12 Sep 2013: (2013) Correction: Cryptococcus gattii in the United States: Genotypic Diversity of Human and Veterinary Isolates. PLoS ONE 8(9): 10.1371/annotation/c7250cbd-4c85-423a-8b09-da596a72f830. doi: 10.1371/annotation/c7250cbd-4c85-423a-8b09-da596a72f830 | View correction
Cryptococcus gattii infections are being reported in the United States (US) with increasing frequency. Initially, US reports were primarily associated with an ongoing C. gattii outbreak in the Pacific Northwest (PNW) states of Washington and Oregon, starting in 2004. However, reports of C. gattii infections in patients from other US states have been increasing since 2009. Whether this is due to increasing frequency of disease, greater recognition within the clinical community, or both is currently unknown.
During 2005–2013, a total of 273 C. gattii isolates from human and veterinary sources in 16 US states were collected. Of these, 214 (78%) were from the Pacific Northwest (PNW) and comprised primarily the clonal C. gattii genotypes VGIIa (64%), VGIIc (21%) and VGIIb (9%). The 59 isolates from outside the PNW were predominantly molecular types VGIII (44%) and VGI (41%). Genotyping using multilocus sequence typing revealed small clusters, including a cluster of VGI isolates from the southeastern US, and an unrelated cluster of VGI isolates and a large cluster of VGIII isolates from California. Most of the isolates were mating type MATα, including all of the VGII isolates, but one VGI and three VGIII isolates were mating type MATa.
We provide the most comprehensive report to date of genotypic diversity of US C. gattii isolates both inside and outside of the PNW. C. gattii may have multiple endemic regions in the US, including a previously-unrecognized endemic region in the southeast. Regional clusters exist both in California and the Southeastern US. VGII strains associated with the PNW outbreak do not appear to have spread substantially beyond the PNW.
Citation: Lockhart SR, Iqbal N, Harris JR, Grossman NT, DeBess E, et al. (2013) Cryptococcus gattii in the United States: Genotypic Diversity of Human and Veterinary Isolates. PLoS ONE 8(9): e74737. doi:10.1371/journal.pone.0074737
Editor: Dee A. Carter, University of Sydney, Australia
Received: June 26, 2013; Accepted: August 6, 2013; Published: September 3, 2013
This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Funding: The authors have no support or funding to report.
Competing interests: The authors have declared that no competing interests exist.
Cryptococcosis is primarily caused by two species, Cryptococcus neoformans and C. gattii. Cryptococcus neoformans is found worldwide and infects both healthy and immunocompromised patients, although in the HIV era it is nearly always identified as a pathogen in immunocompromised hosts [1–3]. Cryptococcus gattii has a more limited global distribution and, though previously associated with immunocompetent hosts, can cause infection in immunocompromised hosts as well [1,2,4–7]. Cryptococcus gattii was once thought to be exclusive to tropical and sub-tropical climates, but infections have recently been identified in temperate climates [8–12]. There are four recognized molecular types of C. gattii: VGI, VGII, VGIII and VGIV [13,14]. The global distribution of these genotypes is not uniform: VGII and VGIII infections are the most-frequently identified isolates in the Americas, VGIV infections occur almost exclusively in Africa, and VGI predominates in Europe, Australia and Asia [5,9,11,15–21].
Cryptococcus gattii infections have been long recognized as present, but infrequent, in the US [22–26]. By the early 2000s, although sporadic cases had been recorded from a few US states, the only endemic areas in North America were thought to be Southern California and Mexico [7,22–25]. Beginning in 1999, a large number of C. gattii infections were identified during a short period of time in animals and humans living on temperate Vancouver Island and mainland British Columbia [9,27–30]. Infections were soon identified in the Pacific Northwest (PNW) US as well [31–37]. US cases outside the PNW, especially in California, have been noted in the past [23,26,38–42], but increased awareness of C. gattii infections associated with the PNW outbreak may have increased awareness of and surveillance for cases from other US states [4,43–48]. Here we report the distribution and genotypic variability of 273 human and veterinary isolates of C. gattii collected in the United States between January 2005 and January 2013, both inside and outside the PNW region.
Material and Methods
Isolates were submitted to the Centers for Disease Control and Prevention (CDC) through passive surveillance by state public health departments of Oregon and Washington (the disease is reportable in both states), through passive surveillance in other US states, and through requests on various clinical microbiology listserv groups to submit isolates to the CDC Fungus Reference Laboratory. Isolates were confirmed as C. gattii by melanin production on DOPA media and by the production of a blue color following growth on Canavanine-Glycine-Bromthymol blue media . All isolates were assigned a unique identifier and stored at -80°C.
Multilocus sequence typing
Isolates were subtyped using multilocus sequence typing (MLST). The URA5, IGS1, CAP59, LAC1, GPD1, PLB1, and SOD1 gene fragments were amplified as described  for all isolates. Allele numbers and sequence types (ST) were determined using the online C. gattii MLST database (http://mlst.mycologylab.org/DefaultInfo.aspx?Page=Cgattii). All new alleles were submitted to the ISHAM MLST database for inclusion and are currently available as part of the database.
All seven MLST alleles for each isolate were concatenated and aligned using the ClustalW function in BioEdit 7.0.0 . Phylogenic analysis was performed using the Mega 4.1 software package . Dendrograms were constructed by using Neighbor-Joining method using the default parameters in the Mega software.
