101
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Okafor EC, Hullsiek KH, Williams DA, Scriven JE, Rhein J, Nabeta HW, Musubire AK, Rajasingham R, Muzoora C, Schutz C, Meintjes G, Meya DB, Boulware DR. Correlation between Blood and CSF Compartment Cytokines and Chemokines in Subjects with Cryptococcal Meningitis. Mediators Inflamm 2020; 2020:8818044. [PMID: 33177951 PMCID: PMC7644322 DOI: 10.1155/2020/8818044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Though peripheral blood is a crucial sample to study immunology, it is unclear whether the immune environment in the peripheral vasculature correlates with that at the end-organ site of infection. Using cryptococcal meningitis as a model, we investigated the correlation between serum and cerebrospinal fluid biomarkers over time. METHODS We analyzed the cerebrospinal fluid and serum of 160 subjects presenting with first episode cryptococcal meningitis for soluble cytokines and chemokines measured by Luminex assay. Specimens were collected at meningitis diagnosis, 1-week, and 2-week post cryptococcal diagnosis. We compared paired samples by Spearman's correlation and the p value was set at <0.01. RESULTS Of the 21 analytes tested at baseline, there was no correlation detected between nearly all analytes. A weak negative correlation was found between serum and cerebrospinal fluid levels of interferon-gamma (Rho = -0.214; p = .007) and interleukin-4 (Rho = -0.232; p = .003). There was no correlation at 1-week post cryptococcal diagnosis. However, at 2-week post cryptococcal diagnosis, there was a weak positive correlation of granulocyte-macrophage colony-stimulating factor levels (Rho = 0.25; p = .007) in serum and cerebrospinal fluid. No cytokine or chemokine showed consistent correlation overtime. CONCLUSION Based on our analysis of 21 biomarkers, serum and cerebrospinal fluid immune responses do not correlate. There appears to be a distinct immune environment in terms of soluble biomarkers in the vasculature versus end-organ site of infection. While this is a model of HIV-related cryptococcal meningitis, we postulate that assuming the blood compartment is representative of the immune function at the end-organ site of infection may not be appropriate.
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Affiliation(s)
| | | | - Darlisha A. Williams
- Department of Medicine, University of Minnesota, 55455 Minneapolis, MN, USA
- Infectious Diseases Institute, Makerere University, P.O. Box 22418 Kampala, Uganda
| | - James E. Scriven
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, Observatory 7925 University of Cape Town, South Africa
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, 55455 Minneapolis, MN, USA
- Infectious Diseases Institute, Makerere University, P.O. Box 22418 Kampala, Uganda
| | - Henry W. Nabeta
- Infectious Diseases Institute, Makerere University, P.O. Box 22418 Kampala, Uganda
| | - Abdu K. Musubire
- Infectious Diseases Institute, Makerere University, P.O. Box 22418 Kampala, Uganda
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, 55455 Minneapolis, MN, USA
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, P.O. Box 1410 Mbarara, Uganda
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, Observatory 7925 University of Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, Observatory 7925 University of Cape Town, South Africa
| | - David B. Meya
- Department of Medicine, University of Minnesota, 55455 Minneapolis, MN, USA
- Infectious Diseases Institute, Makerere University, P.O. Box 22418 Kampala, Uganda
| | - David R. Boulware
- Department of Medicine, University of Minnesota, 55455 Minneapolis, MN, USA
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102
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Phase I EnACT Trial of the Safety and Tolerability of a Novel Oral Formulation of Amphotericin B. Antimicrob Agents Chemother 2020; 64:AAC.00838-20. [PMID: 32747357 PMCID: PMC7508607 DOI: 10.1128/aac.00838-20] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/24/2020] [Indexed: 11/20/2022] Open
Abstract
Amphotericin B deoxycholate (AMB) has substantial toxicities. A novel encochleated amphotericin B deoxycholate (cAMB) formulation has oral bioavailability, efficacy in an animal model, and minimal toxicity due to targeted drug delivery into macrophages, where intracellular fungi reside. We conducted a phase I, ascending-dose trial of cAMB administered at 1.0 g, 1.5 g, or 2.0 g per day in 4 to 6 divided doses among HIV-positive survivors of cryptococcosis (n = 9 per cohort). Amphotericin B deoxycholate (AMB) has substantial toxicities. A novel encochleated amphotericin B deoxycholate (cAMB) formulation has oral bioavailability, efficacy in an animal model, and minimal toxicity due to targeted drug delivery into macrophages, where intracellular fungi reside. We conducted a phase I, ascending-dose trial of cAMB administered at 1.0 g, 1.5 g, or 2.0 g per day in 4 to 6 divided doses among HIV-positive survivors of cryptococcosis (n = 9 per cohort). We assessed the tolerability of cAMB and the adverse events (AEs) associated with cAMB treatment over 3 days. A second trial (n = 9) assessed the tolerability of 1.5 g/day given for 7 days. In the single-ascending-dose study, all subjects received their full daily dose without vomiting (100% tolerability). The cohort receiving 1.0 g had 4 transient clinical AEs in 2 subjects within 48 h and 8 laboratory AEs (n = 6 grade 2, n = 2 grade 1). The cohort receiving 1.5 g had 7 clinical AEs in 1 subject attributed to acute gastroenteritis (n = 4 grade 2) and 5 laboratory AEs (n = 1 grade 2). The cohort receiving 2.0 g had 20 clinical AEs among 5 subjects within 48 h (n = 3 grade 2) and 11 laboratory AEs (n = 2 grade 2, n = 1 grade 3). From a qualitative survey, 26 of 27 subjects (96%) preferred their experience with oral cAMB over their prior experience with intravenous (i.v.) AMB. The second, multiple-dose cohort received 1.5 g/day for 1 week, with 98.4% (248/252) of the doses being taken. Overall, 5 clinical AEs (n = 5 grade 1) and 6 laboratory AEs (n = 6 grade 1) occurred without kidney toxicity. Oral cAMB was well tolerated when given in 4 to 6 divided daily doses without the toxicities commonly seen with i.v. AMB. (This study has been registered at ClinicalTrials.gov under registration no. NCT04031833.)
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103
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Nel J, Dlamini S, Meintjes G, Burton R, Black JM, Davies NECG, Hefer E, Maartens G, Mangena PM, Mathe MT, Moosa MY, Mulaudzi MB, Moorhouse M, Nash J, Nkonyane TC, Preiser W, Rassool MS, Stead D, van der Plas H, van Vuuren C, Venter WDF, Woods JF. Southern African HIV Clinicians Society guidelines for antiretroviral therapy in adults: 2020 update. South Afr J HIV Med 2020; 21:1115. [PMID: 33101723 PMCID: PMC7564911 DOI: 10.4102/sajhivmed.v21i1.1115] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jeremy Nel
- Helen Joseph Hospital, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Sipho Dlamini
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Rosie Burton
- Southern African Medical Unit, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - John M Black
- Department of Medicine, Division of Infectious Diseases, Livingstone Tertiary Hospital, Port Elizabeth, South Africa
| | | | - Eric Hefer
- Private Practice Medical Adviser, Johannesburg, South Africa
| | - Gary Maartens
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Phetho M Mangena
- Department of Internal Medicine, School of Medicine, Pietersburg Hospital, Polokwane, South Africa.,Department of Medicine, School of Medicine, University of Limpopo, Turfloop, South Africa
| | | | - Mahomed-Yunus Moosa
- Department of Infectious Diseases, Division of Internal Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Michelle Moorhouse
- Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Nash
- Specialist Family Physician, Amathole District Clinical Specialist Team, East London, South Africa
| | - Thandeka C Nkonyane
- Department of Infectious Diseases, Faculty of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Department of Medicine, Dr George Mokhari Hospital, Pretoria, South Africa
| | - Wolfgang Preiser
- Department of Medical Virology, National Health Laboratory Service, Tygerberg, South Africa.,Department of Pathology, Faculty of Medicine and Health, Stellenbosch University, Cape Town, South Africa
| | - Mohammed S Rassool
- Clinical HIV Research Unit, Wits Health Consortium, Johannesburg, South Africa
| | - David Stead
- Department of Medicine, Faculty of Infectious Diseases, Frere and Cecilia Makiwane Hospitals, East London, South Africa.,Department of Medicine, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
| | - Helen van der Plas
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Cloete van Vuuren
- Department of Internal Medicine, Military Hospital, Bloemfontein, South Africa.,Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joana F Woods
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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104
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Kwizera R, Sadiq A, Ndyetukira JF, Nalintya E, Williams D, Rhein J, Boulware DR, Meya DB. Impact of community engagement and social support on the outcomes of HIV-related meningitis clinical trials in a resource-limited setting. RESEARCH INVOLVEMENT AND ENGAGEMENT 2020; 6:49. [PMID: 32843994 PMCID: PMC7441728 DOI: 10.1186/s40900-020-00228-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/11/2020] [Indexed: 05/16/2023]
Abstract
BACKGROUND Clinical trials remain the cornerstone of improving outcomes for HIV-infected individuals with cryptococcal meningitis. Community engagement aims at involving participants and their advocates as partners in research rather than merely trial subjects. Community engagement can help to build trust in communities where these trials are conducted and ensure lasting mutually beneficial relationships between researchers and the community. Similarly, different studies have reported the positive effects of social support on patient's outcomes. We aimed to describe our approach to community engagement in Uganda while highlighting the benefits of community engagement and social support in clinical trials managing patients co-infected with HIV and cryptococcal meningitis. METHODS We carried out community engagement using home visits, health talks, posters, music and drama. In addition, social support was given through study staff individually contributing to provide funds for participants' food, wheel chairs, imaging studies, adult diapers, and other extra investigations or drugs that were not covered by the study budget or protocol. The benefits of this community engagement and social support were assessed during two multi-site, randomized cryptococcal meningitis clinical trials in Uganda. RESULTS We screened 1739 HIV-infected adults and enrolled 934 with cryptococcal meningitis into the COAT and ASTRO-CM trials during the period October 2010 to July 2017. Lumbar puncture refusal rates decreased from 31% in 2010 to less than 1% in 2017. In our opinion, community engagement and social support played an important role in improving: drug adherence, acceptance of lumbar punctures, data completeness, rate of screening/referrals, reduction of missed visits, and loss to follow-up. CONCLUSIONS Community engagement and social support are important aspects of clinical research and should be incorporated into clinical trial design and conduct. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01075152 and NCT01802385.
