protected] (A. Villarroel).
during which a live single male kid was delivered. In spite of daily cleaning and systemic treatment with oxytetracycline for 4 weeks (20 mg/Kg, subcutaneous [SQ], once every 5 days), the infection progressed rapidly, presenting as the main characteristics a massive granulomatous inflammation and draining of a vaseline-like fluid (Fig. 1). Local reaction could be observed to two different types of suture material used during the cesarean section. The doe had a rough and sebaceous coat, but appeared well and was behaving otherwise normally. Cytological evaluation of the draining material revealed cryptococcal organisms with granulomatous inflammation. The State Veterinary Laboratory diagnosed the organism as Cryptococcus gattii, and the Centers for Disease Control typed it as Cryptococcus gattii type VGIIa. 2.1. Treatment After confirmation of the diagnosis (July 2010, month 3), and given the progressive extension of the infection (Fig. 2), surgery was elected to remove as much as possible of the infected tissues. The extensive mycoses involved the left flank subcutis, all muscular layers and likely penetrated into the peritoneum, although this could not be confirmed at the time because the peritoneum was not incised to prevent further dissemination of the organism into the peritoneal cavity. All but four of the visible cryptococcomas were debrided, because they were attached to the peritoneum (Fig. 3). Special care was placed in identifying any possible cause for this infection at the surgical site. A small (1 2 mm) piece of straw was found in the external oblique muscle layer, which was considered a possible culprit for the fungal infection, but it could not be confirmed.
2211-7539/$ - see front matter & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.mmcr.2012.09.005
92
A. Villarroel, T.R. Maggiulli / Medical Mycology Case Reports 1 (2012) 91–94
Fig. 2. Incision site infected with Cryptococcus gattii type VGIIa in a 5-year-old LaMancha goat 9 weeks after undergoing a cesarean section (month 3). The evolution of the granulomatous inflammation is evident in comparison to 2 weeks prior (Fig. 1). Notice the presence of a strand of catgut suture (marked with an arrow) that was used during the cesarean section (day 0).
Fig. 1. Incision site infected with Cryptococcus gattii type VGIIa in a 5-year-old LaMancha goat 7 weeks after undergoing a cesarean section. Granulomatous inflammation and a vaseline-like fluid were the most notable characteristics at presentation (month 2).
Long-term treatment with oral fluconazole was established at 5 mg/Kg/day PO for 6 months (July 2010 through January 2011, month 3 through month 9). The doe also received an immunostimulant agent twice, in July (month 3) and August 2010 (month 4) (Immunoboost [Bioniche Animal Health USA, Inc., Bogart, GA], 1 ml, SQ) at the time of follow-up visits. During these visits, local reaction was noticed to the surgical material used at the debridement intervention, which was purposefully changed from that used during the cesarean section due to the initial reaction. Milk production increased gradually to approximately 50% of the normal amount in previous lactations (none of the milk was used for human consumption). After 6 months of daily antifungal treatment (January 2011, month 9), the goat appeared normal and had recovered a normal hair coat. Evaluation of a blood sample at this time indicated possible presence of chronic inflammation (serum TP¼8.9 mg/dl). For this reason, an ultrasonographic evaluation of the incision site and abdomen was performed, which revealed three deep muscular masses, resembling fibrous tissue in the same areas where the non-debrided cryptococcomas were localized. No other abnormalities were diagnosed.
Fig. 3. Incision site infected with Cryptococcus gattii type VGIIa in a 5-year-old LaMancha goat during debridement surgery (month 3). Notice the various muscular layers that have been debrided, and the presence of several round cryptococcomas along the incision line, the most evident being the one in the center of the picture (ventral).
A. Villarroel, T.R. Maggiulli / Medical Mycology Case Reports 1 (2012) 91–94
Fig. 4. Intraperitoneal cryptococcoma of Cryptococcus gattii type VGIIa organisms in a LaMancha goat 16 months post-debridement surgery (month 19). Notice the large cryptococcoma (15 cm diameter) embedded in the omentum.
