Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Molecular detection and identifcation of Rickettsia species in ticks domestic Triatoma infestans buy strattera 10 mg with visa medications zoloft side effects. Canine heartworm pathogens in domestic dogs on the border of Noel Kempf Mercado disease in Porto Velho: frst record buy 25 mg strattera with mastercard medications that cause hair loss, distribution map and occurrence of National Park strattera 40 mg generic symptoms carbon monoxide poisoning, Bolivia. Epidemiological aspects pathogen exposure of domestic dogs in the Isoso of Bolivia. Conserv of flariosis in dogs on the coast of Parana state, Brazil: with emphasis Biol. Hepatozoon canis infecting dogs in the State of Espirito Santo, Moreno, Santa Cruz de la Sierra, Bolivia; 2006. Zoonotic cutaneous leishmaniasis due to Leishmania in sheep, goats and dogs in Cordillera Province, Bolivia. Zentralblatt (Viannia) braziliensis associated with domestic animals in Venezuela and Veterinarmedizin Reihe B. Prevalence of antibodies to Borrelia burgdorferi, Borrelia parkeri Surveillance for zoonotic vector-borne infections using sick dogs from and Borrelia turicatae in human settlements of the Cordillera Province, southeastern Brazil. Serological survey of Leishmania infantum and Trypanosoma dogs and Rickettsia parkeri in Amblyomma tigrinum ticks, Cochabamba cruzi in dogs from urban areas of Brazil and Colombia. Hepatozoon canis infection associ in the Municipality of Paraty, State of Rio de Janeiro, Brazil. Participacao do cao no ciclo de transmissao da leishmaniose tegumen 2009;179:145?8. Seroprevalence rates of antibodies against Leishmania infantum and 2003;19:1877?80. Survey of canine heartworm in the city of Recife, ease region in northern Colombia reveals the importance of Triatoma Pernambuco, Brazil. Investigations on naturally occurring in cats in Cuiaba, state of Mato Grosso, central-western region of Brazil. Trypanosoma evansi infections in horses, cattle, dogs and capybaras Rev Bras Parasitol Vet. Vet ceae) in dogs and Rhipicephalus sanguineus (Acari: Ixodidae) ticks from Parasitol. Domestic and wild mammals infection by Trypanosoma evansi in a pris Sero-prevalence and risk indicators for canine ehrlichiosis in three rural tine area of the Brazilian Pantanal region. Ehrlichio characterization of isolates of Trypanosoma evansi from Pantanal of sis in anemic, thrombocytopenic, or tick-infested dogs from a hospital Matogrosso-Brazil. Serologic prevalence of Diroflaria immitis, Ehrlichia canis, and by Leishmania (Leishmania) chagasi and Trypanosoma (Trypanozoon) Borrelia burgdorferi infections in Brazil. Prevalence of Ehrlichia canis infection in tion of Trypanosoma evansi isolated from capybaras and dogs in Brazil. Molecular epidemiology of the emerging zoonosis agent Anaplasma Molecular detection of Ehrlichia canis in dogs from the Pantanal of phagocytophilum (Foggie, 1949) in dogs and ixodid ticks in Brazil. Ehrlichia spp infection in rural dogs from remote indigenous villages Detection of Anaplasma phagocytophilum in Brazilian dogs by real-time in north-eastern Brazil. Bartonella infection in urban and rural dogs from investigation in dogs from Brazil. Surveillance using serological and molecular methods for the detection Maggi and Kramer Parasites Vectors (2019) 12:145 Page 29 of 37 of infectious agents in captive Brazilian neotropic and exotic felids. A Rickettsia haemominutum? in a lion (Panthera leo) from a Brazilian zoological parkeri-like agent infecting Amblyomma calcaratum nymphs from wild garden. Rickettsial infection in Amblyomma nodosum ticks (Acari: human beings, dogs and horses in a rural settlement in southern Brazil. Rickettsial infection in ticks (Acari: Ixodidae) collected lar detection of hemoplasma infection among cats from Sao Luis island, on birds in southern Brazil. Detection of hemoplasma and Bartonella species and co-infection Pantanal region of Mato Grosso, midwestern Brazil. Cytauxzoon felis and Candidatus Mycoplasma haemo and ecological aspects of the Atlantic rainforest Rickettsia, the causa minutum? coinfection