Mating type determination
Mating type was determined for each isolate by amplification of the MFa and MFα pheromones, as described previously . Mating assays were performed on V8 agar as previously described  using wild-type strains described in this study as mating pairs.
The CDC Human Research Protection Office found this surveillance activity to be exempt from IRB approval as surveillance without identifiers under 45 CFR 46.101(b)(4). No experiments were performed on animals.
Between January 2005 and January 2013, the CDC received 169 human isolates and 104 veterinary isolates from 16 US states (Table 1, Table S1). Most isolates were from symptomatic humans or animals living in Oregon (n=151), Washington (n=63), and California (n=32). Twenty-seven (10%) isolates came from other states throughout the continental US, Alaska and Hawaii. Thirteen (48%) of these 27 non-PNW isolates came from the southeast states of South Carolina, Georgia, Florida and Alabama. Sixty-eight (65%) veterinary isolates were from cats and dogs; isolates also came from llamas and alpacas, porpoises and dolphins, goats, elk, horses, sheep, ferrets, and a cow.
The majority of the isolates in this collection (78%) originated in the PNW, and were mostly VGIIa (64%), VGIIb (9%), or VGIIc (21%). A higher proportion of Oregon (n=41, 27%) than Washington (n=3, 5%) isolates was VGIIc (p<0.001), and a lower proportion of Oregon isolates (n=91, 60%) than Washington isolates (n=46, 73%) was VGIIa (p=0.03) (Table 2). For the three patients with VGIIc infection in Washington, acquisition of the infection in neighboring Oregon could not be ruled out. Two isolates from Oregon and one isolate from Washington were identified as molecular type VGII, but not VGIIa, VGIIb or VGIIc. There were three VGII isolates from California, one VGIIa and two VGIIb. Six VGII isolates came from Hawaii, Colorado, Florida, Idaho and Utah. All except the Hawaii and Florida isolates could be associated with a travel history to the PNW.
|Number of isolates|
|State||VGI||VGII not a, b or c||VGIIa||VGIIb||VGIIc||VGIII|
Eleven (5%) isolates from Washington and Oregon were VGI (n=5) or VGIII (n=6). In contrast, 18 (57%) isolates from California were molecular type VGIII and 11 (33%) were VGI. Of the 30 VGIII isolates, 18 (60%) were from California; the rest were from Georgia (n=2), New Mexico (n=2), Alabama (n=1), Michigan (n=1), Alaska (n=1), and South Carolina (n=1). No isolates of molecular type VGIV were identified in this US collection.
The state with the most C. gattii isolates outside of the PNW and California was Georgia. Of eight isolates from Georgia, six (75%) were molecular type VGI and two (25%) were molecular type VGIII. Overall, VGI isolates were reported from 11 different states, VGIII isolates were reported from eight states and VGII isolates were reported from eight states (Figure 1).
Figure 1. US map showing C. gattii distribution.
The map shows the distribution of C. gattii molecular types by the state of origin. Because complete travel histories are not known for all patients contributing isolates, it is possible that some infections were acquired in states other than the ones in which they were recognized.doi:10.1371/journal.pone.0074737.g001
LAC 1 was the most informative locus with 17 alleles represented in the collection, 9 of them in VGIII isolates (Table 3). CAP59 was the least informative locus with only 10 alleles represented. VGIII isolates had the greatest number of total alleles across all loci (n=37) and VGII, despite being the most abundant molecular type by far, had the fewest total alleles across all loci (n=25). There were no alleles that were shared across molecular type; each was unique to VGI, VGII or VGIII.
|Allele name||# of alleles||VGI||VGII||VGIII|
|Number of STsa||12||7||15|
Among the 273 isolates, 34 MLST sequence types (STs) were identified. There were 12 STs among the 29 VGI isolates, 15 STs among the 32 VGIII isolates, and seven STs among the 212 VGII isolates. There were only 15 STs among the 214 PNW isolates (VGI had five STs for five isolates; VGII had 5 STs for 203 isolates; VGIII had five STs for six isolates), with approximately equal diversity between human isolates (9 STs) and veterinary isolates (11 STs). Most of the genotypic diversity in the collection originated outside the PNW; there were 24 STs among only 59 isolates. Although the VGI and VGIII isolates were highly diverse, certain STs within each molecular type appeared with greater frequency. Within VGI, nine (31%) of 29 isolates were ST51. These isolates were mostly from California, but also included isolates from Oregon, New Mexico and Rhode Island. The second-most-frequent VGI ST was ST162, comprising five (63%) of eight isolates from Georgia (5/6 VGI isolates from Georgia), one of two from Florida, and one of two from Michigan. Within VGIII, 10 (31%) of 32 isolates were ST75, and three were the closely-related ST139. Most (77%) of these ST75 and ST139 isolates were from California, but one each also came from Oregon, Washington, and Alaska (the Alaska isolate was from a cat that previously resided in California, and the Washington human case was from a person that had recently moved from California to Washington).
Genotypic distribution among veterinary cases
Among the isolates from dogs, all 24 were VGII isolates (VGIIa=19; VGIIb=3; VGIIc=2). In contrast, in cats, seven (17%) isolates were molecular type VGIII, and one was molecular type VGI. All five isolates from Washington porpoises were VGIIb; however, a single isolate from an Oregon porpoise was VGIIa. All three horse isolates were VGIIb, one each from Oregon, Washington and California. Of the 11 isolates from camelids, eight (72%) were VGIIa, two were VGIIc, and one was VGIII.