Serology titers against Cryptococcus spp. were first measured at the time of initiation of treatment with fluconazole at 1:4096 and they progressively decreased over time to 1:2048 during treatment, and later increased to 1:8192 immediately after treatment (January 2011, month 9). Titers never decreased beyond 1:2048 when monitored during the following 6 months (through July 2011, month 15). 2.2. Follow up The doe remained in good condition after surgical debridement. Milk production remained at the same level and estrus cycles were regular, although conception failed despite multiple attempts. In November 2011 (month 19) the doe presented to the veterinary hospital with a complaint of acute hemoglobinuria. Abdominal ultrasound showed a round mass in the caudal abdomen that was approximately 15 cm in diameter and presumed to be at that time the uterine body filled with purulent material. Exploratory laparotomy revealed the mass was a peritoneal cryptococcoma (confirmed by cytology) not associated with the uterus, but embedded in the omentum and measured 15 cm in diameter (Fig. 4). After the cryptococcoma and adjacent omentum were surgically removed, the doe recovered well from anesthesia but general health declined over the next 2 days, at which point humane euthanasia was elected. The final diagnosis was immune-mediated hemolytic anemia with secondary renal failure. No post-mortem exam could be performed.
93
The fact that the doe had reacted to three different types of suture material used during the two surgeries (cesarean section and debridement surgery) suggests some kind of immune system aggravation. However, it should not be considered as immunodeficiency, as the immune system was fighting extraneous material. The small piece of straw found in the external oblique muscle layer, which was considered a possible culprit for the fungal infection, was likely acquired post-operatively, because the cesarean section had been performed in a veterinary hospital under sterile conditions. The animal was returned home immediately after surgery, as it is common with these types of interventions in food-animals. Therefore, it was hypothesized that the piece of straw resulted from postoperative contamination in the normal environment of the goat, and therefore had to penetrate the wound from outside of the skin. No other animals in the same premises have shown any signs consistent with cryptococcal infection. The decision for the dose and length of treatment with oral fluconazole was established based on available literature in horses, cats and dogs [9,10,14] because no reports of treatment in foodanimals could be found. Although goats are ruminants, and therefore the bioavailability of oral medications usually varies from that in monogastric animals, oral administration was considered as the only viable option in this case. Intravenous administration would have been preferred, but it proved impossible to maintain an intact catheter in place for longer than 12 h in this goat, and intravenous administration had to be performed over a period of 30 min which would have been untenable over a period of 6 months. Bioavailability of oral fluconazole could not be established. However, the positive clinical changes observed in the doe without any other treatment seemed to support the idea of its effectiveness. Possible explanations for the intraperitoneal cryptococcoma found during the exploratory laparotomy in November are (a) local dissemination of a cryptococcoma that had already penetrated the peritoneal cavity prior to surgical debridement, (b) hematogenous dissemination of one of the partially-debrided cryptococcomas during the surgery of June 2010, or (c) it could have already been present intraperitoneally at the time of the debridement surgery, but was not observed because the peritoneum was not incised during debridement. The massive size of this cryptococcoma suggests a long-term presence. The persistence of the intraperitoneal cryptococcoma despite antifungal treatment could be explained by two things. Cryptococcus gattii, especially VGII isolates, has been shown to have variable susceptibility to fluconazole [15,16]. This is not very likely in this case, as all other cryptococcomas completely disappeared during the treatment period. The most likely reason is due to the encapsulated nature of the cryptococcoma and the location in the omentum, embedded in low-perfusion tissue (Fig. 4) that may have limited the access of antifungal drugs and the immune system to the infection site. However, this encapsulation may not have prevented the massive release of cryptococcal antigen when Cryptococcus gattii is extruded out of the phagolysosomes [17], which would explain the immunemediated hemolytic anemia diagnosed in this animal.
3. Discussion To our knowledge, this is the first report of cutaneous cryptococcosis in a goat, as well as the first report of long-term survival of a goat infected with Cryptococcus gattii. Cutaneous cryptococcosis has been reported in humans [12] and cats [13] with varying results. Most patients recovered from the infection with either antifungal treatment alone or combined with surgical debridement. The goat presented in this case was treated similarly, with a combination of debridement and long-term antifungal administration.
Conflict of interest There are none.