in a Brazilian domestic cat (Felis catus). Prevalence of Ehrlichia canis, Anaplasma platys, Babesia canis plasmas among domiciled and free-roaming cats in Campo Grande, vogeli, Hepatozoon canis, Bartonella vinsonii berkhofi, and Rickettsia spp. Infection by spotted fever rickettsiae in people, dogs, horses immitis, Ehrlichia canis, Borrelia burgdorferi, and Babesia canis in feral and and ticks in Londrina, Parana State, Brazil. Rickettsia species infecting Amblyomma cooperi ticks from an unclassifed trypanosomatid responsible for human cutaneous lesions area in the state of Sao Paulo, Brazil, where Brazilian spotted fever is in Martinique (French West Indies) is the most divergent member of the endemic. Studies on vectors of Trypanosoma cruzi in Trinidad, state of Santa Catarina, Brazil. Georges K, Ezeokoli C, Auguste T, Seepersad N, Pottinger A, Spara enfermedad de Chagas en Chile. Nodulos parasitarios cutaneos: estudio ultrasonogra dad de Chagas en el Altiplano chileno Aspectos epidemiologicos, fco de tres casos poco frecuentes en la edad pediatrica. Evidencia clinica y serologica de agents in ticks (Acari: Argasidae, Ixodidae) from Chile. Estado actual de la seroprevalencia de la infeccion chagasica roborreliosis en Chile. Bol Chil Identifcacion molecular de Ehrlichia canis en un canino de la ciudad de Parasitol. Hallazgo de Ehrlichia canis Infeccion por Trypanosoma cruzi en animales domesticos de sectores en Chile, informe preliminar. Infestacion domiciliaria por triatominos, tasas de infeccion de estos por Vet Microbiol. Infestacion triatomidea domiciliaria e infeccion por Trypano domestic-wildlife interface: implications for public health and wildlife. Molecular and serological mological and seroepidemiological study of the vectorial-transmission detection of Ehrlichia canis and Babesia vogeli in dogs in Colombia.
- Virilizing ovarian tumor
- Hashimoto Pritzker syndrome
- Lagophthalmia cleft lip palate
- Hirschsprung disease
- Isthmian coarctation
- Corneodermatoosseous syndrome
- Pseudovaginal perineoscrotal hypospadias
- Developmental dysphasia familial
- Whooping cough (Pertussis)
In countries with low living standards it is nearly 100% in adults purchase strattera 10mg on line symptoms food poisoning, in industrial nations it is between 40 and 70% purchase strattera 18mg otc medications definitions. In Germany around 45 50% of pregnant women are seropositive and strattera 18mg low cost treatment zoster ophthalmicus, thus, protected from a primary infection. In immunocompetent individuals the infection is usually asymptomatic or unspecific, or with symptoms similar to mononucleosis. Symptoms can appear more severe in immunosuppressed patients both for primary and for recurring infections (e. Depending on the gestation age and the time of the primary infection, the intrauterine transmission rate rises from 30% in the first trimester to 70% in the third trimester. Lead symptoms of congenital cytomegalovirus syndrome are systemic/visceral manifestations, microcephaly, intracranial calcifications, cramping, hearing impairment and chorioretinitis. The detection of specific IgA antibodies does not provide any additional information. Various cell lines and virus strains are used to detect neutralizing antibodies (specialized diagnostics). IgM antibodies usually drop below the detection limit within 8 12 weeks; however, in individual cases they can persist for much longer (months to years). IgG antibodies can be detected in rising concentrations within the first 2 months after the infection, and then in low titers for the rest of the individual?s life. IgG avidity is low in the acute stages; a high avidity is an indication of an infection that occurred long ago. It should be noted that the reference ranges vary from manufacturer to manufacturer. The results should be interpreted with caution, especially with the low IgG antibody concentrations. Recurring infections are indicated through the positive detection of the pathogen in the presence of highly avid IgG antibodies. They cannot be reliably diagnosed serologically and are difficult