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Affiliation(s)
- Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O.BOX 22418 Kampala, Uganda
| | - Alisat Sadiq
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O.BOX 22418 Kampala, Uganda
| | - Jane Frances Ndyetukira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O.BOX 22418 Kampala, Uganda
| | - Elizabeth Nalintya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O.BOX 22418 Kampala, Uganda
| | - Darlisha Williams
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O.BOX 22418 Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN USA
| | - Joshua Rhein
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O.BOX 22418 Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN USA
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN USA
| | - David B. Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O.BOX 22418 Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN USA
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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105
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Kasibante J, Rutakingirwa MK, Kagimu E, Ssebambulidde K, Ellis J, Tugume L, Mpoza E, Cresswell F, Meya DB. Tuberculosis preventive therapy (TPT) to prevent tuberculosis co-infection among adults with HIV-associated cryptococcal meningitis: A clinician's perspective. J Clin Tuberc Other Mycobact Dis 2020; 20:100180. [PMID: 32875123 PMCID: PMC7452161 DOI: 10.1016/j.jctube.2020.100180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
As part of the END TB strategy, the World Health organization (WHO) recommends provision of tuberculosis preventive therapy (TPT) to all people at high risk of developing active TB disease. Patients with HIV-associated cryptococcal meningitis are severely immunocompromised and therefore should be eligible for TPT. In this commentary we discuss the challenges associated with starting tuberculosis preventive therapy in patients with HIV associated cryptococcal meningitis in a clinical setting, we highlight the benefit, existing gaps and research opportunities of tuberculosis preventive therapy in this patient population.
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Affiliation(s)
- John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Clinical Research Department, London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Fiona Cresswell
- Clinical Research Department, London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK.,Medical Research Council - Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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106
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Eneh PC, Hullsiek KH, Kiiza D, Rhein J, Meya DB, Boulware DR, Nicol MR. Prevalence and nature of potential drug-drug interactions among hospitalized HIV patients presenting with suspected meningitis in Uganda. BMC Infect Dis 2020; 20:572. [PMID: 32758158 PMCID: PMC7405463 DOI: 10.1186/s12879-020-05296-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/26/2020] [Indexed: 11/25/2022] Open
Abstract
Background Management of co-infections including cryptococcal meningitis, tuberculosis and other opportunistic infections in persons living with HIV can lead to complex polypharmacotherapy and increased susceptibility to drug-drug interactions (DDIs). Here we characterize the frequency and types of potential DDIs (pDDIs) in hospitalized HIV patients presenting with suspected cryptococcal or tuberculous meningitis. Methods In a retrospective review of three cryptococcal meningitis trials between 2010 and 2017 in Kampala, Uganda, medications received over hospitalization were documented and pDDI events were assessed. IBM Micromedex DRUGDEX® online drug reference system was used to identify and describe potential interactions as either contraindicated, major, moderate or minor. For antiretroviral DDIs, the Liverpool Drug Interactions Checker from the University of Liverpool was also used to further describe interactions observed. Results In 1074 patients with suspected meningitis, pDDIs were present in 959 (overall prevalence = 89.3%) during the analyzed 30 day window. In total, 278 unique interacting drug pairs were identified resulting in 4582 pDDI events. Of all patients included in this study there was a mean frequency of 4.27 pDDIs per patient. Of the 4582 pDDI events, 11.3% contraindicated, 66.4% major, 17.4% moderate and 5% minor pDDIs were observed. Among all pDDIs identified, the most prevalent drugs implicated were fluconazole (58.4%), co-trimoxazole (25.7%), efavirenz (15.6%) and rifampin (10.2%). Twenty-one percent of the contraindicated pDDIs and 27% of the major ones involved an antiretroviral drug. Increased likelihood of QT interval prolongation was the most frequent potential clinical outcome. Dissonance in drug interaction checkers was noted requiring clinicians to consult more than one database in making clinical decisions about drug combinations. Conclusions The overall prevalence of pDDIs in this population is high. An understanding of drug combinations likely to result in undesired clinical outcomes, such as QT interval prolongation, is paramount. This is especially important in resource limited settings where availability of therapeutic drug monitoring and laboratory follow-up are inconsistent. Adequate quantification of the increased likelihood of adverse clinical outcomes from multiple drug-drug interactions of the same kind in a single patient is needed to aid clinical decisions in this setting.
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Affiliation(s)
- Prosperity C Eneh
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | | | - Daniel Kiiza
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - David B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA.,College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R Boulware
- Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Melanie R Nicol
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA.
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107
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Okurut S, Boulware DR, Olobo J, Meya DB. Landmark clinical observations and immunopathogenesis pathways linked to HIV and Cryptococcus fatal central nervous system co-infection. Mycoses 2020; 63:840-853. [PMID: 32472727 PMCID: PMC7416908 DOI: 10.1111/myc.13122] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022]
Abstract
Cryptococcal meningitis remains one of the leading causes of death among HIV-infected adults in the fourth decade of HIV era in sub-Saharan Africa, contributing to 10%-20% of global HIV-related deaths. Despite widespread use and early induction of ART among HIV-infected adults, incidence of cryptococcosis remains significant in those with advanced HIV disease. Cryptococcus species that causes fatal infection follows systemic spread from initial environmental acquired infection in lungs to antigenaemia and fungaemia in circulation prior to establishment of often fatal disease, cryptococcal meningitis in the CNS. Cryptococcus person-to-person transmission is uncommon, and deaths related to blood infection without CNS involvement are rare. Keen to the persistent high mortality associated with HIV-cryptococcal meningitis, seizures are common among a third of the patients, altered mental status is frequent, anaemia is prevalent with ensuing brain hypoxia and at autopsy, brain fibrosis and infarction are evident. In addition, fungal burden is 3-to-4-fold higher in those with seizures. And high immune activation together with exacerbated inflammation and elevated PD-1/PD-L immune checkpoint expression is immunomodulated phenotypes elevated in CSF relative to blood. Lastly, though multiple Cryptococcus species cause disease in this setting, observations are mostly generalised to cryptococcal infection/meningitis or regional dominant species (C neoformans or gattii complex) that may limit our understanding of interspecies differences in infection, progression, treatment or recovery outcome. Together, these factors and underlying mechanisms are hypotheses generating for research to find targets to prevent infection or adequate therapy to prevent persistent high mortality with current optimal therapy.
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Affiliation(s)
- Samuel Okurut
- Research DepartmentInfectious Diseases InstituteMakerere UniversityKampalaUganda
- Department of MicrobiologySchool of Biomedical SciencesCollege of Health SciencesMakerere UniversityKampalaUganda
| | - David R. Boulware
- Division of Infectious Diseases and International MedicineDepartment of MedicineUniversity of MinnesotaMinneapolisMinnesota
| | - Joseph Olobo
- Department of Immunology and Molecular BiologySchool of Biomedical SciencesCollege of Health SciencesMakerere UniversityKampalaUganda
| | - David B. Meya
- Research DepartmentInfectious Diseases InstituteMakerere UniversityKampalaUganda
- Division of Infectious Diseases and International MedicineDepartment of MedicineUniversity of MinnesotaMinneapolisMinnesota
- Department of MedicineSchool of MedicineCollege of Health SciencesMakerere UniversityKampalaUganda
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108
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Kalinoski T, Malenfant J, Yim C, Jeng A. Case Report: A Case of Severe Cryptococcal Immune Reconstitution Inflammatory Syndrome Presenting with Brain and Intradural Abscesses in an HIV Patient. Am J Trop Med Hyg 2020; 103:713-718. [PMID: 32342852 PMCID: PMC7410480 DOI: 10.4269/ajtmh.20-0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/23/2020] [Indexed: 11/07/2022] Open
Abstract
Clinical worsening or new manifestation of cryptococcal disease following initiation of anti-retroviral therapy (ART) in an HIV patient is a hallmark of cryptococcal immune reconstitution inflammatory syndrome (C-IRIS). However, it can be difficult to distinguish IRIS from worsening or new infection. Here, we present a case of severe C-IRIS involving multiple cerebellar, spinal, and intradural abscesses and spinal arachnoiditis 7 months after ART initiation in an AIDS patient with uncertain prior ART compliance. He had multiple prior episodes of cryptococcal meningitis with complications necessitating ventriculoperitoneal shunt placement and was on suppressive fluconazole when he developed worsening brain manifestations. He received empiric anti-cryptococcal re-induction without improvement. All cerebrospinal fluid cultures remained sterile, with negative Cryptococcus PCR testing, and his condition continued to worsen prior to corticosteroid initiation. Ultimately, C-IRIS was diagnosed by brain biopsy. This case demonstrates an extreme in severity of C-IRIS and in the timeline of presentation after ART initiation.
