Co-circulation of human metapneumovirus and SARS-associated coronavirus during a major nosocomial SARS outbreak in Hong Kong

Background

The clinico-epidemiological significance of human metapneumovirus (hMPV) detected during the SARS outbreak is unknown.

Objectives

To characterize a nosocomial hMPV outbreak during the 2003 SARS epidemic.

Study design and methods

All available nasopharyngeal aspirate (NPA) collected from confirmed patients during the first 8 weeks of the SARS outbreak in 2003 were tested for hMPV by a nested RT-PCR assay targeting the F-gene. Clinico-epidemiological information was used to analyze the relationship of hMPV co-infection to specific risk factors (demographics/symptoms/outcomes; status as health-care workers (HCWs)/patients; history of exposure/contact; ward location). Multivariate logistic regression analysis was performed to determine independent risk factors.

Results

An hMPV outbreak occurred during 6–16 March 2003 (first week of the Hong Kong SARS epidemic). hMPV RNA was detected in 31 of 155 (20%) NPAs from SARS patients. HCW status (OR 2.72, 95% CI 1.11–6.68; p = 0.029) or epidemiological linkage to the SARS outbreak ward (OR 3.59, 95% CI 1.42–9.05; p = 0.007) were independent factors associated with hMPV infection. Symptoms of cough and coryza were more common in co-infected individuals (22.6% vs. 15.9%) but this was not statistically significant. Other clinical manifestations and outcomes were not different in co-infected patients.

Conclusions

A major nosocomial hMPV outbreak involving HCWs occurred during the early SARS epidemic. Patients with dual hMPV and SARS infection were not sicker than those with SARS infection only.

Hypercytokinemia and hyperactivation of phospho-p38 mitogen-activated protein kinase in severe human influenza A virus infection

BACKGROUND

We postulate that hypercytokinemia plays a role in immunopathogenesis of severe human influenza.

METHODS

We prospectively studied 39 consecutive patients who were hospitalized with severe influenza A virus infection. On laboratory confirmation of the diagnosis, paired acute-phase (obtained at hospital admission) and convalescent-phase (obtained >10 days after hospital admission) plasma samples were collected for assay of 11 cytokines and chemokines (interleukin [IL] 1 beta; IL-6; IL-10; IL-12p70; tumor necrosis factor alpha; IL-8; monokine induced by interferon [IFN]-gamma; IFN-inducible protein 10; monocyte chemoattractant protein 1; regulated upon activation, normal T cell-expressed and secreted; and IFN-gamma) using cytometric bead-array analysis and enzyme-linked immunosorbent assay. Simultaneously, virus concentration in the acute-phase nasopharyngeal aspirate was determined using real-time quantitative reverse-transcriptase polymerase chain reaction. Intracellular signaling molecules regulating lymphocyte activation, phospho-p38 mitogen-activated protein kinase and phospho-extracellular signal-regulated protein kinase in CD4+ and CD8+ T lymphocytes were studied in the acute-phase samples using flow cytometric analysis and were compared with results for samples from healthy control subjects.

RESULTS

Statistically significant increases in plasma IL-6 (3.7-fold increase), IL-8 (2.6-fold increase), IFN-induced protein 10 (4.9-fold increase), and monokine induced by IFN-gamma (2.3-fold increase) concentrations were detected during acute illness (P < .01 for all, by Wilcoxon signed-rank test); the highest concentrations were observed on symptom days 3 and 4. Corresponding plasma cytokine and chemokine concentrations and nasopharyngeal viral loads showed statistically significant correlations (rho = 0.41, 0.49, 0.54, and 0.46, respectively; P < or = .01). Phospho-p38 mitogen-activated protein kinase expression in CD4+ lymphocytes was increased, correlating with cytokine concentrations (e.g., for IFN-induced protein 10, rho = 0.78; P < .01); phospho-extracellular signal-regulated protein kinase was suppressed. Advanced age and comorbidity were associated with aberrant IL-6, IL-8, and monokine induced by IFN-gamma responses (P < .05, by Mann-Whitney U test). An elevated IL-6 concentration was independently associated with prolonged hospitalization (hospitalization for >5 days; P = .02), adjusted for age, comorbidity, and virus load.

