A Case of “Cryptammonia”: Disseminated Cryptococcal Infection Generating Profound Hyperammonemia in a Liver Transplant Recipient

Phillips, Steven M; Pouch, Stephanie M.; Lo, Denise J.; Kandiah, Sheetal; Lomashvili, Koba A.; Subramanian, Ram; Moran, Paul; Killian, Alley; Kandiah, Prem

doi:10.1177/23247096221129467

Cited by 1 publication

(2 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The association between hyperammonemia and cryptococcal infections raises important considerations. Elevated ammonia levels could accelerate the clinical deterioration of patients, exacerbating neurological symptoms and potentially contributing to the poor outcomes observed in severe cases ( 1 – 3 ).…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Host and fungal factors both contribute to cryptococcosis-associated hyperammonemia (cryptammonia)

Baker,

Schachter,

Phillips

et al. 2024

Microbiol Spectr

Self Cite

View full text Add to dashboard Cite

Cryptococcus neoformans and Cryptococcus gattii are both known urease producers and have the potential to cause hyperammonemia. We hypothesized that the risk of hyperammonemia is increased by renal failure, burden of cryptococcal infection, and fungal strain characteristics. We performed a retrospective review of plasma ammonia levels in patients with cryptococcal infections. Risk factors for hyperammonemia were statistically compared between patients with and without hyperammonemia (>53 µmol/L). Cryptococcal cells from three patients included in the study were recovered from our biorepository. Strain characteristics including urease activity, ammonia production, growth curves, microscopy, melanin production, and M13 molecular typing were analyzed and compared with a wild-type (WT) C. neoformans strain. We included 29 patients, of whom 37.9% had hyperammonemia, 59% had disseminated cryptococcal infection (DCI), and 41% had isolated central nervous system infection. Thirty-eight percent of patients had renal failure and 28% had liver disease. Renal failure was associated with 4.4 times (95% confidence interval [CI] 1.5, 13.0) higher risk of hyperammonemia. This risk was higher in DCIs (RR 6.2, 95% CI 1.0, 40.2) versus isolated cryptococcal meningitis (RR 2.5, 95% CI, 0.40, 16.0). Liver disease and cryptococcal titers were not associated with hyperammonemia. C. neoformans from one patient with extreme hyperammonemia demonstrated a 4- to 5-fold increase in extracellular urease activity, slow growth, enlarged cell size phenotypes, and diminished virulence factors. Hyperammonemia was strongly associated with renal failure in individuals with DCI, surpassing associations with liver failure or cryptococcal titers. However, profound hyperammonemia in one patient was attributable to high levels of urease secretion unique to that cryptococcal strain. Prospective studies are crucial to exploring the significance of this association. IMPORTANCE Cryptococcus produces and secretes the urease enzyme to facilitate its colonization of the host. Urease breaks down urea into ammonia, overwhelming the liver’s detoxification process and leading to hyperammonemia in some hosts. This underrecognized complication exacerbates organ dysfunction alongside the infection. Our study investigated this intricate relationship, uncovering a strong association between the development of hyperammonemia and renal failure in patients with cryptococcal infections, particularly those with disseminated infections. We also explore mechanisms underlying increased urease activity, specifically in strains associated with extreme hyperammonemia. Our discoveries provide a foundation for advancing research into cryptococcal metabolism and identifying therapeutic targets to enhance patient outcomes.

show abstract

Section: Discussionmentioning

confidence: 99%

“…We recently reported a case of profound and clinically significant cryptococcosis-associated hyperammonemia and found two other cases reported in the medical literature ( 1 – 3 ). All three cases were accompanied with renal failure and a disseminated infection.…”

Section: Introductionmentioning

confidence: 89%