to distinguish from primary infections. A positive IgM finding in connection with a clear rise in IgG titers in the course of the disease is an indication of a recurrence. These tests are mostly used for research purposes and not for routine diagnostic testing. If the diagnosis is made in the late second or third trimester, neither a negative IgM result, nor a high IgG avidity index can rule out a primary infection in early pregnancy. For immunodeficient patients, serological diagnostic testing plays a subordinate role due to its limited explanatory power. Differences in sensitivity and specificity of the tests from different manufacturers, the administration of blood products, and immunoglobulins can lead to problems interpreting the test. In these situations, measuring cellular immunity can contribute to clarifying questionable results. Since the specificity of the IgM detection is limited, the diagnosis, particularly in pregnant women, should be confirmed by an additional serological test (e. If applicable, additional serological test to Positive Positive Low (moderate) Primary infection more precisely establish point of 2 infection, continuative diagnostics Primary infection? Control after around 10 days to detect or Cannot be Negative Positive False-positive IgM rule out a seroconversion, second IgM determined antibodies? In the initial test during pregnancy, a determination of IgM antibodies should be considered so that an acute infection is not overlooked (particularly in pregnant women with high risk of exposure). In the past 50 years the incidence rate has increased 30-fold with geographic distribution also increasing (now affecting more than 100 countries in which around 2. In Germany there has been an increasing number of reported cases of dengue fever that have been clinically and diagnostically confirmed in laboratories (2011: 288 cases; 2012: 616 cases; 2013: 879 cases). The percentage distribution of the countries (continents) in which the infection was acquired has changed little: 77% of the reported infections were acquired in Asian countries (primarily Thailand), 18% in South and Central American countries and 2% in African countries; Madeira was named a region of infection for the first time in 2012. Primary infections are mostly light and often have a double-peaking fever with headache, muscle ache and pain in the extremities. The disease lessens in most patients after around 7 days (mostly) without consequence. Often a rd th second rash (maculopapular or morbiliform) appears on the 3 to 5 day. Dengue virus infections lead to a life-long serotype-specific immunity, but only a short-term cross immunity to other serotypes. Rapid diagnostic tests also serve to quickly diagnose people returning from the tropics and to differentially diagnose falciparum malaria. Dengue virus-specific molecular biological and cell culture-based plaque reduction and (micro)neutralization tests are also available to directly detect the pathogen. Dengue virus-specific IgM antibodies can be detected in 80% of all dengue fever cases as early as on day 5 of the disease and in 93 99% of the cases on days 6 to 10. The sensitivity and specificity of the IgM antibody tests are 90% and 98% respectively, however they depend strongly on the quality of the antigens used in the test and can fluctuate greatly in the commercially available tests. It should be noted that IgM antibodies can be detected 2 to 3 months (sometimes up to 6 months) after the disease and are thus not always proof of an acute infection. In order to unequivocally clarify this, a serum from the acute and from the recovery phase is often necessary, particularly when the acute phase sample is collected at a point in time when the IgM antibodies were not yet detectable. Furthermore, there is a certain cross-reactivity with other flaviviruses (including the West Nile virus, St. Louis encephalitis virus, Japanese encephalitis virus, Zika virus, and the yellow fever virus). A primary dengue virus infection is characterized by the fact that the antibody response is slow and has low titer levels.