CONCLUSIONS

Hypercytokinemia (of proinflammatory and T helper 1 cytokines) is detected in severe influenza, correlating with clinical illness and virus concentration. Hyperactivation of phospho-p38 mitogen-activated protein kinase (in T helper cells) is possibly involved. Early viral suppression may attenuate these potentially deleterious cytokine responses.

Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) as a predictor of response in head and neck squamous cell carcinoma (HNSCC)

6007

Background: We wish to assess on a preliminary basis whether pretreatment DCE-MRI predicts response to chemoradiation in HNSCC. Methods: Tumor perfusion was assessed in 14 patients (median age, 56y; 13 M, 1 F; squamous cell cancer 13, poorly differentiated carcinoma 1; base of tongue 6; tonsil 6; larynx 1; nasopharynx 1) with nodal metastases (size >1 cc for DCE-MRI; N1, 3; N2a, 2; N2b, 4; N2c, 4; N3, 1; Stage III, 3; Stage IVa, 10; Stage IVb, 1) prior to platin-based concurrent chemoradiation therapy. Data were acquired on a 1.5 Tesla clinical scanner with a standard MRI protocol using a clinical contrast agent (Gd-DTPA). The two compartment model analysis measured the rate constants of the contrast agent transfer between the lesion and plasma compartments (kep) and elimination by the plasma (kel). Each patient was assigned a single MR imaging parameter of uptake slope and compartmental model (Akep) on the basis of the histogram analysis of all individually fit tumor voxels. Histogram analysis calculated the amplitude (a), width (s), and median (μ) of the distribution from the fitting procedure. Overall response was determined approximately 2–5 months post treatment. Results: DCE-MRI data showed a rapid rise in the time intensity curves for viable appearing tumor, whereas muscle showed minimal signal enhancement. The mean Akep value was higher for complete responders (CR/near CR, n = 7) than for incomplete responders (ICR, n = 7; 3 partial response, 4 no response) (12.29/min±4.09 vs 7.11/min±2.51 [P = 0.04]. The preliminary histogram analysis for the slope showed that the width and median were able to differentiate between CR and ICR, P=0.039 and P=0.013 respectively, while amplitude was not significant (P=0.150). Conclusions: These preliminary data suggest that DCE-MRI may prove to be a useful predictor of response in HNSCC patients, and thus may enhance prognostication, patient selection, and treatment outcomes.

No significant financial relationships to disclose.

A phase II trial of irinotecan, 5-fluorouracil and leucovorin in patients with previously untreated advanced colorectal cancer (CRC)