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Affiliation(s)
- Thomas Kalinoski
- Department of Internal Medicine, Olive View – UCLA Medical Center, Sylmar, California
| | - Jason Malenfant
- Division of Infectious Diseases, Olive View – UCLA Medical Center, Sylmar, California
| | - Catherine Yim
- Department of Radiology, Olive View – UCLA Medical Center, Sylmar, California
| | - Arthur Jeng
- Division of Infectious Diseases, Olive View – UCLA Medical Center, Sylmar, California
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109
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Haumba SM, Toda M, Jeffries R, Ehrenkranz P, Pasipamire M, Ao T, Lukhele N, Mazibuko S, Mkhontfo M, Smith RM, Chiller T. Prevalence of cryptococcal antigen (CrAg) among HIV-positive patients in Eswatini, 2014-2015. Afr J Lab Med 2020; 9:933. [PMID: 32832407 PMCID: PMC7433303 DOI: 10.4102/ajlm.v9i1.933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 04/07/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis is a leading cause of death amongst people living with HIV. However, routine cryptococcal antigen (CrAg) screening was not in the national guidelines in Eswatini. OBJECTIVES A cross-sectional study was conducted between August 2014 and March 2015 to examine CrAg prevalence at Mbabane Government Hospital in Eswatini. METHODS We collected urine and whole blood from antiretroviral-therapy-naïve patients with HIV and a cluster of differentiation 4 (CD4) counts < 200 cells/mm3 for plasma and urine CrAg lateral flow assay (LFA) screening at the national HIV reference laboratory. Two CD4 cut-off points were used to estimate CrAg prevalence: CD4 < 100 and < 200 cells/mm3. Sensitivity and specificity of urine CrAg LFA was compared to plasma CrAg LFA. RESULTS Plasma CrAg prevalence was 4% (8/182, 95% confidence interval [CI]: 2-8) amongst patients with CD4 counts of < 200 cells/mm3, and 8% (8/102, 95% CI: 3-15) amongst patients with CD4 counts of < 100 cells/mm3. Urine CrAg LFA had a sensitivity of 100% (95% CI: 59-100) and a specificity of 80% (95% CI: 72-86) compared with plasma CrAg LFA tests for patients with CD4 < 200 cells/mm3. Forty-three per cent of 99 patients with CD4 < 100 were at World Health Organization clinical stages I or II. CONCLUSION The prevalence of CrAg in Eswatini was higher than the current global estimate of 6% amongst HIV-positive people with CD4 < 100 cell/mm3, indicating the importance of initiating a national screening programme. Mechanisms for CrAg testing, training, reporting, and drug and commodity supply issues are important considerations before national implementation.
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Affiliation(s)
| | - Mitsuru Toda
- Epidemic Intelligence Service (EIS), Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services (CSELS), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States
- Mycotic Diseases Branch (MDB), Division of Foodborne, Waterborne, and Environmental Disease (DFWED), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States
| | | | - Peter Ehrenkranz
- Global Development, Bill and Melinda Gates Foundation, Seattle, Washington, United States
| | | | - Trong Ao
- Centers for Disease Control and Prevention (CDC), Mbabane, Eswatini
| | - Nomthandazo Lukhele
- Ministry of Health Eswatini National AIDS Programme (ENAP), Mbabane, Eswatini
| | - Sikhathele Mazibuko
- Ministry of Health Eswatini National AIDS Programme (ENAP), Mbabane, Eswatini
| | | | - Rachel M Smith
- Mycotic Diseases Branch (MDB), Division of Foodborne, Waterborne, and Environmental Disease (DFWED), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States
| | - Tom Chiller
- Mycotic Diseases Branch (MDB), Division of Foodborne, Waterborne, and Environmental Disease (DFWED), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States
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110
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Skipper C, Schleiss MR, Bangdiwala AS, Hernandez-Alvarado N, Taseera K, Nabeta HW, Musubire AK, Lofgren SM, Wiesner DL, Rhein J, Rajasingham R, Schutz C, Meintjes G, Muzoora C, Meya DB, Boulware DR. Cytomegalovirus Viremia Associated With Increased Mortality in Cryptococcal Meningitis in Sub-Saharan Africa. Clin Infect Dis 2020; 71:525-531. [PMID: 31504335 PMCID: PMC7384323 DOI: 10.1093/cid/ciz864] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/30/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis and tuberculosis are both important causes of death in persons with advanced human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). Cytomegalovirus (CMV) viremia may be associated with increased mortality in persons living with HIV who have tuberculosis. It is unknown whether concurrent CMV viremia is associated with mortality in other AIDS-related opportunistic infections. METHODS We prospectively enrolled Ugandans living with HIV who had cryptococcal meningitis from 2010-2012. Subsequently, we analyzed stored baseline plasma samples from 111 subjects for CMV DNA. We compared 10-week survival rates among those with and without CMV viremia. RESULTS Of 111 participants, 52% (58/111) had detectable CMV DNA (median plasma viral load 498 IU/mL, interquartile range [IQR] 259-2390). All samples tested were positive on immunoglobin G serology. The median CD4+ T cell count was 19 cells/µL (IQR 9-70) and did not differ by the presence of CMV viremia (P = .47). The 10-week mortality rates were 40% (23/58) in those with CMV viremia and 21% (11/53) in those without CMV viremia (hazard ratio 2.19, 95% confidence interval [CI] 1.07-4.49; P = .03), which remained significant after a multivariate adjustment for known risk factors of mortality (adjusted hazard ratio 3.25, 95% CI 1.49-7.10; P = .003). Serum and cerebrospinal fluid cytokine levels were generally similar and cryptococcal antigen-specific immune stimulation responses did not differ between groups. CONCLUSIONS Half of persons with advanced AIDS and cryptococcal meningitis had detectable CMV viremia. CMV viremia was associated with an over 2-fold higher mortality rate. It remains unclear whether CMV viremia in severely immunocompromised persons with cryptococcal meningitis contributes directly to this mortality or may reflect an underlying immune dysfunction (ie, cause vs effect). CLINICAL TRIALS REGISTRATION NCT01075152.
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Affiliation(s)
- Caleb Skipper
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Mark R Schleiss
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | | | - Kabanda Taseera
- Department of Medicine, Mbarara University of Science and Technology, Uganda
| | - Henry W Nabeta
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Sarah M Lofgren
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Darin L Wiesner
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Joshua Rhein
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, South Africa
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Uganda
| | - David B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Sereti I, Sheikh V, Shaffer D, Phanuphak N, Gabriel E, Wang J, Nason MC, Roby G, Ngeno H, Kirui F, Pau A, Mican JM, Rupert A, Bishop R, Agan B, Chomchey N, Teeratakulpisarn N, Tansuphaswadikul S, Langat D, Kosgei J, French M, Ananworanich J, Sawe F. Prospective International Study of Incidence and Predictors of Immune Reconstitution Inflammatory Syndrome and Death in People Living With Human Immunodeficiency Virus and Severe Lymphopenia. Clin Infect Dis 2020; 71:652-660. [PMID: 31504347 PMCID: PMC7384325 DOI: 10.1093/cid/ciz877] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients living with human immunodeficiency virus (PLWH) with low CD4 counts are at high risk for immune reconstitution inflammatory syndrome (IRIS) and death at antiretroviral therapy (ART) initiation. METHODS We investigated the clinical impact of IRIS in PLWH and CD4 counts <100 cells/μL starting ART in an international, prospective study in the United States, Thailand, and Kenya. An independent review committee adjudicated IRIS events. We assessed associations between baseline biomarkers, IRIS, immune recovery at week 48, and death by week 48 with Cox models. RESULTS We enrolled 506 participants (39.3% were women). Median age was 37 years, and CD4 count was 29 cells/μL. Within 6 months of ART, 97 (19.2%) participants developed IRIS and 31 (6.5%) died. Participants with lower hemoglobin at baseline were at higher IRIS risk (hazard ratio [HR], 1.2; P = .004). IRIS was independently associated with increased risk of death after adjustment for known risk factors (HR, 3.2; P = .031). Being female (P = .004) and having a lower body mass index (BMI; P = .003), higher white blood cell count (P = .005), and higher D-dimer levels (P = .044) were also significantly associated with increased risk of death. Decision-tree analysis identified hemoglobin <8.5 g/dL as predictive of IRIS and C-reactive protein (CRP) >106 μg/mL and BMI <15.6 kg/m2 as predictive of death. CONCLUSIONS For PLWH with severe immunosuppression initiating ART, baseline low BMI and hemoglobin and high CRP and D-dimer levels may be clinically useful predictors of IRIS and death risk.
