MICROBIOLOGY

September 17 to October 14, 2018

“Invasion of Encapsulated Yeast to the Central Nervous System of 28-yeal-old

Male”

A Case study presented to the faculty of

Medical Laboratory Science
In partial fulfilment of the Internship Training for the
Degree of Bachelor in Medical Laboratory Science

Presented by: Romie Bren G. Solacito, Dominique Ranz D. Saragoza, Apple Jade B.
Parba, Chryzelle Joy C. Soguilon, Denzel Paolo M. Villanueva, and Abdul Ameer A.
Marzan

Clinical Instructor: Jason T. Chua, RMT

Anna-Lee B. Bandoy, RMT, MSMT
I. Title - Invasion of Encapsulated Yeast to the Central Nervous System of 28-
yeal-old Male

II. Author
Romie Bren G. Solacito
Medical Technology Intern
University of the Immaculate Conception
Davao City
September 2018

Dominique Ranz D. Saragoza

Medical Technology Intern
University of the Immaculate Conception
Davao City
September 2018

Apple Jade B. Parba

Medical Technology Intern
University of the Immaculate Conception
Davao City
September 2018

Chryzelle Joy C. Soguilon

Medical Technology Intern
University of the Immaculate Conception
Davao City
September 2018

Denzel Paolo M. Villanueva

Medical Technology Intern
University of the Immaculate Conception
 Davao City
Spetember 2018

Abdul Ameer A. Marzan

Medical Technology Intern
University of the Immaculate Conception
Davao City
September 2018

Maria Rhygie Ballara

Medical Technology Intern
University of the Immaculate Conception
Davao City
September 2018

III. Definition of Terms

Meningitis – inflammation of meninges
Fungal Meningitis – inflammation of meninges caused by fungi
Cryptococcal Meningitis – inflammation of meninges caused by Cryptococcus
species
Hypokalemia – deficiency of potassium in the bloodstream

IV. Clinical History

Patient: Patient X/28/Male/Davao City
Health History: Fluctuating Potassium Level
Chief Complaint: worsening headache, cough, fever, body malaise, light
sensitive and stiff neck
 V. Physical Examination
Physical Examination
Temperature 39 degrees Celsius Increased
Pulse Rate 115 beats per minute Increased
Blood Pressure 140/90 Increased