14599

Background: We prospectively conducted a phase II trial to test the efficacy and safety of irinotecan, 5-fluorouracil and leucovorin (FOLFIRI) regimens for the first-line treatment of previously untreated patients with recurrent or metastatic advanced CRC. Methods: Thirty-four previously untreated patients with advanced CRC were enrolled in this study from June 2001 to December 2006. Eligible patients had histologically confirmed adenocarcinoma, no prior systemic therapy in palliative setting, ECOG PS = 2, adequate organ function, written informed consent and at least one measurable disease. The patients received either irinotecan 180 mg/m2 on day 1 with a LV bolus of 200 mg/m2 and a FU bolus of 400 mg/m2, and this was followed by a FU continuous infusion of 600 mg/m2 on day 1 and day 2 (the classic FOLFIRI regimen), or they were treated with a LV bolus of 400 mg/m2 and a FU bolus of 400 mg/m2 followed by a FU continuous infusion of 2,400 mg/m2 for 46 hours (the simplified FOLFIRI regimen), and these treatments were repeated every 2 weeks until disease progression. Results: There were 13 females and 21 males with median age of 54 years (range: 41–79). The most common metastatic sites were lung and liver. A total of 262 cycles were administrated with median 6 cycles per patient (range: 1–22). All pts were evaluable for toxicity, and 30 pts for response to the treatment. The objective response rate was 26.4% with 2 complete responses respectively. Sixteen (47%) pts had stable disease and 7 (20.5%) had a progression. The tumor control rate was 73.4%. The median TTP was 5.3 months, and the overall survival was 10.1 months. The prognostic factor for longer TTP and survival was the ECOG performance status (PS). The type of regimens was not affected on response rate, TTP and survival. The chemotherapy was generally well tolerated and the most common grade 3–4 toxicities were neutropenia, diarrhea. The non- hematological toxicities were similar for both treatment groups, with more frequent grade =3 neutropenia being noted for the simplified FOLFIRI regimen. Conclusions: The FOLFIRI regimen was demonstrated to have a moderate antitumor activity with acceptable toxicity profiles, and tend to show more favorable outcome for patients with good ECOG PS.

No significant financial relationships to disclose.

Features discriminating SARS from other severe viral respiratory tract infections

This study investigated the discriminatory features of severe acute respiratory syndrome (SARS) and severe non-SARS community-acquired viral respiratory infection (requiring hospitalization) in an emergency department in Hong Kong. In a case-control study, clinical, laboratory and radiological data from 322 patients with laboratory-confirmed SARS from the 2003 SARS outbreak were compared with the data of 253 non-SARS adult patients with confirmed viral respiratory tract infection from 2004 in order to identify discriminatory features. Among the non-SARS patients, 235 (93%) were diagnosed as having influenza infections (primarily H3N2 subtype) and 77 (30%) had radiological evidence of pneumonia. In the early phase of the illness and after adjusting for baseline characteristics, SARS patients were less likely to have lower respiratory symptoms (e.g. sputum production, shortness of breath, chest pain) and more likely to have myalgia (p < 0.001). SARS patients had lower mean leukocyte and neutrophil counts (p < 0.0001) and more commonly had “ground-glass” radiological changes with no pleural effusion. Despite having a younger average age, SARS patients had a more aggressive respiratory course requiring admission to the ICU and a higher mortality rate. The area under the receiver operator characteristic curve for predicting SARS when all variables were considered was 0.983. Using a cutoff score of >99, the sensitivity was 89.1% (95%CI 82.0–94.0) and the specificity was 98.0% (95%CI 95.4–99.3). The area under the receiver operator characteristic curve for predicting SARS when all variables except radiological change were considered was 0.933. Using a cutoff score of >8, the sensitivity was 80.7% (95%CI 72.4–87.3) and the specificity was 94.5% (95%CI 90.9–96.9). Certain clinical manifestations and laboratory changes may help to distinguish SARS from other influenza-like illnesses. Scoring systems may help identify patients who should receive more specific tests for influenza or SARS.

Role of laboratory variables in differentiating SARS-coronavirus from other causes of community-acquired pneumonia within the first 72 h of hospitalization