The sequences for all seven loci were concatenated and neighbor-joining trees were derived for each molecular type. VGI isolates could be divided into three clusters with strong bootstrap support (Figure 2). Cluster 1 isolates were primarily from California, while cluster 2 isolates were primarily from the Southeastern US. There were shared alleles between the clades for CAP59, GPD1, LAC1, and PLB1. No alleles were shared between clades for SOD1, URA5 and IGS1. The VGII isolates were clustered in the major genotypes VGIIa, VGIIb and VGIIc (Figure 3). There were five VGII isolates that were not VGIIa, VGIIb, or VGIIc; three clustered with VGIIc, one clustered with VGIIa and one clustered with VGIIb. Molecular type VGIII isolates could be divided into two clusters with good bootstrap support (Figure 4). Based on common alleles between the two studies, these two lineages correspond to the VGIIIa and VGIIIb lineages that have been previously described for isolates from California . Most VGIIIa isolates originated in California, but the six VGIIIb isolates came from five different states. The isolates from South Carolina and Georgia fell outside of the two clusters. There were shared alleles across the two clusters for CAP59, SOD1, and URA5.
Figure 2. Phylogenetic analysis of VGI isolates.
The neighbor-joining tree was constructed using the maximum-likelihood model and reveals three well supported clades among VGI isolates. Bootstrap values (1000 replicates) are shown next to the branches. CA isolates are blue, Pacific Northwest isolates are red and Southeast US isolates are green.doi:10.1371/journal.pone.0074737.g002
Figure 3. Phylogenetic analysis of VGII isolates.
The neighbor-joining tree was constructed using the maximum-likelihood model and reveals that all VGII isolates can be clustered with VGIIa, VGIIb, or VGIIc.doi:10.1371/journal.pone.0074737.g003
Figure 4. Phylogenetic analysis of VGIII isolates.
The neighbor-joining tree was constructed using the maximum-likelihood model and reveals two well supported clades. Bootstrap values (1000 replicates) are shown next to the branches. CA isolates are blue, Pacific Northwest isolates are red and Southeast US isolates are green.doi:10.1371/journal.pone.0074737.g004
Mating type (MAT) was determined for all isolates. There were 269 MATα, including all of the VGII isolates, and 4 MATa isolates. The MATa isolates included a VGI isolate from a dolphin from Hawaii, a VGIII isolate from a human case in New Mexico, a VGIII isolate from a human case in California and a VGIII from a cat in Oregon. All four MATa isolates corresponded to a unique ST in the collection. Two of the MATa isolates were confirmed by the production of basidiospores from traditional mating assays with MATα isolates.
This analysis of sequence type diversity of C. gattii isolates from a US population provides significant new information about this emerging infection in the US. First, the endemic geographic range for C. gattii in the US extends beyond the PNW and California, and potentially comprises much of the southeast US. Second, C. gattii genotypic diversity in the US outside of the PNW is much higher than in the PNW. Finally, we identified circulating clusters in the US population that are predominant within each molecular type, and these clusters seem to have geographic associations.
C. neoformans has long been divided into four distinct groups by serology . It wasn’t until the 1970s that two of the serotypes, B and C, were recognized as an independent species (species gattii) [56–58]. Using serotyping as a retrospective species identification tool, there is a long history of C. gattii in the US. Wilson and colleagues  were the first to recognize that C. neoformans isolates from California were primarily serotypes B and C. Shortly after that, Denton and DiSalvo  reported a serotype C environmental isolate from an abandoned house in Augusta, Georgia, as well as three patient isolates - two serotype C and one serotype B - from an Augusta Hospital. In 1977, Bennett and colleagues performed serosurveillance on a collection of 272 Cryptococcus spp isolates from 31 US states , reporting 39 serotype B or C isolates from patients in 10 different states, including Alabama, California, Georgia, Minnesota, New Jersey, North Carolina, Oklahoma, Pennsylvania, Texas, and Washington; 25 (64%) came from southern California. Unfortunately, travel histories were not available for patients providing isolates, so possible acquisition in states outside the patients’ state of residence could not be investigated and all environmental isolates within that collection were serotype A or D (species neoformans). Fromtling  reported isolates of serotype B or C from patients in Alabama, Tennessee, and Louisiana with no travel history to any other endemic region. Older reports document patients from Oklahoma and New York with C. gattii serotype B and C infections, but past travel to an endemic region could not be ruled out [42,59]. More recently, C. gattii patients were identified from southern California, Georgia, Rhode Island, New Mexico, Florida, and North Carolina, although the North Carolina patient likely acquired his infection in California [7,26,43–48]. In this study, we identified C. gattii isolates from 16 different US states. Although travel history was not known for many of the patients, this study indicates that C. gattii patients are geographically dispersed in the US. Some may have a travel history to endemic regions, but others may have acquired their infection locally in unrecognized endemic regions. Five patients from Georgia, one from Florida, and one from Alabama had no documented travel history outside of the southeast US within the year before their illness, indicating an infection that was likely acquired locally. The tropical climate of HI makes findings of C. gattii infections there unsurprising. The isolates from Michigan and Montana are perhaps the most intriguing. The Michigan VGIII isolate falls into the clade with VGIII isolates from California (figure 4). The Montana and Michigan VGI isolates fall into the clade with isolates from the southeast US (Figure 2), but it cannot be ruled out that their infections were acquired locally.
