Feline cryptococcosis. Impact of current research on clinical management

Disease summary: Cryptococcosis, principally caused by Cryptococcus neoformans and Cryptococcus gattii, is the most common systemic mycosis of cats worldwide. Cats may be infected following inhalation of spores from the environment, with the nasal cavity suspected as being the initial site of colonization and subsequent infection. Other sites of infection in cats are the skin, lungs, lymph nodes, central nervous system (CNS), eyes and, occasionally, periarticular connective tissue. Cryptococcosis can be diagnosed using serology (antigen testing), cytologic examination of smears, histopathology or culture. Treatment of localized disease is generally successful using azole antifungal drugs; however, cats with CNS involvement or disseminated disease require additional treatment with amphotericin B, with or without flucytosine. The prognosis is variable, depending on host and pathogen factors. Some cats require long-term (>1 year) treatment or indefinite therapy. Patient group: Cats of any breed, gender and age may be affected. Retroviral status does not appear to be a risk factor for developing cryptococcosis and indoor cats are not protected from disease. Global importance: Feline cryptococcosis occurs worldwide, but is most frequently reported in Australia, western Canada and the western United States. Species and molecular type vary in different geographical regions and may affect clinical presentation and antifungal susceptibility patterns. Clinical challenges: Serologic tests that detect cryptococcal antigen in serum are sensitive and specific, but false negatives can occur in cats with localized disease. Long-term drug therapy can be expensive and has the potential for toxicity. The extent to which the pathogenicity and antifungal susceptibility is affected by molecular type is currently under study. Evidence base: This review draws on recent literature relating to epidemiology, CNS involvement and advanced diagnostic imaging to update clinicians regarding research findings relevant to clinical practice.