The Centers for Disease Control and Prevention (CDC) recommend that SARS-coronavirus (SARS-CoV) testing be considered in epidemiologically high-risk patients hospitalized with community-acquired pneumonia (CAP) if no alternative diagnosis is identified after 72 h. The aim of this study was to identify routine laboratory variables that might indicate the need for SARS-CoV testing. Routine hematological/biochemical variables in patients with laboratory-confirmed SARS (2003) were compared with those in consecutive patients hospitalized June–December 2004 with radiologically confirmed CAP. Stepwise logistic regression analyses were performed to identify discriminating variables at baseline and by day 3 of hospitalization. Nasopharyngeal aspiration and antigen detection for influenza virus and respiratory syncytial virus using an immunofluorescence assay (IFA) were routinely performed in patients with CAP. Altogether, 181 patients with CAP (who remained undiagnosed by IFA) and 303 patients with SARS were studied. The mean intervals from symptom onset to admission were 3.1 and 2.8 days, respectively (p > 0.05). The etiological agent of CAP was identified retrospectively in only 39% of cases, the majority being bacterial pathogens. At baseline, age and absolute neutrophil count (ANC) were the only independent discriminating variables (p < 0.0001). Using a value of <4.4 × 10⁹/l as the cutoff for ANC, the sensitivity and specificity of ANC for discriminating SARS were 64 and 95%, respectively (AUC 0.90). By day 3 of hospitalization, age (p < 0.0001), change in ANC (p = 0.0003), and change in bilirubin (p = 0.0065) were discriminating variables. A model combining age <65 years, a change in ANC of >−3 × 10⁹/l, and a change in bilirubin of ≥0 mmol/l had a sensitivity of 43% and a specificity of 95% for SARS (AUC 0.90). There are only a few laboratory features (including lymphopenia) that clearly discriminate SARS from other causes of CAP. Nevertheless, when evaluating epidemiologically high-risk patients with CAP and no immediate alternative diagnosis, a low ANC on presentation along with poor clinical and laboratory responses after 72 h of antibiotic treatment may raise the index of suspicion for SARS and indicate a need to perform SARS-CoV testing.

Cross-sectional comparison of physical activity and inactivity patterns in Chinese and Filipino youth

BACKGROUND

To compare and contrast youth physical activity (PA) and inactivity patterns in two developing Asian countries: the Philippines and China.

METHODS

Comparative analysis of 1997-1999 Cebu Longitudinal Health and Nutrition Survey and the 1997 China Health and Nutrition Survey, large-scale surveys that included questions on type, frequency and duration of: commuting mode to school, sports/exercise in and outside of school, select sedentary activities and chores.

RESULTS

Filipino data included 760 males and 872 females aged 14-16 years. The comparable Chinese sample consisted of 202 males and 197 females. Active commuting is proportionately high in both countries (70-71% in the Philippines vs. 77-90% in China), although commuting by bicycling is rare in the Philippines (<1%) vs. China ( approximately 35%). Patterns of school sport/exercise participation differ between countries by gender; more Filipino males report school sport/exercise than females (63 vs. 49%) vs. China, where more females participate than males (75 vs. 69%). Sport/exercise outside of school is proportionately low (6-12%) for youth from both countries with a single exception: 74% of Filipino males participate in extra-curricular sport/exercise. Although a higher percentage of Filipino youth report watching television >4 h/day (<10%) vs. Chinese youth (<1%), both are lower than comparable US reports.

CONCLUSION

In the Philippines, continued modernization augurs a decrease in local primary PA sources (chores and active commuting). In China, where youth already are not expected to perform chores, shifts to more passive commuting modes (i.e. increased motorized transportation) are anticipated.

Phase II study of genexol (paclitaxel) and carboplatin as first-line treatment of advanced or metastatic non-small-cell lung cancer (NSCLC)