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Affiliation(s)
- Irini Sereti
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Virginia Sheikh
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Douglas Shaffer
- Walter Reed Army Institute of Research/US Army Medical Research Directorate–Africa, Nairobi, Kenya
- Walter Reed Army Institute of Research, US Military Human Immunodeficiency Virus Research Program, Silver Spring, Maryland, USA
| | - Nittaya Phanuphak
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Erin Gabriel
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Jing Wang
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc, National Cancer Institute Campus at Frederick, Maryland, USA
| | - Martha C Nason
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Gregg Roby
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Hellen Ngeno
- Walter Reed Army Institute of Research/US Army Medical Research Directorate–Africa, Nairobi, Kenya
| | - Fredrick Kirui
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
| | - Alice Pau
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joann M Mican
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adam Rupert
- Applied and Developmental Research Directorate, AIDS Monitoring Laboratory, Leidos Biomedical Research, Inc, Frederick, Maryland, USA
| | - Rachel Bishop
- National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Brian Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Nitiya Chomchey
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Nipat Teeratakulpisarn
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Deborah Langat
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Josphat Kosgei
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Martyn French
- University of Western Australia, Medical School and School of Biomedical Sciences, Nedlands, Australia
| | - Jintanat Ananworanich
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- US Military Human Immunodeficiency Virus Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Department of Global Health, Amsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Fredrick Sawe
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
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A pragmatic approach to managing antiretroviral therapy-experienced patients diagnosed with HIV-associated cryptococcal meningitis: impact of antiretroviral therapy adherence and duration. AIDS 2020; 34:1425-1428. [PMID: 32590438 PMCID: PMC7473821 DOI: 10.1097/qad.0000000000002556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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113
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Li YY, Dong RJ, Shrestha S, Upadhyay P, Li HQ, Kuang YQ, Yang XP, Zhang YG. AIDS-associated Talaromyces marneffei central nervous system infection in patients of southwestern China. AIDS Res Ther 2020; 17:26. [PMID: 32456686 PMCID: PMC7249401 DOI: 10.1186/s12981-020-00281-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 05/15/2020] [Indexed: 12/12/2022] Open
Abstract
Background The clinical and laboratory characteristics of AIDS-associated Talaromyces marneffei infection, a rare but a fatal mycosis disease of the central nervous system, remain unclear. Case presentation Herein, we conducted a retrospective study of ten AIDS patients with cerebrospinal fluid culture-confirmed central nervous system infection caused by Talaromyces marneffei. All 10 patients were promptly treated with antifungal treatment for a prolonged duration and early antiviral therapy (ART). Among them, seven patients were farmers. Nine patients were discharged after full recovery, while one patient died during hospitalization, resulting in a mortality rate of 10%. All patients initially presented symptoms and signs of an increase in intracranial pressure, mainly manifesting as headache, dizziness, vomiting, fever, decreased muscle strength, diplopia or even altered consciousness with seizures in severe patients. Nine patients (90%) showed lateral ventricle dilatation or intracranial infectious lesions on brain CT. Cerebrospinal fluid findings included elevated intracranial pressure, increased leukocyte count, low glucose, low chloride and high cerebrospinal fluid protein. The median CD4+ T count of patients was 104 cells/μL (IQR, 36–224 cells/μL) at the onset of the disease. The CD4+ T cell counts of three patients who eventually died were significantly lower (W = 6.00, p = 0.020) than those of the patients who survived. Conclusions The common clinical symptoms of T. marneffei central nervous system infection are associated with high intracranial pressure and intracranial infectious lesions. Earlier recognition and diagnosis and a prolonged course of amphotericin B treatment followed by itraconazole combined with early ART might reduce the mortality rate.
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114
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Boyd MA, Boffito M, Castagna A, Estrada V. Rapid initiation of antiretroviral therapy at HIV diagnosis: definition, process, knowledge gaps. HIV Med 2020; 20 Suppl 1:3-11. [PMID: 30724450 DOI: 10.1111/hiv.12708] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2018] [Indexed: 01/14/2023]
Abstract
Initiating antiretroviral therapy (ART) as early as the day of HIV diagnosis is a strategy of increasing global interest to control the HIV epidemic and optimize the health of people living with HIV (PLWH). No detrimental effects of rapid-start ART have been identified in randomized controlled trials undertaken in low- or middle-income countries, or in cohort studies performed in high-income countries. Rapid-start ART may be a key approach in reaching the 2020 Joint United Nations Programme on HIV/AIDS goal of 90% of all PLWH knowing their status, 90% of those diagnosed receiving sustained ART, and 90% of those receiving ART achieving viral suppression; it may also be important for achieving the suggested fourth "90%" goal: improving health-related quality-of-life in PLWH. Presently there is insufficient broad evidence for guidelines to recommend universal test-and-treat strategies for all people, in all settings, at HIV diagnosis; consequently, there is a pressing need to conduct high-quality studies that investigate immediate ART initiation. This article evaluates global evidence regarding rapid-start ART, including same-day start, with particular focus on the implementation of this strategy in high-income countries.
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Affiliation(s)
- M A Boyd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - M Boffito
- Chelsea and Westminster Hospital, London, UK.,Imperial College London, London, UK
| | - A Castagna
- Clinic of Infectious Diseases, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - V Estrada
- Hospital Clinico San Carlos, Universidad Complutense, Madrid, Spain
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115
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Mortality After Cryptococcal Infection in the Modern Antiretroviral Therapy Era. J Acquir Immune Defic Syndr 2020; 82:81-87. [PMID: 31408451 DOI: 10.1097/qai.0000000000002095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The prevalence of cryptococcosis in people living with HIV (PLWH) in the developed world has decreased considerably in the modern antiretroviral therapy (ART) era. Although early mortality of PLWH with opportunistic infections is well understood, overall mortality has not been previously evaluated. METHODS We conducted a retrospective cohort study of cryptococcosis in PLWH from January 1, 2002, to July 1, 2017. Data were also evaluated before and after 2008 to evaluate the possible effect of modern ART on outcomes. Death date was obtained from the hospital's medical informatics database and the Social Security Death Index. Participants were grouped as survivors, early-mortality (death <90 days), and late-mortality (death ≥90 days) individuals. RESULTS We reviewed 105 PLWH with cryptococcosis, with 55 survivors (52.4%), 17 early-mortality (16.2%), and 33 late-mortality individuals (31.4%). Overall, mortality was 47.6% (n = 50) with a median follow-up of 3.7 years (interquartile range 1.1, 8.1 years). Late-mortality individuals were less likely to be virally suppressed at the last observation compared with survivors (24% vs 62%, P < 0.001). Individuals diagnosed in the modern ART era had significantly lower mortality (hazard ratio 0.5, confidence interval: 0.2 to 0.8) and were more likely to be virally suppressed at the last observation (57% vs 29%, P = 0.003). Individuals with government-provided insurance had a higher mortality compared to those with private insurance (hazard ratio 2.8, confidence interval: 1.1 to 7.2, P = 0.013). CONCLUSIONS Despite improvements in ART, PLWH have high mortality after cryptococcal infection that persists beyond their initial hospitalization. Lower mortality was associated with increased HIV viral suppression and private insurance in the modern ART era.
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Rajasingham R, Boulware DR. Cryptococcal Antigen Screening and Preemptive Treatment-How Can We Improve Survival? Clin Infect Dis 2020; 70:1691-1694. [PMID: 31179484 PMCID: PMC7145997 DOI: 10.1093/cid/ciz488] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/06/2019] [Indexed: 12/26/2022] Open
Affiliation(s)
- Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis
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117
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Cresswell FV, Ellis J, Kagimu E, Bangdiwala AS, Okirwoth M, Mugumya G, Rutakingirwa M, Kasibante J, Quinn CM, Ssebambulidde K, Rhein J, Nuwagira E, Tugume L, Martyn E, Skipper CP, Muzoora C, Grint D, Meya DB, Bahr NC, Elliott AM, Boulware DR. Standardized Urine-Based Tuberculosis (TB) Screening With TB-Lipoarabinomannan and Xpert MTB/RIF Ultra in Ugandan Adults With Advanced Human Immunodeficiency Virus Disease and Suspected Meningitis. Open Forum Infect Dis 2020; 7:ofaa100. [PMID: 32373646 PMCID: PMC7192026 DOI: 10.1093/ofid/ofaa100] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diagnosis of extrapulmonary tuberculosis (TB) remains challenging. We sought to determine the prevalence of disseminated TB by testing urine with TB-lipoarabinomannan (TB-LAM) lateral flow assay and Xpert MTB/RIF Ultra (Ultra) in hospitalized adults. METHODS We prospectively enrolled human immunodeficiency virus (HIV)-positive adults with suspected meningitis in Uganda during 2018-2020. Participants underwent standardized urine-based TB screening. Urine (60 mcL) was tested with TB-LAM (Alere), and remaining urine was centrifuged with the cell pellet resuspended in 2 mL of urine for Xpert Ultra testing. RESULTS We enrolled 348 HIV-positive inpatients with median CD4 of 37 cells/mcL (interquartile range, 13-102 cells/mcL). Overall, 26% (90 of 348; 95% confidence interval [CI], 21%-30%) had evidence of disseminated TB by either urine assay. Of 243 participants with both urine TB-LAM and Ultra results, 20% (48 of 243) were TB-LAM-positive, 12% (29 of 243) were Ultra-positive, and 6% (14 of 243) were positive by both assays. In definite and probable TB meningitis, 37% (14 of 38) were TB-LAM-positive and 41% (15 of 37) were Ultra-positive. In cryptococcal meningitis, 22% (40 of 183) were TB-LAM-positive and 4.4% (6 of 135) were Ultra-positive. Mortality trended higher in those with evidence of disseminated TB by either assay (odds ratio = 1.44; 95% CI, 0.83-2.49; P = .19) and was 6-fold higher in those with definite TB meningitis who were urine Ultra-positive (odds ratio = 5.67; 95% CI, 1.13-28.5; P = .04). CONCLUSIONS In hospitalized Ugandans with advanced HIV disease and suspected meningitis, systematic screening with urine TB-LAM and Ultra found a high prevalence of urine TB test positivity (26%). In those with TB meningitis, urine tests were positive in over one third. There was little concordance between Ultra and TB-LAM, which warrants further investigation.