Acknowledgments We would like to thank Dr. Erica McKenzie, Associate Professor of Internal Medicine, and the members of the clinical pathology
94
A. Villarroel, T.R. Maggiulli / Medical Mycology Case Reports 1 (2012) 91–94
section of the Veterinary Diagnostic Laboratory at Oregon State University for their insight and help during this study. References [1] Datta K, Bartlett KH, Baer R, Byrnes E, Galanis E, Heitman J, et al. Spread of Cryptococcus gattii into Pacific Northwest region of the United States. Emerging Infectious Disease 2009;15(8):1185–1191. [2] Debess E, Cieslak PR, Marsden-Haug N, Goldoft M, Wohrle R, Free C, et al. Emergence of Cryptococcus gattii—Pacific Northwest, 2004–2010. MMWR— Morbidity and Mortalility Weekly Report 2010;59(28):865–868. [3] Marr KA. Cryptococcus gattii as an important fungal pathogen of western North America. Expert Review of Anti-Infective Therapy 2012;10(6): 637–643. [4] Okamoto K, Hatakeyama S, Itoyama S, Nukui Y, Yoshino Y, Kitazawa T, et al. Cryptococcus gattii genotype VGIIa infection in man, Japan, 2007. Emerging Infectious Disease 2010;16(7):1155–1157. [5] Byrnes III EJ, Marr KA. The Outbreak of Cryptococcus gattii in Western North America: epidemiology and clinical issues. Current Infectious Disease Reports 2011;13(3):256–261. [6] Ngamskulrungroj P, Chang Y, Sionov E, Kwon-Chung KJ. The primary target organ of Cryptococcus gattii is different from that of Cryptococcus neoformans in a murine model. MBio 2012;3(3):e00103–e00112. [7] Torres-Rodriguez JM, Baro T, Morera Y, Alia C, Lopez O, Hermoso dM. Molecular characterization of Cryptococcus neoformans var. gattii causing epidemic outbreaks of cryptococcosis in goats. Caracterization molecular de Cryptococcus neoformans var. gattii causante de brotes epidemicos de criptococosis en cabras. Revista Iberoamericana Micologia 1999;16:164–165. [8] Harris JR, Lockhart SR, Debess E, Marsden-Haug N, Goldoft M, Wohrle R, et al. Cryptococcus gattii in the United States: clinical aspects of infection with an emerging pathogen. Clinical Infectious Disease 2011;53(12):1188–1195.
[9] Graves TK, Barger AM, Adams B, Krockenberger MB. Diagnosis of systemic cryptococcosis by fecal cytology in a dog. Veterinary Clinical Pathology 2005;34(4):409–412. [10] O’Brien CR, Krockenberger MB, Martin P, Wigney DI, Malik R. Long-term outcome of therapy for 59 cats and 11 dogs with cryptococcosis. Australian Veterinary Journal 2006;84(11):384–392. [11] Chapman HM, Robinson WF, Bolton JR, Robertson JP. Cryptococcus neoformans infection in goats. Australian Veterinary Journal 1990;67:263–265. [12] Marques SA, Bastazini Jr. I, Martins AL, Barreto JA, Barbieri D’Elia MP, Lastoria JC, et al. Primary cutaneous cryptococcosis in Brazil: report of 11 cases in immunocompetent and immunosuppressed patients. International Journal of Dermatology 2012;51(7):780–784. [13] Medleau L, Hall EJ, Goldschmidt MH, Irby N. Cutaneous cryptococcosis in three cats. Journal of the American Veterinary Medical Association 1985;187: 169–170. [14] Hart KA, Flaminio MJ, LeRoy BE, Williams CO, Dietrich UM, Barton MH. Successful resolution of cryptococcal meningitis and optic neuritis in an adult horse with oral fluconazole. Journal of Veterinary Internal Medicine 2008;22(6):1436–1440. [15] Varma A, Kwon-Chung KJ. Heteroresistance of Cryptococcus gattii to fluconazole. Antimicrobial Agents and Chemotherapy 2010;54(6):2303–2311. [16] Hagen F, Illnait-Zaragozi MT, Bartlett KH, Swinne D, Geertsen E, Klaassen CH, et al. In vitro antifungal susceptibilities and amplified fragment length polymorphism genotyping of a worldwide collection of 350 clinical, veterinary, and environmental Cryptococcus gattii isolates. Antimicrobial Agents and Chemotherapy 2010;54(12):5139–5145. [17] Alvarez M, Saylor C, Casadevall A. Antibody action after phagocytosis promotes Cryptococcus neoformans and Cryptococcus gattii macrophage exocytosis with biofilm-like microcolony formation. Cell Microbiol 2008;10(8): 1622–1633.