Although C. gattii infections outside of the PNW and California have been documented previously, there has been very little information about the molecular type of the isolates outside of the PNW [43–48]. Here we show that the diversity of C. gattii genotypes outside of the PNW is high, and that VGI, VGIII, and VGII may all be endemic to the US. Even though the majority of the isolates in this study came from Oregon and Washington, there was less genotypic diversity among the isolates from these two states than among the isolates from the rest of the US with only 15 genotypes identified among 214 isolates from Washington and Oregon; 93% of the isolates from Washington and Oregon were one of three VGII genotypes. This is similar to findings in Australia where genotypic diversity among VGII isolates was low as well, with the majority of isolates in the genotype VGIIb . One possibility is that VGII is the more recent colonizer of North America and Australia and has not yet had a chance to establish clonal diversity in these two geographic locales. It has been predicted that VGII is the ancestral clade of C. gattii and that it has its origins in South America [14,61]. In support of that hypothesis and in contrast to what was found in the US and Australia, in Brazil the majority of isolates are VGII, but there is a tremendous amount of genotypic diversity among isolates including some closely related to VGIIa and VGIIc (L. Bonfietti and S. Lockhart, unpublished data). We did identify two new VGII STs, one that clustered with VGIIc and one that clustered with VGIIa. Continued surveillance in the PNW will show whether these are single occurrences or new emerging genotypes. The MATa mating type has not been identified among the VGII isolates from the PNW outbreak [35,36], and we did not identify any MATa VGII isolates in this study.
There were 24 genotypes among the 59 isolates collected outside the PNW (one unique ST for every 2.5 isolates). C. gattii isolates from outside the PNW were almost exclusively molecular types VGI and VGIII. There was significantly more diversity among the VGI and VGIII isolates than among the VGII isolates, with 12 VGI STs and 15 VGIII STs. Consistent with a previous report that identified MATa VGIII isolates in California , we found MATa in VGIII isolates from California, New Mexico, and Oregon and a VGI isolate from Hawaii. The presence of isolates of both mating types could lead to more active recombination within the population and could be an explanation for the increased diversity of the VGI and VGIII isolates when compared to the VGII isolates. The increased diversity and the presence of both mating types is also an indicator that VGI and VGIII have been present in the US for much longer than VGII.
Despite the diversity outside of the PNW, there were clusters of STs. There was a cluster of closely related VGI isolates in the southeastern states of Georgia and Florida and a small cluster of VGIII isolates from Georgia and South Carolina. Similar to what had been reported previously from HIV-infected persons , this study identified a cluster of closely related VGIII isolates from California, primarily among HIV-uninfected persons . However, we also identified a cluster of VGI isolates from California that was unrelated to the VGI isolates found in the southeastern US. Clusters of a single sequence type spread over a large geographic area may be an indicator of the longevity of a clonal group within the geographic region.
There were several limitations to this study. Surveillance outside of the PNW was passive, and most likely did not include the entire spectrum of C. gattii disease; that is, mild cases might have been missed, and if different genotypes represent mild versus severe disease, our genetic profile of cases might be biased. Additionally, outside of the PNW, cryptococcal infections are rarely identified to the species level (e.g., neoformans versus gattii). Second, because limited patient information was collected for many of the cases from outside the PNW, we did not have all of the travel histories and therefore cannot exclude travel-acquired infections for some patients. Finally, veterinary isolates were collected primarily from the PNW and therefore the genotypic diversity that may be present in the veterinary population may be underrepresented in this analysis.
Cryptococcus gattii is now recognized as endemic to the US. Our results increase knowledge about the diversity of C. gattii isolates from the US and describe a new endemic region in the Southeastern US. Taking into account historical data from Georgia about C. gattii, including environmental isolates of C. gattii from >50 years ago , and the 13 cases from Georgia, South Carolina, Florida and Alabama in this report, it seems likely that the southeast US has been an endemic zone for C. gattii for a long time, with clinical cases perhaps going unrecognized previously.
Further knowledge of the distribution and diversity of C. gattii in the US is important: recent work has shown that there are differences in antifungal susceptibility between the molecular types [63–65], and there may be differences in clinical presentation between C. gattii infections with different molecular types . C. gattii infections often require lengthier treatments and more aggressive interventions [1,2,66–68], making distinction of these infections from C. neoformans infections extremely important. Increased vigilance for C. gattii infection throughout the US will help define the endemic region within the US.
The findings and conclusions of this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Molecular type origin and sequence type of all isolates analyzed in this study.
The authors wish to acknowledge Dawn Daly and Robert Vega at the Oregon State Public Health Laboratory, Paul Cieslak at the Oregon Department of Human Services, Cyndi Free at the Washington State Department of Health and Dan Bradway at Washington Animal Disease Diagnostic Lab, and all members of the Pacific Northwest Cryptococcus gattii Public Health Working Group for academic discussion of data. We would also like to acknowledge the efforts of the clinicians and technicians who provided isolates for this study including Brenda Sellers and Carlos Franco-Paredes, Susan Vergara, Louisa Catrodale, Samuel Lee, Brian Wickes, ARUP Laboratories, Gail Sondermeyer, Linda Kuo, Matthew Crist, Melissa Tobin D’Angelo, Monear Makvandi, Chad Smelser, John Greene, Danielle Stanek, Kimberly Signs, Randall Nett, David Rotstein, Karen Bartlett, Linda Hoang, Steven Moser, John Baddley and Pete Pappas.