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Affiliation(s)
- Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jayne Ellis
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ananta S Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael Okirwoth
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gerald Mugumya
- Microbiology Laboratory, Kiruddu Referral Hospital, Kampala, Uganda
| | | | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Carson M Quinn
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Emily Martyn
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Caleb P Skipper
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Daniel Grint
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Alison M Elliott
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Pastick KA, Nalintya E, Tugume L, Ssebambulidde K, Stephens N, Evans EE, Ndyetukira JF, Nuwagira E, Skipper C, Muzoora C, Meya DB, Rhein J, Boulware DR, Rajasingham R. Cryptococcosis in pregnancy and the postpartum period: Case series and systematic review with recommendations for management. Med Mycol 2020; 58:282-292. [PMID: 31689712 PMCID: PMC7179752 DOI: 10.1093/mmy/myz084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/03/2019] [Accepted: 07/18/2019] [Indexed: 01/21/2023] Open
Abstract
Cryptococcal meningitis causes 15% of AIDS-related deaths. Optimal management and clinical outcomes of pregnant women with cryptococcosis are limited to case reports, as pregnant women are often excluded from research. Amongst pregnant women with asymptomatic cryptococcosis, no treatment guidelines exist. We prospectively identified HIV-infected women who were pregnant or recently pregnant with cryptococcosis, screened during a series of meningitis research studies in Uganda from 2012 to 2018. Among 571 women screened for cryptococcosis, 13 were pregnant, one was breastfeeding, three were within 14 days postpartum, and two had recently miscarried. Of these 19 women (3.3%), 12 had cryptococcal meningitis, six had cryptococcal antigenemia, and one had a history of cryptococcal meningitis and was receiving secondary prophylaxis. All women with meningitis received amphotericin B deoxycholate (0.7-1.0 mg/kg). Five were exposed to 200-800 mg fluconazole during pregnancy. Of these five, three delivered healthy babies with no gross physical abnormalities at birth, one succumbed to meningitis, and one outcome was unknown. Maternal meningitis survival rate at hospital discharge was 75% (9/12), and neonatal/fetal survival rate was 44% (4/9) for those mothers who survived. Miscarriages and stillbirths were common (n = 4). Of six women with cryptococcal antigenemia, two received fluconazole, one received weekly amphotericin B, and three had unknown treatment courses. All women with antigenemia survived, and none developed clinical meningitis. We report good maternal outcomes but poor fetal outcomes for cryptococcal meningitis using amphotericin B, without fluconazole in the first trimester, and weekly amphotericin B in place of fluconazole for cryptococcal antigenemia.
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Affiliation(s)
- Katelyn A Pastick
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elizabeth Nalintya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nicole Stephens
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emily E Evans
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jane Frances Ndyetukira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caleb Skipper
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B Meya
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Rutakingirwa MK, Cresswell FV, Kwizera R, Ssebambulidde K, Kagimu E, Nuwagira E, Tugume L, Mpoza E, Dobbin J, Williams DA, Muzoora C, Meya DB, Boulware DR, Hullsiek KH, Rhein J. Tuberculosis in HIV-Associated Cryptococcal Meningitis is Associated with an Increased Risk of Death. J Clin Med 2020; 9:E781. [PMID: 32183112 PMCID: PMC7141367 DOI: 10.3390/jcm9030781] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/28/2020] [Accepted: 02/28/2020] [Indexed: 01/31/2023] Open
Abstract
Tuberculosis (TB) and cryptococcal meningitis are leading causes of morbidity and mortality in advanced HIV disease. Data are limited on TB co-infection among individuals with cryptococcal meningitis. We performed a retrospective analysis of HIV-infected participants with cryptococcal meningitis from 2010-2017. Baseline demographics were compared between three groups: 'prevalent TB' if TB treated >14 days prior to cryptococcal meningitis diagnosis, 'concurrent TB' if TB treated ± 14 days from diagnosis, or 'No TB at baseline'. We used time-updated proportional-hazards regression models to assess TB diagnosis as a risk for death. Of 870 participants with cryptococcal meningitis, 50 (6%) had prevalent TB, 67 (8%) had concurrent TB, and 753 (86%) had no baseline TB. Among participants without baseline TB, 67 (9%) were diagnosed with incident TB (after >14 days), with a median time to TB incidence of 41 days (IQR, 22-69). The 18-week mortality was 50% (25/50) in prevalent TB, 46% (31/67) in concurrent TB, and 45% (341/753) in the no TB group (p = 0.81). However, TB co-infection was associated with an increased hazard of death (HR = 1.75; 95% CI, 1.33-2.32; p < 0.001) in a time-updated model. TB is commonly diagnosed in cryptococcal meningitis, and the increased mortality associated with co-infection is a public health concern.
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Affiliation(s)
- Morris K. Rutakingirwa
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
| | - Enock Kagimu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda; (E.N.); (C.M.)
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
| | - Edward Mpoza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
| | - Joanna Dobbin
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
| | - Darlisha A. Williams
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda; (E.N.); (C.M.)
| | - David B. Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Kathy H. Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Joshua Rhein
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda; (F.V.C.); (R.K.); (K.S.); (E.K.); (L.T.); (E.M.); (J.D.); (D.A.W.); (D.B.M.)
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
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Okurut S, Meya DB, Bwanga F, Olobo J, Eller MA, Cham-Jallow F, Bohjanen PR, Pratap H, Palmer BE, Hullsiek KH, Manabe YC, Boulware DR, Janoff EN. B Cell Compartmentalization in Blood and Cerebrospinal Fluid of HIV-Infected Ugandans with Cryptococcal Meningitis. Infect Immun 2020; 88:e00779-19. [PMID: 31871098 PMCID: PMC7035924 DOI: 10.1128/iai.00779-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/18/2019] [Indexed: 12/17/2022] Open
Abstract
Activated B cells modulate infection by differentiating into pathogen-specific antibody-producing effector plasmablasts/plasma cells, memory cells, and immune regulatory B cells. In this context, the B cell phenotypes that infiltrate the central nervous system during human immunodeficiency virus (HIV) and cryptococcal meningitis coinfection are ill defined. We characterized clinical parameters, mortality, and B cell phenotypes in blood and cerebrospinal fluid (CSF) by flow cytometry in HIV-infected adults with cryptococcal (n = 31) and noncryptococcal (n = 12) meningitis and in heathy control subjects with neither infection (n = 10). Activation of circulating B cells (CD21low) was significantly higher in the blood of subjects with HIV infection than in that of healthy controls and greater yet in matched CSF B cells (P < 0.001). Among B cell subsets, elevated frequencies of memory and plasmablasts/plasma cells most clearly distinguished the CSF from blood compartments. With cryptococcal meningitis, lower frequencies of expression of the regulatory protein programmed death-1 (PD-1) on plasmablasts/plasma cells in blood (median, 7%) at presentation were associated with significantly decreased 28-day survival (29% [4/14 subjects]), whereas higher PD-1 expression (median, 46%) characterized subjects with higher survival (88% [14/16 subjects]). With HIV infection, B cell differentiation and regulatory markers are discrete elements of the circulating and CSF compartments with clinical implications for cryptococcal disease outcome, potentially due to their effects on the fungus and other local immune cells.