VI. Laboratory Findings

CHEMISTRY REPORT – July 19, 2018
Sodium 137.77mmol/L 136.0 – 144.0mmol/L
Potassium 3.92mmol/L 3.6 – 5.1mmol/L
CHEMISTRY REPORT – July 25, 2018 (Specimen - CSF)
Protein 156.04mg/dL 15.0 – 45.0mg/dL
Glucose 2.9mmol/L 2.30 – 4.10mmol/L
CLINICAL MICROSCOPY REPORT – July 25, 2018 (Specimen - CSF)
Gross Examination
- Volume 0.70mL
- Color Colorless
- Clarity Clear
Microscopic Examination
- Cell Count 22.00/uL
Differential Cell Count
- Predominant Cells Lymphocytes
- Red Blood Cells 86/uL
MICROBIOLOGY REPORT – July 26, 2018 (CSF)
Direct Gram Stain No Organism Found
Acid-Fast Bacilli No Acid-Fast Bacilli Found
KOH No Fungus Found
MacConkey No Growth for 24-Hours of Incubation
Sheep Blood Agar No Growth for 24-Hours of Incubation
Chocolate Agar No Growth for 24-Hours of Incubation
Thioglycolate Broth Clear
MICROBIOLOGY REPORT – July 27, 2018 (CSF)
MacConkey No Growth for 48-Hours of Incubation
Sheep Blood Agar No Growth for 48-Hours of Incubation
Chocolate Agar No Growth for 48-Hours of Incubation
HEMATOLOGY REPORT – July 27, 2018
Hemoglobin 112.0g/L 135 – 175g/L
Hematocrit 0.31 0.4 – 0.52
RBC Count 3.38x106/uL 4.2 – 6.1
WBC Count 3.73x103/uL 5.0 - 10.0
- Neutrophil 67% 55 – 75
- Lymphocytes 19% 20 – 35
- Monocytes 10% 2 – 10
- Eosinophils 4% 1–8
- Basophils 0% 0–1
Platelet Count 3
352x10 /uL 150.0 – 400.0
MCH 33.1pg 25.7 – 32.2pg
MCHC 35.7g/dL 32.3 – 36.5g/dL
MCV 92.9fL 79.0 – 92.2fL
CHEMISTRY REPORT – July 27, 2018
Creatinine 58.46umol/L 57-113
Calcium 2.24mmol/L 2.23 – 2.58mmol/L
Potassium 3.23mmol/L 3.6-5.1mmol/L
Magnesium 0.96mmol/L 0.74 – 1.03mmol/L
Sodium 136.07mmol/L 136.00-144.00mmol/L
MCV 93.4fL 79.0 – 92.2fL
MICROBIOLOGY REPORT – July 28, 2018 (CSF)
MacConkey No Growth for 72-Hours of Incubation
Sheep Blood Agar No Growth for 72-Hours of Incubation
Chocolate Agar White Colonies
- Gram Stain Starburst Patter
- Germ Tube Candida Non-albicans
- India Ink Encapsulated Yeast
HEMATOLOGY REPORT – July 28, 2018
Hemoglobin 107.0g/L 135 – 175g/L
Hematocrit 0.31 0.4 – 0.52
RBC Count 6
3.31x10 /uL 4.2 – 6.1
WBC Count 3
4.42x10 /uL 5.0 - 10.0
- Neutrophil 73% 55 – 75
- Lymphocytes 17% 20 – 35
- Monocytes 10% 2 – 10
- Eosinophils 0% 1–8
- Basophils 0% 0–1
Platelet Count 3
396x10 /uL 150.0 – 400.0
MCH 32.3pg 25.7 – 32.2pg
MCHC 34.6g/dL 32.3 – 36.5g/dL
MCV 93.4fL 79.00 – 92.20fL
 MICROBIOLOGY REPORT – July 29, 2018 (CSF)
Sabouraud Dextrose Agar Mucoid Colonies
ViTEK 2 System
- Identification Cryptococcus neoformans
- Sensitivity Test Sensitive – Amphotericin B