Comparison of Long-term group=108 long-term Short-term group=107 Significantly higher rate of favorable outcomes hypothermia (4-6 for long-term group purchase strattera online now medications used to treat fibromyalgia. The studies that compare hypothermia to normothermia 7 10 mg strattera with visa medicine 93 948,10-15 represent a body of literature with conflicting results buy strattera 18mg free shipping medicine of the people. Despite attempts to improve study designs and research questions over time, there are important differences in several aspects of the studies. The authors reported non-significant trends toward better outcomes and no significant differences in most complications in the hypothermia 11 patients. They found no difference in mortality, but more patients in the hypothermia group had better outcomes. Authors suggested that hypothermia was not induced quickly enough to produce a benefit in normothermic patients, and that rewarming patients who arrived hypothermic was detrimental. Enrollment in this study was stopped for futility when interim analyses found no difference in mortality or neurological outcomes and calculated that the hypothesized difference could not be reached even if full enrollment was completed. Follow-up was completed for enrolled patients, and exploratory subgroup analyses revealed that in patients with surgically removed hematomas the hypothermia group had better outcomes, while in patients with diffuse brain injuries there was no significant difference in outcomes. These findings suggest a potential underlying reason for the null finding, but would need to be tested in studies designed to determine if there is a difference in outcome for different types of patients before it could be used to inform evidence-based recommendations. While this was stronger than the subgroup analysis from a single study, there were important differences. For example, patients in the later study reached target temperatures earlier than those in the first study, in which the time to target temperature was mixed. For this analysis, the authors compared patients who were cooled more quickly, within 1. Fewer patients who were cooled quickly had negative outcomes (41%), while more patients who were cooled slowly or treated with normothermia had negative outcomes (62%, p=0. While other studies also compared hypothermia to normothermia, they differed in important ways. The hypothermia 15 group was kept cool for 3 to 5 days and had lower mortality rates. One study randomized 215 patients at three medical centers 8 to long-term and short-term hypothermia. Lui, 2006 conducted a preliminary study that compared 9 head only (selective brain cooling) with full body (systemic cooling) and normothermia. Class 3 Studies the summary of evidence from Class 3 studies of prophylactic hypothermia is summarized in Table 2-3. Complications (pulmonary infection, urinary tract infection, and thrombocytopenia) were not significantly different. None of these studies found any statistically significant difference in mortality. Four reported better neurological 46 20-22,24 19,23 outcomes in patients treated with hypothermia, while two found no difference. High rates of prasugrel and ticagrelor non responder in patients treated with therapeutic hypothermia after cardiac arrest. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomised controlled trial. Effect of long-term mild hypothermia or short-term mild hypothermia on outcome of patients with severe traumatic brain injury. Effects of selective brain cooling in patients with severe traumatic brain injury: a preliminary study. Moderate hypothermia improves imbalances of thromboxane A2 and prostaglandin I2 production after traumatic brain injury in humans. Effect of long-term mild hypothermia therapy in patients with severe traumatic brain injury: 1-year follow-up review of 87 cases. Early induction of hypothermia for evacuated intracranial hematomas: a post hoc analysis of two clinical trials. Discrete cerebral hypothermia in the management of traumatic brain injury: a randomized controlled trial. Applying cerebral hypothermia and brain oxygen monitoring in treating severe traumatic brain injury. Effects of therapeutic mild hypothermia on patients with severe traumatic brain injury after craniotomy. Noninvasive selective brain cooling by head and neck cooling is protective in severe traumatic brain injury. Mild hypothermia therapy reduces blood glucose and lactate and improves neurologic outcomes in patients with severe traumatic brain injury. The landmark work of Weed and McKibben disproved this long-held dogma when they demonstrated dramatic changes in the volume of the brain resulting from administration of hypertonic or hypotonic intravenous solutions. Since that time, intravenous administration of hyperosmolar agents has become routine in the management of intracranial hypertension and herniation syndromes. Mannitol and hypertonic saline are routinely employed hyperosmolar agents in North America. Although mannitol can be used as a resuscitation fluid, its eventual diuretic effect is undesirable in hypotensive patients and 6 attention needs to be paid to replacing intravascular volume loss. While mannitol was previously thought to reduce intracranial pressure through simple brain dehydration, both mannitol and hypertonic saline work to reduce intracranial pressure, at least in part, through reducing blood viscosity, leading to improved microcirculatory flow of blood constituents and consequent constriction of the pial arterioles, resulting in decreased cerebral blood volume and 5,7,8 intracranial pressure. While there is increasing use of hypertonic saline as an alternative hyperosmotic agent, there is insufficient evidence available from comparative studies to support a formal recommendation.