We also wish to thank Dr. Wieland Meyer and Carolina Firacative for help with the allele assignments, and Ana Litvintseva for critical reading of the manuscript.
Conceived and designed the experiments: SL JH ED RW NM DV. Performed the experiments: SL NI NG. Analyzed the data: SL NI NG JH. Contributed reagents/materials/analysis tools: ED RW NM DV. Wrote the manuscript: SL JH.
- 1. Mitchell DH, Sorrell TC, Allworth AM, Heath CH, McGregor AR et al. (1995) Cryptococcal disease of the CNS in immunocompetent hosts: influence of cryptococcal variety on clinical manifestations and outcome. Clin Infect Dis 20: 611–616. doi:10.1093/clinids/20.3.611. PubMed: 7756484.
- 2. Speed B, Dunt D (1995) Clinical and host differences between infections with the two varieties of Cryptococcus neoformans. Clin Infect Dis 21: 28–34. doi:10.1093/clinids/21.1.28. PubMed: 7578756.
- 3. Friedman GD, Fessel WJ, Udaltsova NV, Hurley LB (1995) Cryptococcosis: the 1981–2000 epidemic. Mycoses 48: 122–125. doi: 10.1111/j.1439-0507.2004.01082.x
- 4. Harris JR, Lockhart SR, DeBess EE, Marsden-Haug N, Goldoft M et al. (2011) Cryptococcus gattii in the United States: clinical aspects of infection with an emerging pathogen. Clin Infect Dis 53: 1188-1195. doi:10.1093/cid/cir723. PubMed: 22016503.
- 5. Galanis E, Hoang L, Kibsey P, Morshed M, Phillips P (2009) Clinical presentations, diagnosis and management of Cryptococcus gattii cases: lessons learned from British Columbia. Can J Infect Dis Med Microbiol 20: 23-28. PubMed: 20190892.
- 6. Steele KT, Thakur R, Nthobatsang R, Steenhoff AP, Bisson GP (2010). In-hospital mortality of HIV-infected cryptococcal meningitis patients with C. gattii and C. neoformans infection in Gaborone, Botswana. Med Mycol 48: 1112-1115. doi: 10.3109/13693781003774689
- 7. Chaturvedi S, Dyavaiah M, Larsen RA, Chaturvedi V (2005) Cryptococcus gattii in AIDS patients, southern California. Emerg Infect Dis 11: 1686-1692. doi:10.3201/eid1111.040875. PubMed: 16318719.
- 8. Kwon-Chung KJ, Bennett JE (1984) Epidemiologic differences between the two varieties of Cryptococcus neoformans. Am J Epidemiol 120: 123-130. PubMed: 6377880.
- 9. Kidd SE, Hagen F, Tscharke RL, Huynh M, Bartlett KH et al. (2004) A rare genotype of Cryptococcus gattii caused the cryptococcosis outbreak on Vancouver Island (British Columbia, Canada). Proc Natl Acad Sci U S A 101: 17258-17263. doi:10.1073/pnas.0402981101. PubMed: 15572442.
- 10. Okamoto K, Hatakeyama S, Itoyama S, Nukui Y, Yoshino Y et al. (2010) Cryptococcus gattii genotype VGIIa infection in man, Japan, 2007. Emerg Infect Dis 16: 1155-1157. doi:10.3201/eid1607.100106. PubMed: 20587194.
- 11. Chowdhary A, Randhawa HS, Boekhout T, Hagen F, Klaassen CH et al. (2012) Temperate climate niche for Cryptococcus gattii in Northern Europe. Emerg Infect Dis 18: 172-174. doi:10.3201/eid1801.111190. PubMed: 22261398.
- 12. Hagen F, Colom MF, Swinne D, Tintelnot K, Iatta R et al. (2012) Autochthonous and dormant Cryptococcus gattii infections in Europe. Emerg Infect Dis 18: 1618-1624. doi:10.3201/eid1810.120068. PubMed: 23017442.
- 13. Bovers M, Hagen F, Kuramae EE, Boekhout T (2008) Six monophyletic lineages identified within Cryptococcus neoformans and Cryptococcus gattii by multi-locus sequence typing. Fungal Genet Biol 45: 400-421. doi:10.1016/j.fgb.2007.12.004. PubMed: 18261945.
- 14. Ngamskulrungroj P, Gilgado F, Faganello J, Litvintseva AP, Leal AL et al. (2009) Genetic diversity of the Cryptococcus species complex suggests that Cryptococcus gattii deserves to have varieties. PLOS ONE 4: e5862. doi:10.1371/journal.pone.0005862. PubMed: 19517012.
- 15. Meyer W, Castañeda A, Jackson S, Huynh M, Castañeda E et al. (2003) Molecular typing of IberoAmerican Cryptococcus neoformans isolates. Emerg Infect Dis 9: 189-195. doi:10.3201/eid0902.020246. PubMed: 12603989.
