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

• Type of Material: Article
• Authors: Rosanna P. Baker, Johns Hopkins School of Public Health; Maria Schachter, Emory University; Steven Phillips, University of Nebraska; Sheetal Kandiah, Emory University; Mirza Farrque, Emory University; Arturo Casadevall, Johns Hopkins School of Public Health; Prem A. Kandiah, Emory University
• Language: English
• Date: 2024-07
• Publisher: American Society for Microbiology
• Publication Version: Final Published Version
• Copyright Statement: © 2024 Baker et al.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): https://doi.org/10.1128%2Fspectrum.03902-23
• Title of Journal or Parent Work: Microbiology Spectrum
• Volume: 12
• Issue: 7
• Start Page: e03902-23
• Keywords: urease; acetohydroxamic acid; Cryptococcus; hyperammonemia; cryptammonia; mycology; ammonia; Cryptococcus neoformans
• Research Categories: Health Sciences, Pathology; Biology, Microbiology

Abstract

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.