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Affiliation(s)
- Samuel Okurut
- Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
- Laboratory Department, Makerere University Walter Reed Project, Kampala, Uganda
| | - David B Meya
- Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Freddie Bwanga
- Department of Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Olobo
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Michael A Eller
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Fatim Cham-Jallow
- Laboratory Department, Makerere University Walter Reed Project, Kampala, Uganda
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Paul R Bohjanen
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Harsh Pratap
- Mucosal and Vaccine Research Program Colorado, Department of Medicine, University of Colorado Denver, Aurora, Colorado, USA
| | - Brent E Palmer
- Mucosal and Vaccine Research Program Colorado, Department of Medicine, University of Colorado Denver, Aurora, Colorado, USA
| | - Katharine H Hullsiek
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Yukari C Manabe
- Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edward N Janoff
- Mucosal and Vaccine Research Program Colorado, Department of Medicine, University of Colorado Denver, Aurora, Colorado, USA
- Denver Veterans Affairs Medical Center, Denver, Colorado, USA
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Antimicrobial Therapy in the Context of the Damage-Response Framework: the Prospect of Optimizing Therapy by Reducing Host Damage. Antimicrob Agents Chemother 2020; 64:AAC.01800-19. [PMID: 31740558 DOI: 10.1128/aac.01800-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
By design, antimicrobial agents act directly on microbial targets. These drugs aim to eliminate microbes and are remarkably effective against susceptible organisms. Nonetheless, some patients succumb to infectious diseases despite appropriate antimicrobial therapy. Today, with very few exceptions, physicians select antimicrobial therapy based on its activity against the targeted organism without consideration of how the regimen affects patients' immune responses. An important concept to emerge in the past few decades is that immune responses to microbes can be detrimental by enhancing host damage, which can translate into clinical disease. A central tenet of the damage-response framework (DRF) of microbial pathogenesis is that the relevant outcome of host-microbe interaction is the damage that occurs in the host, which can be due to microbial factors, host factors, or both. Given that host damage can make patients sick, reducing it should be a goal of treating infectious diseases. Inflammation and damage that stem from the host response to an infectious disease can increase during therapy with some antimicrobial agents and decrease during therapy with others. When a patient cannot eliminate a microbe with their own immune response, antimicrobial therapy is essential for microbial elimination, and yet it can affect the inflammatory response. In this essay, we discuss antimicrobial therapy in the context of the DRF and propose that consideration of the DRF may help tailor therapy to a patient's need to augment or reduce inflammation.
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122
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Top-cited articles in cerebrospinal fluid leak (rhinorrhea and otorrhea) (1945-2018). Braz J Otorhinolaryngol 2020; 87:557-571. [PMID: 31982378 PMCID: PMC9422470 DOI: 10.1016/j.bjorl.2019.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/10/2019] [Indexed: 11/20/2022] Open
Abstract
Introduction As scientific knowledge has grown in biomedicine, it has also become necessary to develop tools to manage and understand the body of evidence. In that sense, bibliometrics has become a consolidated discipline for analyzing scientific activity, enabling the characterization of a particular field or area of knowledge by means of the quantification of the bibliographic characteristics of scientific publications. Objective The objective of this study was to determine the most frequently cited articles in the field of cerebrospinal fluid rhinorrhea and otorrhea. Methods The searches took place on the Clarivate Analytics Web of Science platform, which includes the MEDLINE database. The study period was limited to 1945–2018. Results The 101 most cited articles in the field of cerebrospinal fluid leak were published in 36 journals, and the most important specialties contributing to the literature were neurosurgery and otorhinolaryngology. Of the 101 top-cited articles, 70% were published from 1990 to 2018, with two distinct periods of high scientific productivity: 1990–1999 and 2000–2009. In the first period, the main topic of research interest was endoscopic sinus surgery for cerebrospinal fluid fistulas, whereas from 2000 to 2009, documents focused more on surgical aspects of extended skull base approaches. The articles received 73–767 citations. The top article over the whole study period was “A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap” by Hadad et al., which was published 2006 in Laryngoscope. Its publication represented an inflection point in the literature on cerebrospinal fluid leak and endoscopic skull base surgery, and it gave rise to numerous other research publications. Conclusion Different surgical innovations in the field of cerebrospinal fluid leak sparked two different periods of intense scientific activity. Otorhinolaryngology and neurosurgery were the dominant specialties. The most frequent topic studied was endoscopic surgery; others included clinical and diagnostic features, neurinoma surgery, and cerebrospinal fluid leak related to temporal bone fractures.
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Cryptococcal Immune Reconstitution Inflammatory Syndrome: a Paradoxical Response to a Complex Organism. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Eriksen J, Carlander C, Albert J, Flamholc L, Gisslén M, Navér L, Svedhem V, Yilmaz A, Sönnerborg A. Antiretroviral treatment for HIV infection: Swedish recommendations 2019. Infect Dis (Lond) 2020; 52:295-329. [PMID: 31928282 DOI: 10.1080/23744235.2019.1707867] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The Swedish Reference Group for Antiviral Therapy (RAV) published recommendations for the treatment of HIV infection in this journal most recently in 2017. An expert group under the guidance of RAV here provides updated recommendations. The most important updates in the present guidelines are the following: (a) The risk of HIV transmission through condomless sex from individuals with fully suppressed HIV viral load is effectively zero. (b) Pre-exposure prophylaxis (PrEP) is recommended for groups with a high risk of HIV infection. (c) Since the last update, two new substances have been registered: bictegravir and doravirine. (d) Dual treatment may be an alternative in selected patients, using lamivudine + dolutegravir or lamivudine + boosted darunavir/atazanavir. As with previous publications, recommendations are evidence-graded in accordance with the Oxford Centre for Evidence Based Medicine. This document does not cover treatment of opportunistic infections and tumours.
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Affiliation(s)
- Jaran Eriksen
- Unit of Infectious Diseases/Venhälsan, Södersjukhuset, Stockholm, Sweden.,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Christina Carlander
- Department of Infectious Diseases, Västmanland County Hospital, Västerås, Sweden.,Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jan Albert
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Leo Flamholc
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Navér
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Paediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Veronica Svedhem
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Aylin Yilmaz
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Sönnerborg
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Tugume L, Rhein J, Hullsiek KH, Mpoza E, Kiggundu R, Ssebambulidde K, Schutz C, Taseera K, Williams DA, Abassi M, Muzoora C, Musubire AK, Meintjes G, Meya DB, Boulware DR. HIV-Associated Cryptococcal Meningitis Occurring at Relatively Higher CD4 Counts. J Infect Dis 2020; 219:877-883. [PMID: 30325463 DOI: 10.1093/infdis/jiy602] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/10/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis can occur in persons with less-apparent immunosuppression. We evaluated clinical characteristics and outcomes of persons with HIV-related Cryptococcus presenting with higher CD4 counts. METHODS We enrolled 736 participants from 2 prospective cohorts in Uganda and South Africa from November 2010 to May 2017. We compared participants with CD4 <50, 50-99, or ≥100 cells/μL by clinical characteristics, cerebrospinal fluid (CSF) parameters, and 18-week survival. RESULTS Among first episode of cryptococcosis, 9% presented with CD4 ≥100 cells/μL. Participants with CD4 ≥100 cells/μL presented more often with altered mental status (52% vs 39%; P = .03) despite a 10-fold lower initial median CSF fungal burden of 7850 (interquartile range [IQR] 860-65500) versus 79000 (IQR 7400-380000) colony forming units/mL (P < .001). Participants with CD4 ≥100 cells/μL had higher median CSF levels of interferon-gamma, interleukin (IL)-6, IL-8, and IL-13, and lower monocyte chemokine, CCL2 (P < .01 for each). Death within 18 weeks occurred in 47% with CD4 <50, 35% with CD4 50-99, and 40% with CD4 ≥100 cells/μL (P = .04). CONCLUSION HIV-infected individuals developing cryptococcal meningitis with CD4 ≥100 cells/μL presented more frequently with altered mental status despite having 10-fold lower fungal burden and with greater Th2 (IL-13) immune response. Higher CD4 count was protective despite an increased propensity for immune-mediated damage, consistent with damage-response framework. CLINICAL TRIAL REGISTRATION NCT01075152 and NCT01802385.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | - Darlisha A Williams
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | - Mahsa Abassi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
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Sereti I. Immune reconstruction inflammatory syndrome in HIV infection: beyond what meets the eye. TOPICS IN ANTIVIRAL MEDICINE 2020; 27:106-111. [PMID: 32224502 PMCID: PMC7162680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A high proportion of individuals with HIV infection currently are diagnosed at an advanced stage of disease (late presenters), increasing their risk for immune reconstitution inflammatory syndrome (IRIS). IRIS typically occurs within 6 months of initiation of antiretroviral therapy (ART) in patients with low CD4+ cell counts and can occur before any marked elevation in CD4+ count is achieved on ART. In addition to low CD4+ count at ART initiation, 2 other major clinical predictors of IRIS are preexisting opportunistic infection (including subclinical infection) and shorter treatment period for opportunistic infection prior to starting ART. Mycobacterial infection-associated IRIS, including tuberculosis (TB)-associated IRIS, and cryptococcal infection-associated IRIS are the most common forms of the syndrome. Corticosteroid prophylaxis and early treatment can be effective in reducing incidence of TB-IRIS and severity of symptoms in select patients. Sterilization of the cerebrospinal fluid should be achieved prior to starting ART in patients with TB meningitis and cryptococcal meningitis. This article summarizes a presentation by Irini Sereti, MD, MHS, at the International Antiviral Society-USA (IAS-USA) continuing education program held in Washington, DC, in April 2019.