- 16. Campbell LT, Fraser JA, Nichols CB, Dietrich FS, Carter D et al. (2005) Clinical and environmental isolates of Cryptococcus gattii from Australia that retain sexual fecundity. Eukaryot Cell 4: 1410-1419. doi:10.1128/EC.4.8.1410-1419.2005. PubMed: 16087746.
- 17. Litvintseva AP, Thakur R, Reller LB, Mitchell TG (2005) Prevalence of clinical isolates of Cryptococcus gattii serotype C among patients with AIDS in Sub-Saharan Africa. J Infect Dis 192: 888-892. doi:10.1086/432486. PubMed: 16088839.
- 18. Feng X, Yao Z, Ren D, Liao W, Wu J (2008) Genotype and mating type analysis of Cryptococcus neoformans and Cryptococcus gattii isolates from China that mainly originated from non-HIV-infected patients. FEMS Yeast Res 8: 930-938. doi:10.1111/j.1567-1364.2008.00422.x. PubMed: 18671745.
- 19. Trilles L, Lazéra Mdos S. , Wanke B. , Oliveira RV. , Barbosa. et. al. (2008) Regional pattern of the molecular types of Cryptococcus neoformans and Cryptococcus gattii in Brazil. Mem Inst Oswaldo Cruz 103: 455-462. PubMed : 18797758.
- 20. Hagen F, Illnait-Zaragozi MT, Bartlett KH, Swinne D, Geertsen E et al. (2010) In vitro antifungal susceptibilities and amplified fragment length polymorphism genotyping of a worldwide collection of 350 clinical, veterinary, and environmental Cryptococcus gattii isolates. Antimicrob Agents Chemother 54: 5139-5145. doi:10.1128/AAC.00746-10. PubMed: 20855729.
- 21. Chowdhary A, Randhawa HS, Sundar G, Kathuria S, Prakash A et al. (2011) In vitro antifungal susceptibility profiles and genotypes of 308 clinical and environmental isolates of Cryptococcus neoformans var. grubii and Cryptococcus gattii serotype B from north-western India. J Med Microbiol 60: 961-967. doi:10.1099/jmm.0.029025-0. PubMed: 21393452.
- 22. Bennett JE, Kwon-Chung KJ, Howard DH (1977) Epidemiologic differences among serotypes of Cryptococcus neoformans. Am J Epidemiol 105: 582-586. PubMed: 326036.
- 23. Kwon-Chung KJ, Bennett JE (1984) High prevalence of Cryptococcus neoformans var. gattii in tropical and subtropical regions. Zentralbl Bakteriol Mikrobiol Hyg A 257: 213-218. PubMed: 6207684.
- 24. Kwon-Chung KJ, Bennett JE (1984) Epidemiologic differences between the two varieties of Cryptococcus neoformans. Am J Epidemiol 120: 123-130. PubMed: 6377880.
- 25. Pfeiffer T, Ellis D (1991) Environmental isolation of Cryptococcus neoformans gattii from California. J Infect Dis 163: 929-930. doi:10.1093/infdis/163.4.929. PubMed: 2010649.
- 26. Brandt ME, Hutwagner LC, Klug LA, Baughman WS, Rimland D et al. (1996) Molecular subtype distribution of Cryptococcus neoformans in four areas of the United States. J Clin Microbiol 34: 912-917. PubMed: 8815107.
- 27. Stephen C, Lester S, Black W, Fyfe M, Raverty S (2002) Multispecies outbreak of cryptococcosis on southern Vancouver Island, British Columbia, Can. Vet J 43: 792-794.
- 28. Fraser JA, Subaran RL, Nichols CB, Heitman J (2003) Recapitulation of the sexual cycle of the primary fungal pathogen Cryptococcus neoformans var. gattii: implications for an outbreak on Vancouver Island, Canada. Eukaryot Cell 2: 1036-1045. doi:10.1128/EC.2.5.1036-1045.2003. PubMed: 14555486.
- 29. Hoang LM, Maguire JA, Doyle P, Fyfe M, Roscoe DL (2004) Cryptococcus neoformans infections at Vancouver Hospital and Health Sciences Centre (1997-2002): epidemiology, microbiology and histopathology. J Med Microbiol 53: 935-940. doi:10.1099/jmm.0.05427-0. PubMed: 15314203.
- 30. Fraser JA, Giles SS, Wenink EC, Geunes-Boyer SG, Wright JR et al. (2005) Same-sex mating and the origin of the Vancouver Island Cryptococcus gattii outbreak. Nature 437: 1360-1364. doi:10.1038/nature04220. PubMed: 16222245.
- 31. Upton A, Fraser JA, Kidd SE, Bretz C, Bartlett KH (2007) First contemporary case of human infection with Cryptococcus gattii in Puget Sound: evidence for spread of the Vancouver Island outbreak. J Clin Microbiol 45: 3086-3088. doi:10.1128/JCM.00593-07. PubMed: 17596366.
- 32. Kidd SE, Chow Y, Mak S, Bach PJ, Chen H et al. (2007) Characterization of environmental sources of the human and animal pathogen Cryptococcus gattii in British Columbia, Canada, and the Pacific Northwest of the United States. Appl Environ Microbiol 73: 1433-1443. doi:10.1128/AEM.01330-06. PubMed: 17194837.
- 33. MacDougall L, Kidd SE, Galanis E, Mak S, Leslie MJ et al. (2007) Spread of Cryptococcus gattii in British Columbia, Canada, and detection in the Pacific Northwest, USA. Emerg Infect Dis 13: 42-50. doi:10.3201/eid1301.060827. PubMed: 17370514.