Fuzzy pattern classification of hemodynamic data can be used to determine noninvasive intracranial pressure order strattera no prescription medications 5113. Continuous monitoring of jugular bulb oxygen saturation in comatose patients-therapeutic implications strattera 40 mg with mastercard symptoms parkinsons disease. Characterizing the dose-response relationship between mannitol and intracranial pressure in traumatic brain injury patients using a high-frequency physiological data collection system purchase strattera overnight treatment 34690 diagnosis. Monitoring of cerebral metabolism: non-ischemic impairment of oxidative metabolism following severe traumatic brain injury. Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcome after severe traumatic brain injury. Intracranial multimodal monitoring for acute brain injury: a single institution review of current practices. Normobaric hyperoxia-induced improvement in cerebral metabolism and reduction in intracranial pressure in patients with severe head injury: a prospective historical cohort-matched study. Intracranial pressure monitoring in intensive care: clinical advantages of a computerized system over manual recording. Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury. The impact of prehospital ventilation on outcome after severe traumatic brain injury. Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Clinical variables and neuromonitoring information (intracranial pressure and brain tissue oxygenation) as predictors of brain-death development after severe traumatic brain injury. However, some may be poorly designed, lack sufficient patient numbers, or suffer from other methodological inadequacies that render them Class 2 or 3. Class 2 Evidence is derived from cohort studies including prospective, retrospective, and case control. Class 3 Evidence is derived from case series, databases or registries, case reports, and expert opinion. Quality of the Body of Evidence Assessment Quality of the Body of Evidence Ratings and Criteria Ratings the overall assessment is whether the quality of the body of evidence is high, moderate, low, or insufficient. Further research is very unlikely to change the confidence in the estimate of effect. Further research may change our confidence in the estimate of effect and may change the estimate. This requires at least one high-quality study or moderate-quality with a precise estimate of effect. It may include several moderate quality studies that are generally consistent but with wide confidence intervals (low precision) or a group of studies with some inconsistent findings, but with a majority of studies with similar findings. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate. A low-quality body of evidence may be a single moderate-quality study or multiple studies with inconsistent findings or lack of precision. However, it can occur when there is no consistency across studies and precision is low or varies widely. Criteria: Assessing the quality of the body of evidence involves four domains: the aggregate quality of the studies, the consistency of the results, whether the evidence provided is direct or indirect, and the precision of the evidence. These are defined below: Quality of Individual Studies: this considers the quality of the individual studies. It is rated High (all are similar), Moderate (most are similar), Low (no one conclusion is more frequent). We define it as whether the study population is the same as the population of interest and whether the study includes clinical rather than intermediate outcomes. As outlined in Methods, indirect evidence was only included if no direct evidence was found. Precision: Precision is the degree of certainty surrounding the effect estimate for a given outcome. Hypothermia Interventions Detail Included in the table below are details about the hypothermia intervention in the studies considered for Meta-analysis. Based on this information it was determined that the interventions differed in clinically important ways. Characteristics of the Hypothermia Aibiki, Clifton, Clifton, Clifton, Jiang, Liu, Marion, Intervention 2000 1993 2001 2011 2000 2006 1997 Qiu, 2005 Cooling duration 3-4 48 hours 48 hours 48 hours 3-14 3 days 24 hours 4. A concussion is an impairment in neurological function that is usually short lived, but some symptoms could last longer. Not all concussions cause structural damage that can be seen on neuroimaging techniques, yet concussions usually result in neurological disruption. Students with a brain injury have different needs than students with a learning disability or other types of disabilities. Heart rate variability biofeedback for post-concussion syndrome: Implications for treatment. A preliminary study: Heart rate variability biofeedback for treatment of post-concussion syndrome. Magnetic resonance imaging and computerized tomography in relation to the neurobehavioral sequelae of mild and moderate head injuries. Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November 2012. The fuid nature of services and service providers makes it likely that contact information and service availability will change and that some services and/or providers may not be included. It is the responsibility of the user to verify and investigate services and providers to determine the best options for your individual situation. Except as permitted under the United States Copyright Law of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the written permission of the Brain Injury Association of America, Inc.
