Cryptococcosis due to Cryptococcus gattii in Germany from 2004–2013

The fungal pathogen Cryptococcus gattii was considered to be restricted to tropic and sub- tropic regions. A recent outbreak in North America due to isolates belonging to molecular type VG II, affecting mostly non-immunocompromised hosts, documented the potential public health impact of this fungal pathogen also in temperate regions. Surveillance of these infections in Germany is challenging, as cryptococcosis is not notifiable and often C. gattii is diagnostically not distinguished from the more prevalent Cryptococcus neoformans. We used hospital discharge data and identified cryptococcal isolates received by the German cryptococcosis reference laboratory at the species level to gain insights into the epidemiology of C. gattii-infections in Germany between 2004 and 2013. Between 49 and 60 (Median 57) hospitalizations for cryptococcosis are documented per year. Between 5 and 28 (Median 14) isolates were received at the reference laboratory per year. Among 155 single patient isolates, four C. gattii (3%) of the molecular types VGI and VG III were identified from patients with meningoencephalitis, including one interspecies hybrid. Patient histories and molecular typing suggest that half of the infections were acquired abroad. Only one patient survived the infection. C. gattii remains rarely identified as agent of cryptococcosis in Germany but underestimation is likely. Definition of environmental niches occupied by C. gattii in Germany may help to assess the associated risk of infection and prevent this deadly fungal infection.