VII. Discussion

The patient exhibited broad signs and symptoms of disease. The physician
requested different laboratory test for diagnosis, which was composed of Hematology,
Chemistry, Immunology Test and mark as normal except for the abnormally low
potassium and anemic blood picture. Cerebrospinal Fluid was obtained for the test for
Clinical Microscopy, Chemistry and Microbiology Test.
Clinical Microscopy
suggested that the patient was
having an abnormal value of
lymphocytes present in his/her
Cerebrospinal Fluid. Chemistry
result shows that’s the patient’s
protein is above than its normal
range which is suggestive for
meningitis.
Colonies of Cryptococcus neoformans usually
appear mucoid when first isolated in Saboraud Microbiology report was
dextrose agar (Courtesy to McPherson et. al.).
composed of Gram Satin which was
reported as No Organism Found, KOH was reported as No Fungus Found, and Acid-Fast
Bacilli reported as “No AFB Found”. Culture and Sensitivity uses MacConkey Agar, Sheep
Blood Agar, Chocolate Agar and Tryptic Soy Broth as primary plate. After 24-hours of
incubation at 37 degrees Celsius the
primary plate used was reported as
“No Growth” and suggested for
reincubation. After 24-hours of
reincubation the plates were again
reported for “No Growth”. Another
24-hours had past, MacConkey
reported as “No Growth” while
Sheep Blood Agar and Chocolate Cryptococcus neoformans. India ink preparation
demonstrating the large capsule surrounding
Agar showed mucoid colonies that
budding yeast cells (Courtesy to Murray et. al)
been suggested for work up. The
Gram Stained colony from Chocolate Agar showed the presence of starburst pattern,
India Ink was performed with the presence of large capsule surrounding budding yeast
cells under microscope and this suggested for re-isolation on Sabouraud Dextrose Agar
and performed Germ Tube. After another 24-hours of incubation Germ Tube resulted as
Candida Non-albicans and the pure culture obtained from Sabouraud Dextrose Agar was
ready for ViTEK 2 System microorganism identification and sensitivity testing. The ViTEK
2 System confirmed that the patient was infected with Cryptococcus neoformans and this
organism showed susceptible to Amphotericin B.
Based on other Laboratory Reports present other than Microbiology Report, the
patient manifested abnormal
physiologic response to the infection.
In his Chemistry Report,
Cerebrospinal Fluid – Protein level
was at in above normal state and
Glucose level was at in normal state.
According to Strasinger and Di
Lorenzo (2014) elevated Protein
levels was due to the conditions such
Gram stain of Cryptococcus neoformans showing as meningitis and hemorrhage that
starburst pattern (Courtesy to Strasinger and Di
Lorenzo) damage the blood-brain barrier
causing leakage of plasma proteins to the central nervous system, and normal to
decreased glucose level is also suggestive for Fungal Meningitis. Clinical Microscopy
Report also reported as significant due to the presence of Lymphocytes.
After the diagnosis of the physician to the patient of having Cryptococcal
Meningitis, the physician requested for Chemistry Test – Potassium. Potassium should
be tested before the administration of Amphotericin B as medication because of the side
effect of this medication that can lead to lethal hypokalemia. In the patient’s case,
potassium level was fluctuating that reveals for difficulty in treating fungal meningitis.
According to Abassi, et al. (2015) using Amphotericin B as medication can develop life-
threatening hypokalemia within five days of administration.
According to Fauci, et al. (2015) daily administration of Amphotericin B plus
flucytosine in a span of six to ten weeks can be used as treatment for Cryptococcal
Meningitis without a concomitant immunosuppressive condition. In long duration of
treatment this drug can develop alteration in potassium levels in circulation and by that
the patient should take medication that can also balance his/her potassium level and
fungal meningitis.
The patient was infected by accidentally inhalation of the microorganism. The host
should be immunocompromised
so that the disease occurs but in
case of the patient, the
microorganism itself develop
weakness to the immune system
of the host. According to Fauci, et
al (2015) pathogen expression of
its virulence factor of
polysaccharide capsule can
produce enzymes that can give
survival. The capsule is an
antiphagocytic virulence that can
Natural history of saprobic and parasitic cycle of develop deleterious effect to host
Cryptococcus neoformans. (Courtesy to Murray et al.)
tissue.
 In conclusion, the immunocompetent host was infected by Cryptococcus
neoformans by entering the lungs. In long duration of time of infection, the microorganism
itself develop antiphagocytic effect to the host that leads to weaken the immune system.
The fungus undergoes extrapulmonary dissemination, passed to the blood-brain barrier
by fungal-cell migration across the endothelium and enters the central nervous system.
Clinical manifestation such as worsening fever, headache, lethargy, sensory deficits, and
dementia occur when the fungus reaches the central nervous system and cause disease.
Vaccine for cryptococcosis is not available but infected patient can be treated by
Amphotericin B, an antifungal medicine. The best prognosis is to predispose the
underlying immunologic deficits that can worsen the infection.

VIII. References
Abassi, M. (2015). Cryptococcal Meningitis: Diagnosis and Management Update.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535722/

Fauci, A. S., Hauser, S. L., Jameson, J. L., Kasper, D. L., Longo, D. L., Loscalzo, J.
(2015). Harrison’s Principles Internal Medicine (19th ed.). Mc-Draw Hill Education.

Mahon, M. R., Lehman, D. C., & Manuselis, G. (2015). Textbook of Diagnostic

Microbiology (5th ed.). Maryland Heights, MO: Saunders Elsevier.

Murray, P. R., Rosenthal, K. S., & Pfaller, M. A. (2016). Medical Microbiology (8th ed.).
Philadelphia, PA: Mosby/Elsevier.

McPherson, R.A., Pincus, M. R. (2017). Henry’s Clinical Diagnosis and Management by

Laboratory Methods (23rd ed.). Maryland Heights, MO: Saunders Elsevier.