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Affiliation(s)
- Irini Sereti
- National Institute of Allergy and Infectious Disease at the National Institutes of Health, Bethesda, MD, USA
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Tenforde MW, Gertz AM, Lawrence DS, Wills NK, Guthrie BL, Farquhar C, Jarvis JN. Mortality from HIV-associated meningitis in sub-Saharan Africa: a systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25416. [PMID: 31957332 PMCID: PMC6970088 DOI: 10.1002/jia2.25416] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION HIV-associated cryptococcal, TB and pneumococcal meningitis are the leading causes of adult meningitis in sub-Saharan Africa (SSA). We performed a systematic review and meta-analysis with the primary aim of estimating mortality from major causes of adult meningitis in routine care settings, and to contrast this with outcomes from clinical trial settings. METHODS We searched PubMed, EMBASE and the Cochrane Library for published clinical trials (defined as randomized-controlled trials (RCTs) or investigator-managed prospective cohorts) and observational studies that evaluated outcomes of adult meningitis in SSA from 1 January 1990 through 15 September 2019. We performed random effects modelling to estimate pooled mortality, both in clinical trial and routine care settings. Outcomes were stratified as short-term (in-hospital or two weeks), medium-term (up to 10 weeks) and long-term (up to six months). RESULTS AND DISCUSSION Seventy-nine studies met inclusion criteria. In routine care settings, pooled short-term mortality from cryptococcal meningitis was 44% (95% confidence interval (95% CI):39% to 49%, 40 studies), which did not differ between amphotericin (either alone or with fluconazole) and fluconazole-based induction regimens, and was twofold higher than pooled mortality in clinical trials using amphotericin based treatment (21% (95% CI:17% to 25%), 17 studies). Pooled short-term mortality of TB meningitis was 46% (95% CI: 33% to 59%, 11 studies, all routine care). For pneumococcal meningitis, pooled short-term mortality was 54% in routine care settings (95% CI:44% to 64%, nine studies), with similar mortality reported in two included randomized-controlled trials. Few studies evaluated long-term outcomes. CONCLUSIONS Mortality rates from HIV-associated meningitis in SSA are very high under routine care conditions. Better strategies are needed to reduce mortality from HIV-associated meningitis in the region.
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Affiliation(s)
- Mark W Tenforde
- Division of Allergy and Infectious DiseasesUniversity of Washington School of MedicineSeattleWAUSA
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
| | - Alida M Gertz
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
| | - David S Lawrence
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Nicola K Wills
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
- Welcome Centre for Infectious Diseases Research in AfricaInfectious Disease and Molecular Medicine UnitUniversity of Cape TownCape TownSouth Africa
| | - Brandon L Guthrie
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Carey Farquhar
- Division of Allergy and Infectious DiseasesUniversity of Washington School of MedicineSeattleWAUSA
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
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Stingone C, Sarmati L, Andreoni M. The Clinical Spectrum of Human Immunodeficiency Virus Infection. Sex Transm Infect 2020. [DOI: 10.1007/978-3-030-02200-6_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Masters MC, Krueger KM, Williams JL, Morrison L, Cohn SE. Beyond one pill, once daily: current challenges of antiretroviral therapy management in the United States. Expert Rev Clin Pharmacol 2019; 12:1129-1143. [PMID: 31774001 DOI: 10.1080/17512433.2019.1698946] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Modern antiretroviral therapy (ART) has revolutionized HIV treatment. ART regimens are now highly efficacious, well-tolerated, safe, often with one multi-drug pill, once-daily regimens available. However, clinical challenges persist in managing ART in persons with HIV (PWH), such as drug-drug interactions, side effects, pregnancy, co-morbidities, and adherence.Areas Covered: In this review, we discuss the ongoing challenges of ART for adults in the United States. We review the difficulties of initiating ART and maintaining therapy throughout adulthood and discuss new agents and strategies under investigation to address these issues. A PubMed search was utilized to identify relevant publications and guidelines through July 2019.Expert Opinion: Challenges persist in initiation and maintenance of ART. An individual's coexisting medical, social and personal factors must be considered in selecting and continuing ART to ensure safety, tolerability, and efficacy throughout adulthood. Continued development of new therapeutics and novel approaches to ART, such as long acting drugs or dual therapy, are needed to respond to many of these challenges. In addition, future research must address therapeutic disparities for populations historically underrepresented in clinical trials, including women, people aging with HIV, and those with complex comorbidities.
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Affiliation(s)
- Mary Clare Masters
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen M Krueger
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Janna L Williams
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lindsay Morrison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan E Cohn
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Samayoa B, Aguirre L, Bonilla O, Medina N, Lau-Bonilla D, Mercado D, Moller A, Perez JC, Alastruey-Izquierdo A, Arathoon E, Denning DW, Rodríguez-Tudela JL. The Diagnostic Laboratory Hub: A New Health Care System Reveals the Incidence and Mortality of Tuberculosis, Histoplasmosis, and Cryptococcosis of PWH in Guatemala. Open Forum Infect Dis 2019; 7:ofz534. [PMID: 31915715 PMCID: PMC6942459 DOI: 10.1093/ofid/ofz534] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/12/2019] [Indexed: 01/03/2023] Open
Abstract
Background A Diagnostic Laboratory Hub (DLH) was set up in Guatemala to provide opportunistic infection (OI) diagnosis for people with HIV (PWH). Methods Patients newly presenting for HIV, PWH not receiving antiretrovirals (ARVs) for >90 days but returned to care (Return/Restart), and PWH on ARVs with symptoms of OIs (ARV treatment) were prospectively included. Screening for tuberculosis, nontuberculous mycobacteria (NTM), histoplasmosis, and cryptococcosis was done. Samples were couriered to the DLH, and results were transmitted electronically. Demographic, diagnostic results, disease burden, treatment, and follow-up to 180 days were analyzed. Results In 2017, 1953 patients were included, 923 new HIV infections (an estimated 44% of all new HIV infections in Guatemala), 701 on ARV treatment, and 315 Return/Restart. Three hundred seventeen (16.2%) had an OI: 35.9% tuberculosis, 31.2% histoplasmosis, 18.6% cryptococcosis, 4.4% NTM, and 9.8% coinfections. Histoplasmosis was the most frequent AIDS-defining illness; 51.2% of new patients had <200 CD4 cells/mm3 with a 29.4% OI incidence; 14.3% of OIs in new HIV infections occurred with CD4 counts of 200-350 cells/mm3. OIs were the main risk factor for premature death for new HIV infections. At 180 days, patients with OIs and advanced HIV had 73-fold greater risk of death than those without advanced disease who were OI-free. Conclusions The DLH OI screening approach provides adequate diagnostic services and obtains relevant data. We propose a CD4 screening threshold of <350 cells/mm3. Mortality remains high, and improved interventions are required, including expansion of the DLH and access to antifungal drugs, especially liposomal amphotericin B and flucytosine.
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Affiliation(s)
- B Samayoa
- Asociación de Salud Integral, Guatemala, Guatemala
| | - L Aguirre
- Asociación de Salud Integral, Guatemala, Guatemala
| | - O Bonilla
- Clínica Familiar "Luis Angel García"/Hospital General San Juan de Dios, Guatemala, Guatemala
| | - N Medina
- Asociación de Salud Integral, Guatemala, Guatemala
| | | | - D Mercado
- Clínica Familiar "Luis Angel García"/Hospital General San Juan de Dios, Guatemala, Guatemala
| | - A Moller
- Asociación de Salud Integral, Guatemala, Guatemala
| | - J C Perez
- Clínica Familiar "Luis Angel García"/Hospital General San Juan de Dios, Guatemala, Guatemala
| | - A Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - E Arathoon
- Clínica Familiar "Luis Angel García"/Hospital General San Juan de Dios, Guatemala, Guatemala
| | - D W Denning
- The University of Manchester and the National Aspergillosis Centre, Wythenshawe Hospital, Manchester, UK.,Global Action Fund for Fungal Infections, Geneva, Switzerland
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Frances Ndyetukira J, Kwizera R, Kugonza F, Ahimbisibwe C, Namujju C, Sadiq A, Namudde A. The conundrum of clinical trials and standard of care in sub-Saharan Africa - the research nurse perspective. J Res Nurs 2019; 24:649-660. [PMID: 34394589 PMCID: PMC7932327 DOI: 10.1177/1744987118824625] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Nurses form a very important part of the health workforce in sub-Saharan Africa. Research nurses are critical to the implementation of clinical trials. The duties and responsibilities of a research nurse are complex and continue to evolve as new practices and guidelines are formulated. AIMS In this paper, we have highlighted the major contributions of research nurses in HIV clinical trials in sub-Saharan Africa from the unique perspective of Ugandan nurses. METHODS The requirements and challenges of two multi-site, randomised cryptococcal meningitis clinical trials in Uganda were assessed from the perspective of research nurses conducting complex research in resource-limited settings. RESULTS Over the course of 8 years, approximately 1739 participants were screened and 934 people were enrolled into the two trials. The nurses found that patient education and engagement were among the most important predictors of success in minimising loss to follow-up. CONCLUSIONS Research nurses played a key role in communicating clinical research goals to patients, obtaining informed consent, minimising loss to follow-up, and ensuring that research practices are translated and implemented into standard of care. However, there remains a need to integrate the same level of care provided in clinical research studies to non-study patients.