- 34. Datta K, Bartlett KH, Baer R, Byrnes E, Galanis E et al. (2009) Spread of Cryptococcus gattii into Pacific Northwest region of the United States. Emerg Infect Dis 15: 1185-1191. doi:10.3201/eid1508.081384. PubMed: 19757550.
- 35. Byrnes EJ 3rd, Bildfell RJ, Frank SA, Mitchell TG, Marr KA et al. (2009) Molecular evidence that the range of the Vancouver Island outbreak of Cryptococcus gattii infection has expanded into the Pacific Northwest in the United States. J Infect Dis 199: 1081-1086. doi:10.1086/597306. PubMed: 19220140.
- 36. Byrnes EJ 3rd, Li W, Lewit Y, Ma H, Voelz K et al. (2010) Emergence and pathogenicity of highly virulent Cryptococcus gattii genotypes in the northwest United States. PLOS Pathog 6: e1000850. PubMed: 20421942.
- 37. Iqbal N, DeBess EE, Wohrle R, Sun B, Nett RJ et al. (2010) Correlation of genotype and in vitro susceptibilities of Cryptococcus gattii strains from the Pacific Northwest of the United States. J Clin Microbiol 48: 539-544. doi:10.1128/JCM.01505-09. PubMed: 20007380.
- 38. Denton JF, Di Salvo AF (1968) The prevalence of Cryptococcus neoformans in various natural habitats. Sabouraudia 6: 213-217. doi:10.1080/00362176885190411. PubMed: 5679667.
- 39. Wilson DE, Bennett JE, Bailey JW (1968) Serologic grouping of Cryptococcus neoformans. Proc Soc Exp Biol Med 127: 820-823. doi:10.3181/00379727-127-32812. PubMed: 5651140.
- 40. Kwon-Chung KJ (1976) A new species of Filobasidiella, the sexual state of Cryptococcus neoformans B and C serotypes. Mycologia 68: 942-946. doi:10.2307/3758813. PubMed: 790173.
- 41. Fromtling RA, Shadomy S, Shadomy HJ, Dismukes WE (1982) Serotype B/C Cryptococcus neoformans isolated from patients in nonendemic areas. J Clin Microbiol 16: 408-410. PubMed: 6749900.
- 42. Bottone EJ, Kirschner PA, Salkin IF (1986) Isolation of highly encapsulated Cryptococcus neoformans serotype B from a patient in New York City. J Clin Microbiol 23: 186-188. PubMed: 3517042.
- 43. Byrnes EJ 3rd, Li W, Lewit Y, Perfect JR, Carter DA (2009) First reported case of Cryptococcus gattii in the Southeastern USA: implications for travel-associated acquisition of an emerging pathogen. PLOS ONE 4: e5851. doi:10.1371/journal.pone.0005851. PubMed: 19516904.
- 44. McCulloh RJ, Phillips R, Perfect JR, Byrnes EJ 3rd, Heitman J et al. (2011) Cryptococcus gattii genotype VGI Infection in New England. Pediatr Infect Dis J 30: 1111-1114. doi:10.1097/INF.0b013e31822d14fd. PubMed: 21814154.
- 45. Walraven CJ, Gerstein W, Hardison SE, Wormley F, Lockhart SR et al. (2011) Fatal disseminated Cryptococcus gattii infection in New Mexico. PLOS ONE 6: e28625. doi:10.1371/journal.pone.0028625. PubMed: 22194869.
- 46. Byrnes EJ 3rd, Li W, Ren P, Lewit Y, Voelz K (2011) A diverse population of Cryptococcus gattii molecular type VGIII in Southern California HIV/AIDS patients. PLOS Pathog 7: e1002205. doi: 10.1371/journal.ppat.1002205
- 47. Sellers B, Hall P, Cine-Gowdie S, Hays AL, Patel K (2012) Cryptococcus gattii. An Emerging Fungal Pathog Southeastern United States. AM J Med Sci 343: 510-511. doi: 10.1097/maj.0b013e3182464bc7
- 48. Kunadharaju R, Choe U, Harris JR, Lockhart SR, Greene JN (2013) Cryptococcus gattii: Emerging fungal pathogen in Florida. Emerg Infect Dis, 19: 519-521. PubMed: 23750364.
- 49. Kwon-Chung KJ, Polacheck I, Bennett JE (1982) Improved diagnostic medium for separation of Cryptococcus neoformans var. neoformans (serotypes A and D) and Cryptococcus neoformans var. gattii (serotypes B and C). J Clin Microbiol 15: 535-537. PubMed: 7042750.
- 50. Meyer W, Aanensen DM, Boekhout T, Cogliati M, Diaz MR et al. (2009) Consensus multi-locus sequence typing scheme for Cryptococcus neoformans and Cryptococcus gattii. Med Mycol 12: 1-14. PubMed: 19462334.
- 51. Hall TA (1999) BioEdit: a user-friendly biological sequence alignment editor and analysis program for Windows 95/98/NT. Nucleic Acids Symp 41: 95–98.