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Multiple antibiotic resistant strains of Salmonella have been detected in several cats 10 mg strattera medicine 93 948. Prevention of enteric bacterial zoonoses is based on sanitation and control of exposure to feces buy strattera 10 mg otc symptoms 7 days pregnant. Immunodeficient humans should avoid young animals and animals from crowded or unsanitary housing purchase strattera toronto symptoms norovirus, particularly if clinical signs of gastrointestinal tract disease are occurring. Infection of people by feline enteric agents is usually from contact with feces in the environment, by ingestion of contaminated food or water, or by ingestion of undercooked meat (T. The following guidelines may lessen the risk of transfer of feline enteric zoonotic agents to people. Remove the coverslip and place on a clean microscope slide for microscopic examination 8. Examine the entire area under the coverslip for the presence of eggs, cysts, oocysts, or larvae at 100X. Drugs used in the management feline gastrointestinal diseases Paromomycin 150 mg/kg, q12-24hr, for 5 days, Cryptosporidium spp. Prevalence of enteric zoonoses in cats and kittens a b Adult cats Cats < 1yr (n =206) (n = 263) Ancylostoma spp. Herpesvirus 1 (rhinotracheitis) and calicivirus are the most common viral causes of sneezing and nasal discharge in the cat. Herpesvirus can be documented by direct fluorescent staining of conjunctival scrapings, virus isolation, or polymerase chain reaction. Since herpesvirus can be detected in conjunctival cells of approximately 25% of healthy cats, the positive predictive value of these tests in diseased cats is low. Topical administration of alpha interferon in saline to the eyes of cats with conjunctivitis or the nose may aid in the management of some cats. Lysine and alpha interferon are unlikely to lead to a cure, but hopefully will lessen clinical signs of disease. Intranasal administration of modified live, intranasal herpesvirus 1 and calicivirus vaccines may lessen disease in some chronically infected cats. Acyclovir is an anti-herpesvirus drugs for use in people but can be toxic to cats. After 1 year of age risk of infection by herpesvirus 1, calicivirus, and panleukopenia should be assessed. Almost all cats with mucopurulent or purulent nasal discharge have a bacterial component to their disease. Primary bacterial disease is rare but may be associated with Bordetella bronchiseptica, Mycoplasma spp. L-form bacteria also occasionally infect the nasal cavity and usually respond to doxycycline or quinolones. Most cases of bacterial rhinitis are secondary to other diseases including trauma, neoplasia, inflammation induced by viral infection, foreign bodies, inflammatory polps, and tooth root abscessation. Thus, if routine antibiotic therapy fails, a diagnostic workup should be performed. Due to the large number of normal flora in the nasal cavity, culture and sensitivity results from nasal discharges are hard to interpret. Since bacterial rhinitis leads to chondritis and osteomyelitis, antibiotic therapy should be continued for weeks in cats with chronic disease. I generally use drugs with an anaerobic spectrum that also penetrate bone and cartilage. Doxycycline and metronidazole may be superior to other drugs for the treatment of chronic infections since they may modulate the immune reaction, lessening inflammation. Feline leukemia virus and feline immunodeficiency virus can induce immunosuppression predisposing to bacterial rhinitis. In addition, both viruses have been linked to an increased incidence of lymphoma in cats. Chlamydophila infection in cats generally only results in mild conjunctivitis, and so whether vaccination is ever required is controversial. Duration of immunity for Chlamydophila vaccines may be short-lived, so high-risk cats should be immunized prior to a potential exposure. Many cats have antibodies against Bordetella bronchiseptica and there are sporadic reports of severe lower respiratory disease due to bordetellosis, primarily in young, stressed kittens. However, in pet cats, significance of the problem is undefined and for now Bordetella vaccination should be considered primarily for use in cats at high risk for exposure. During this time period, of the 15,000 cat admissions approximately 1500 had respiratory disease. Since the disease is apparently not life-threatening in adult cats, is uncommon, and responds to a variety of antibiotics, routine use of the vaccine in client-owned cats seemed unnecessary in this population. The route of transmission for Cryptococcus neoformans is thought to be inhalation; nasal and pulmonary disease manifestations are common. Infected cats range from 6 months to 16 years of age, and male cats are over represented in most studies. The nasal discharge can be unilateral or bilateral, ranges from serous to mucopurulent, and often contains blood. Granulomatous lesions extruding from the external nares, facial deformity over the bridge of the nose, and ulcerative lesions on the nasal planum are common. Single or multiple, small (< 1 cm), cutaneous or subcutaneous masses occur in approximately 30% to 50% of cats infected with Cryptococcus neoformans.