17049

Background: Genexol is a polymeric micelle loaded paclitaxel without Cremophor EL (CrEL). CrEL has been shown to cause hypersentivity reaction and neuropathy. To evaluate and efficacy, we conducted a phase II study of CrEL-free paclitaxel (genexol) and carboplatin in patients (pts) of advanced or metastatic NSCLC. Methods: Eligibility criteria included: stage IIIB or IV NSCLC without previous chemotherapy and radiotherapy; written informed consent; measurable lesion; age 18–75; ECOG PS 0–3; adequate bone marrow, liver, and renal function; and no CNS disease. The patients received genexol 225 mg/m2 IV on day 1, followed by carboplatin AUC = 6 IV on day 1 every 3 weeks. Primary end points are response and toxicity. Response evaluations were performed after cycles 2, 4, and 6 of chemotherapy according to the RECIST criteria. Results: 36 pts were enrolled between November 2002 and November 2005. Pts characteristics: median age 63 years (range 45–73), median ECOG PS 1 (range 0–3), 13 stage IIIB and 23 IV, 21 adenocarcinoma and 14 squamous cell carcinoma, and 1 large cell carcinoma. At present, 30 pts were evaluable for response and toxicity. Meidan number of treatment cycles was 4 (range 1–6). Seven pts needed dose reduction. Thirteen pts achieved partial response and 13 pts had stable disease. The response rate 43.3%. Grade (gr) 4 neutropenia occurred in 11 pts (36.7%). Gr 1/2 sensory neuropathy occurred in 13 pts (43.3%) and gr 3/4 sensory neuropathy occurred in 5 pts (50%) among 10 pts over 65 year old. Other toxicities included neutropenic fever in 9 pts (30%), gr 4 thrombocytopenia 3 patients (10%), gr 2 hepatic dysfunction 3%, and gr 3 fatigue 10%. Treatment related mortality was not occurred. Complete analysis will be presented. Conclusions: In this trial, the combination of genexol and carboplatin showed a significant activity with acceptable and manageable toxicities as first line treatment for patients with advanced or metastatic NSCLC and dose reduction needed in older patients.

No significant financial relationships to disclose.

Preliminary results of concurrent chemotherapy with intensity-modulated radiation therapy (IMRT) for advanced cancer of the larynx/hypopharynx

5544

Purpose: Retrospective review of an institution’s IMRT experience in treating advanced laryngeal/hypopharyngeal carcinoma with concurrent chemotherapy. Methods: Between 1/02–6/05, 31 patients with advanced laryngeal/hypopharyngeal carcinoma (74% T3/T4 disease;71% stage IV) underwent combined modality treatment. There were 20 laryngeal and 11 hypopharyngeal carcinomas. All patients received definitive IMRT with a median RT dose of 70 Gy. Concurrent chemotherapy was also given to all patients [cis-platinum (100mg/m2/cycle) or carboplatin/5-fluorouracil (J Clin Oncol 2004;22:69) every 3 weeks for 2–3 planned cycles; 3 patients received a weekly paclitaxel/carboplatin program]. Prophylactic feeding tubes (PEG) were placed in all patients. Acute toxicity and late xerostomia were scored using the RTOG radiation morbidity scale. The 2-year estimates for local progression-free rate (LPF), regional progression-free rate (RPF), distant metastases-free rate (DMF), and overall survival (OS) were calculated using the Kaplan-Meier method. Results: With a median follow-up of 17 months (range: 7–48), 2-year estimates of LPF, RPF, DMF, and OS rates were 76%, 94%, 96%, 87%, respectively. All patients with local failure of laryngeal carcinoma had persistent disease at the end of treatment. Grade ≥2 mucositis was experienced by 68% of the patients during treatment. Xerostomia continued to decrease over time from the end of RT and only 4 still complained of Grade 2 xerostomia. A greater proportion of patients with hypopharynx than larynx cancer were still PEG-dependent (55% versus 25%) after combined modality treatment at the time of this analysis. One patient developed laryngeal necrosis. Conclusions: These preliminary results show that IMRT, in combination with chemotherapy, achieved encouraging local control rates in patients with advanced laryngeal/hypopharyngeal carcinoma. Xerostomia improved over time. Pharyngoesophageal stricture with PEG dependency remains a problem especially in patients with hypopharyngeal carcinoma. Strategies using the ability of IMRT to limit the dose delivered to the esophagus and inferior constrictor musculature may be useful to further minimize this late complication.

No significant financial relationships to disclose.