- 52. Tamura K, Dudley J, Nei M, Kumar S (2007) MEGA4: Molecular Evolutionary Genetics Analysis(MEGA) software version 4.0. Mol Biol Evol 24: 1596–1599. doi: 10.1093/molbev/msm092
- 53. Ngamskulrungroj P, Sorrell TC, Chindamporn A, Chaiprasert A, Poonwan N et al. (2008) Association between fertility and molecular sub-type of global isolates of Cryptococcus gattii molecular type VGII. Med Mycol 46: 665-673. doi:10.1080/13693780802210734. PubMed: 18651305.
- 54. Campbell LT, Fraser JA, Nichols CB, Dietrich FS, Carter D et al. (2005) Clinical and environmental isolates of Cryptococcus gattii from Australia that retain sexual fecundity. Eukaryot Cell 4: 1410-1419. doi:10.1128/EC.4.8.1410-1419.2005. PubMed: 16087746.
- 55. Evans EE (1949) An immunologic comparison of twelve strains of Cryptococcus neoformans (Torula histolytica). Proc Soc Exp Biol Med 71: 644-646. doi:10.3181/00379727-71-17283. PubMed: 18148185.
- 56. Kwon-Chung KJ (1976) A new species of Filobasidiella, the sexual state of Cryptococcus neoformans B and C serotypes. Mycologia 68: 943-946. PubMed: 790173.
- 57. Kwon-Chung KJ, Bennett JE, Theodore TS (1978) Cryptococcus bacillisporus sp. nov. Serotype B–C of Cryptococcus neoformans. Int J Syst Bacteriol 28: 616-620. doi:10.1099/00207713-28-4-616.
- 58. Diaz MR, Boekhout T, Theelen B, Fell JW (2000) Molecular sequence analyses of the intergenic spacer (IGS) associated with rDNA of the two varieties of the pathogenic yeast, Cryptococcus neoformans. Syst Appl Microbiol 23: 535-545. doi:10.1016/S0723-2020(00)80028-4. PubMed: 11249024.
- 59. Muchmore HG, Scott EN, Felton FG, Fromtling RA (1980) Cryptococcus neoformans serotype groups encountered in Oklahoma. Am J Epidemiol 112: 323-328. PubMed: 7424881.
- 60. Carriconde F, Gilgado F, Arthur I, Ellis D, Malik R et al. (2011) Clonality and α-a recombination in the Australian Cryptococcus gattii VGII population--an emerging outbreak in Australia. PLOS ONE. 6: e16936. doi:10.1371/journal.pone.0016936. PubMed: 21383989.
- 61. Meyer W, Gilgado F, Ngamskulrungroj P, Trilles L, Hagen F et al. (2011) Molecular typing of Cryptococcus neoformans/Cryptococcus gattii species complex. In: J. HeitmanTR KozelKJ Kwon-ChungJR PerfectA. Casadevall. Cryptococcus from Human Pathogen to Model Yeast. Washington DC: ASM Press. p. 2011. pp. 358.
- 62. Harris JR, Lockhart SR, Crist M, Aminu L, Sellers B et al. (2013) Cryptococcus gattii: an endemic infection in multiple states outside the Pacific Northwest US. Emerg Infect Dis ( In press).
- 63. Hagen F, Illnait-Zaragozi MT, Bartlett KH, Swinne D, Geertsen E et al. (2010) In vitro antifungal susceptibilities and amplified fragment length polymorphism genotyping of a worldwide collection of 350 clinical, veterinary, and environmental Cryptococcus gattii isolates. Antimicrob Agents Chemother 54: 5139–5145. doi:10.1128/AAC.00746-10. PubMed: 20855729.
- 64. Lockhart SR, Iqbal N, Bolden CB, DeBess EE, Marsden-Haug N et al. (2012) Epidemiological cutoff values for triazole drugs in Cryptococcus gattii: correlation of molecular type and in vitro susceptibility. Diagn Microbiol Infect Dis, 73: 144-148. doi:10.1016/j.diagmicrobio.2012.02.018. PubMed: 22494557.
- 65. Espinel-Ingroff A, Aller AI, Canton E, Castañón-Olivares LR, Chowdhary A et al. (2012) Cryptococcus neoformans-Cryptococcus gattii Species Complex: An International Study of Wild-Type Susceptibility Endpoint Distributions and Epidemiological Cutoff Values for Fluconazole, Itraconazole, Posaconazole and Voriconazole. Antimicrob Agents Chemother, 56: 5898-5906. doi:10.1128/AAC.01115-12. PubMed: 22948877.
- 66. López-Martínez R, Soto-Hernández JL, Ostrosky-Zeichner L, Castanón-Olivares LR, Angeles-Morales V et al. (1996) Cryptococcus neoformans var. gattii among patients with cryptococcal meningitis in Mexico. First observations. Mycopathologia. 134: 61-64. doi:10.1007/BF00436865. PubMed: 8981772.
- 67. Chen YC, Chang SC, Shih CC, Hung CC, Luhbd KT et al. (2000) Clinical features and in vitro susceptibilities of two varieties of Cryptococcus neoformans in Taiwan. Diagn Microbiol Infect Dis 36: 175-183. doi: 10.1016/s0732-8893(99)00137-6
- 68. Chen SC, Slavin MA, Heath CH, Playford EG, Byth K et al. (2012) Clinical manifestations of Cryptococcus gattii infection: determinants of neurological sequelae and death. Clin Infect Dis 55: 789-798. doi:10.1093/cid/cis529. PubMed: 22670042.