Intensity-modulated radiation therapy for head and neck cancer of unknown primary

5565

Background: Unknown primary head and neck cancers often require comprehensive mucosal and bilateral neck irradiation. With conventional techniques, significant toxicity can develop. Intensity modulated radiation therapy (IMRT) has the potential to minimize toxicity. Methods: From 2000–2005, 21 patients received IMRT for unknown primary head and neck cancer at our center. Median age was 57. Clinical stages were: TxN1: 43%; TxN2b:38%; TxN2c:5%; TxN3:14%. Five patients received IMRT with primary intent and 16 as postoperative therapy. Fourteen received concurrent chemotherapy, most with cisplatin (100mg/m2/cycle) or carboplatin (70mg/m2)/ 5FU (600mg/m2) every 3 weeks for 2–3 cycles. Seven received IMRT alone. Median dose was 66 Gy. PEG tube was placed in 13 patients. Toxicities were evaluated. Regional progression free survival (RPFS), distant metastases free survival (DMFS) and overall survival (OS) were calculated with Kaplan Meier curves. Results: Grade 1 and 2 xerostomia was seen in 57% and 43%. Salivary function improved with time. By 6 months, no patient had greater than grade 1 xerostomia. Grade 1, 2, and 3 acute skin toxicity and mucositis were seen in 67%, 29%, 5% and in 33%, 52%, 14%, respectively. PEG tube was required in 72% who had combined modality and 43% with IMRT alone. Of the 13 with PEG tubes, only 3 required PEG support at the time of last follow up. For those who had PEG removed, median time with PEG was 3.8 months from the end of RT. Two patients treated with combined modality and 1 treated with IMRT alone developed esophageal strictures, but all had improvement or resolution with dilation. Two patients had persistent disease after RT and 1 had late regional failure at 39 months. Two patients developed distant metastases and died. With a median follow up of 14.3 months (5.4–73.4), 2 year RPFS, DMFS, and OS were 88.9%, 89.4%, and 84.0%. Conclusions: Preliminary analysis of IMRT for unknown primary head and neck cancer shows acceptable toxicity and encouraging efficacy. Xerostomia was a common acute complication but patients had marked improvement by 6 months. Esophageal strictures were seen but effectively treated with dilation. Techniques to limit esophageal dose may help further minimize this complication.

No significant financial relationships to disclose.

Peptide YY ablation in mice leads to the development of hyperinsulinaemia and obesity

AIMS/HYPOTHESIS

Obese people exhibit reduced circulating peptide YY (PYY) levels, but it is unclear whether this is a consequence or cause of obesity. We therefore investigated the effect of Pyy ablation on energy homeostasis.

METHODS

Body composition, i.p. glucose tolerance, food intake and hypothalamic neuropeptide expression were determined in Pyy knock-out and wild-type mice on a normal or high-fat diet.

RESULTS

Pyy knock-out significantly increased bodyweight and increased fat mass by 50% in aged females on a normal diet. Male chow-fed Pyy (-/-) mice were resistant to obesity but became significantly fatter and glucose-intolerant compared with wild-types when fed a high-fat diet. Pyy knock-out animals exhibited significantly elevated fasting or glucose-stimulated serum insulin concentrations vs wild-types, with no increase in basal or fasting-induced food intake. Pyy knock-out decreased or had no effect on neuropeptide Y expression in the arcuate nucleus of the hypothalamus, and significantly increased proopiomelanocortin expression in this region. Male but not female knock-outs exhibited significantly increased growth hormone-releasing hormone expression in the ventromedial hypothalamus and significantly elevated serum IGF-I and testosterone levels. This sex difference in activation of the hypothalamo-pituitary somatotrophic axis by Pyy ablation may contribute to the resistance of chow-fed male knock-outs to late-onset obesity.

CONCLUSIONS/INTERPRETATION

PYY signalling is important in the regulation of energy balance and glucose homeostasis, possibly via regulation of insulin release. Therefore reduced PYY levels may predispose to the development of obesity, particularly with ageing or under conditions of high-fat feeding.

Cardiovascular complications of severe acute respiratory syndrome

BACKGROUND AND AIMS

Severe acute respiratory syndrome (SARS) is a virulent viral infection that affects a number of organs and systems. This study examined if SARS may result in cardiovascular complications.

METHODS AND RESULTS

121 patients (37.5 (SD13.2) years, 36% male) diagnosed to have SARS were assessed continuously for blood pressure, pulse, and temperature during their stay in hospital. Hypotension occurred in 61 (50.4%) patients in hospital, and was found in 28.1%, 21.5%, and 14.8% of patients during the first, second, and third week, respectively. Only one patient who had transient echocardiographic evidence of impaired left ventricular systolic function required temporary inotropic support. Tachycardia was present in 87 (71.9%) patients, and was found in 62.8%, 45.4%, and 35.5% of patients from the first to third week. It occurred independent of hypotension, and could not be explained by the presence of fever. Tachycardia was also present in 38.8% of patients at follow up. Bradycardia only occurred in 18 (14.9%) patients as a transient event. Reversible cardiomegaly was reported in 13 (10.7%) patients, but without clinical evidence of heart failure. Transient atrial fibrillation was present in one patient. Corticosteroid therapy was weakly associated with tachycardia during the second (chi(2) = 3.99, p = 0.046) and third week (chi(2) = 6.53, p = 0.01), although it could not explain tachycardia during follow up.

CONCLUSIONS

In patients with SARS, cardiovascular complications including hypotension and tachycardia were common but usually self limiting. Bradycardia and cardiomegaly were less common, while cardiac arrhythmia was rare. However, only tachycardia persisted even when corticosteroid therapy was withdrawn.

Cryptococcosis in apparently immunocompetent patients

BACKGROUND

Few reports have described the clinical and microbiological features of cryptococcosis in immunocompetent patients.

AIM

To compare clinical presentations and outcomes of cryptococcosis in immunocompetent vs. immunocompromised patients.

DESIGN

Retrospective case series.

METHODS

All culture- or histology-confirmed cases (n = 46) of cryptococcosis in two acute hospitals in Hong Kong (1995-2005) were included. Clinical presentations, rates of fungaemia, cerebrospinal fluid (CSF) parameters and clinical outcomes were recorded.

RESULTS

Twenty patients (43.5%) were apparently immunocompetent, 17 (37.0%) had predisposing factors other than HIV infection, and 9 (19.6%) were HIV-positive. Thirty-one (67.4%) presented with meningitis, four (8.7%) with pulmonary cryptococcosis, and 11 (23.9%) with extraneural, extrapulmonary cryptococcosis. Of the immunocompetent patients with retrievable isolates (n = 8), three (37.5%) were Cryptococcus gattii; all isolates (n = 6) from immunocompromised patients were Cryptococcus neoformans var. grubii. Immunocompetent patients more commonly presented with meningitis (80.0% vs. 47.1%, p = 0.03), and tended toward lower rates of fungaemia (10.0% vs. 35.3%, p = 0.06) and mortality (25.0% vs. 52.9%, p = 0.06). Death was associated with fungaemia (p = 0.01) and underlying malignancy (p < 0.01). In cryptococcal meningitis, immunocompetent patients had longer mean time from illness onset to presentation (34.4 vs. 12.6 days, p = 0.02), more intense inflammatory responses (CSF: white blood cells 108 vs. 35 x 10(9)/l, p = 0.03; protein 1.61 g/l vs. 0.79 g/l, p = 0.07), less fungaemia (0% vs. 26.7%, p = 0.04) and more satisfactory clinical outcomes (81.3% vs. 46.7%, p = 0.04).

DISCUSSION

A substantial proportion of patients with cryptococcosis are apparently immunocompetent. C. neoformans var. grubii and C. gattii are the common causes. Immunocompetent patients tend to present with localized, indolent neurological disease, with more intense inflammatory responses but better clinical outcomes.