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Affiliation(s)
| | - Richard Kwizera
- Richard Kwizera, Department of Research, Infectious Diseases Institute College of Health Sciences, Makerere University P.O. BOX 22418, Kampala, Uganda.
| | | | | | | | | | - Alice Namudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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Alhadab AA, Rhein J, Tugume L, Musubire A, Williams DA, Abassi M, Nicol MR, Meya DB, Boulware DR, Brundage RC. Pharmacokinetics-pharmacodynamics of sertraline as an antifungal in HIV-infected Ugandans with cryptococcal meningitis. J Pharmacokinet Pharmacodyn 2019; 46:565-576. [PMID: 31584146 PMCID: PMC7004416 DOI: 10.1007/s10928-019-09657-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 09/25/2019] [Indexed: 01/16/2023]
Abstract
The ASTRO-CM dose-finding pilot study investigated the role of adjunctive sertraline for the treatment of HIV-associated cryptococcal meningitis in HIV-infected Ugandan patients. The present study is a post hoc pharmacokinetic-pharmacodynamic analysis of the ASTRO-CM pilot study to provide insight into sertraline exposure-response-outcome relationships. We performed a population pharmacokinetic analysis using sertraline plasma concentration data and correlated various predicted PK-PD indices with the percentage change in log10 CFU/mL from baseline. Sertraline clearance was 1.95-fold higher in patients receiving antiretroviral (ART), resulting in 49% lower drug exposure. To quantify the clinical benefit of sertraline, we estimated rates of fungal clearance from cerebrospinal fluid (CSF) of ASTRO-CM patients using Poisson model and compared the clearance rates to a historical control study (COAT) in which patients received standard Cryptococcus therapy of amphotericin B (0.7-1.0 mg/kg per day) and fluconazole (800 mg/day) without sertraline. Adjunctive sertraline significantly increased CSF fungal clearance rate compared to COAT trial and sertraline effect was dose-independent with no covariate found to affect fungal clearance including ART. Study findings suggest sertraline response could be mediated by different mechanisms than directly inhibiting the initiation of protein translation as previously suggested; this is supported by the prediction of unbound sertraline concentrations is unlikely to reach MIC concentrations in the brain. Study findings also recommend against the use of higher doses of sertraline, especially those greater than the maximum FDA-approved daily dose (200 mg/day), since they unlikely provide any additional benefits and come with greater costs and risk of adverse events.
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Affiliation(s)
- Ali A Alhadab
- Oncology Clinical Pharmacology, Pfizer Inc., 10555 Science Center Dr #2423C, La Jolla, San Diego, CA, 92121, USA.
| | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Mahsa Abassi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Melanie R Nicol
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Medicine, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Richard C Brundage
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
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Tufa TB, Denning DW. The Burden of Fungal Infections in Ethiopia. J Fungi (Basel) 2019; 5:jof5040109. [PMID: 31771096 PMCID: PMC6958437 DOI: 10.3390/jof5040109] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/25/2019] [Accepted: 11/06/2019] [Indexed: 01/03/2023] Open
Abstract
The burden of severe fungal infections (FIs) is not well addressed in Ethiopia. We have estimated the burden of FIs from multiple demographic sources and by searching articles from PubMed. Opportunistic FIs were estimated using modelling and 2017 national HIV data. The burdens of chronic pulmonary aspergillosis (CPA) and allergic bronchopulmonary aspergillosis (ABPA) were estimated by using the prevalence of asthma, chronic obstructive pulmonary disease, and annual the incidence of tuberculosis. Of the 105,000,000 estimated Ethiopian population, 610,000 are thought to have HIV infection. Our estimation of HIV-related FIs were: 9900 cryptococcal meningitis (CM), 12,700 Pneumocystis jirovecii pneumonia (PCP), 76,300 oral and 56,000 oesophageal candidiasis cases. A remarkable 7,051,700 4–14-year-olds probably have tinea capitis and 1,469,000 women probably have recurrent Candida vaginitis. There were 15,200 estimated CPA cases (prevalence) and 11,500 invasive aspergillosis (IA) cases (incidence). Data are scant, but we estimated 5300 candidaemia and 800 Candida peritonitis cases. In conclusion, approximately 8% of Ethiopians suffer from FIs annually, mostly schoolchildren with tinea capitis. IA, CM and PCP are the major causes of fungal deaths. The absence of CD4 count is challenging the identification of HIV patients at risk of opportunistic FIs. There is a pressing need to improve FI diagnosis, probably including national surveillance.
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Affiliation(s)
- Tafese B. Tufa
- Asella Teaching and Referral Hospital, College of Health Sciences, Arsi University, P.O. Box 04, Asella, Ethiopia
- Hirsch Institute of Tropical Medicine (HITM), Heinrich-Heine University, P.O. Box 04, Asella, Ethiopia
- Correspondence:
| | - David W. Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Manchester M23 9LT, UK
- The University of Manchester and Manchester Academic Health Science Centre, Manchester M13 9PL, UK;
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134
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Schäfer G, Hoffmann C, Arasteh K, Schürmann D, Stephan C, Jensen B, Stoll M, Bogner JR, Faetkenheuer G, Rockstroh J, Klinker H, Härter G, Stöhr A, Degen O, Freiwald E, Hüfner A, Jordan S, Schulze Zur Wiesch J, Addo M, Lohse AW, van Lunzen J, Schmiedel S. Immediate versus deferred antiretroviral therapy in HIV-infected patients presenting with acute AIDS-defining events (toxoplasmosis, Pneumocystis jirovecii-pneumonia): a prospective, randomized, open-label multicenter study (IDEAL-study). AIDS Res Ther 2019; 16:34. [PMID: 31729999 PMCID: PMC6857475 DOI: 10.1186/s12981-019-0250-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/26/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To evaluate clinical outcomes after either immediate or deferred initiation of antiretroviral therapy in HIV-1-infected patients, presenting late with pneumocystis pneumonia (PCP) or toxoplasma encephalitis (TE). METHODS Phase IV, multicenter, prospective, randomized open-label clinical trial. Patients were randomized into an immediate therapy arm (starting antiretroviral therapy (ART) within 7 days after initiation of OI treatment) versus a deferred arm (starting ART after completing the OI-therapy). All patients were followed for 24 weeks. The rates of clinical progression (death, new or relapsing opportunistic infections (OI) and other grade 4 clinical endpoints) were compared, using a combined primary endpoint. Secondary endpoints were hospitalization rates after completion of OI treatment, incidence of immune reconstitution inflammatory syndrome (IRIS), virologic and immunological outcome, adherence to proteinase-inhibitor based antiretroviral therapy (ART) protocol and quality of life. RESULTS 61 patients (11 patients suffering TE, 50 with PCP) were enrolled. No differences between the two therapy groups in all examined primary and secondary endpoints could be identified: immunological and virologic outcome was similar in both groups, there was no significant difference in the incidence of IRIS (11 and 10 cases), furthermore 9 events (combined endpoint of death, new/relapsing OI and grade 4 events) occurred in each group. CONCLUSIONS In summary, this study supports the notion that immediate initiation of ART with a ritonavir-boosted proteinase-inhibitor and two nucleoside reverse transcriptase inhibitors is safe and has no negative effects on incidence of disease progression or IRIS, nor on immunological and virologic outcomes or on quality of life.
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Affiliation(s)
- Guido Schäfer
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Keikawus Arasteh
- Department for Infectious Diseases, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Dirk Schürmann
- Department for Pneumology and Infectious Diseases, Charité Universitätsmedizin, Berlin, Germany
| | - Christoph Stephan
- 2nd Medical Department, Section Infectious Diseases, University Medical Center, Frankfurt am Main, Germany
| | - Björn Jensen
- Department for Gastroenterology, Hepatology, Infectious Diseases, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Matthias Stoll
- Department for Immunology and Rheumatology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Johannes R Bogner
- Department for Infectious Diseases, Mediznische Klinik und Poliklinik IV der Universität München, Munich, Germany
| | - Gerd Faetkenheuer
- 1st Medical Department, Section Infectious Diseases, Universitätsklinikum Köln, Cologne, Germany
| | - Jürgen Rockstroh
- Medical Department, Section Infectious Diseases, Universitätsklinikum Bonn, Bonn, Germany
| | - Hartwig Klinker
- Department for Infectious Diseases, Julius Maximilians University, Würzburg, Germany
| | - Georg Härter
- Department for Infectious Diseases, University Hospital, Ulm, Germany
| | - Albrecht Stöhr
- ifi-Institute for Interdisciplinary Medicine, Hamburg, Germany
| | - Olaf Degen
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eric Freiwald
- Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Hüfner
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Jordan
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schulze Zur Wiesch
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marylyn Addo
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Stefan Schmiedel
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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135
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Govender NP, Meintjes G, Mangena P, Nel J, Potgieter S, Reddy D, Rabie H, Wilson D, Black J, Boulware D, Boyles T, Chiller T, Dawood H, Dlamini S, Harrison TS, Ive P, Jarvis J, Karstaedt A, Madua MC, Menezes C, Moosa MYS, Motlekar Z, Shroufi A, Stacey SL, Tsitsi M, van Cutsem G, Variava E, Venter M, Wake R. Southern African HIV Clinicians Society guideline for the prevention, diagnosis and management of cryptococcal disease among HIV-infected persons: 2019 update. South Afr J HIV Med 2019; 20:1030. [PMID: 32201629 PMCID: PMC7081625 DOI: 10.4102/sajhivmed.v20i1.1030] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 02/06/2023] Open
Affiliation(s)
- Nelesh P Govender
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phetho Mangena
- Department of Medicine, Polokwane Hospital, Polokwane, South Africa
| | - Jeremy Nel
- Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Samantha Potgieter
- Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa
| | - Denasha Reddy
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Helena Rabie
- Department of Paediatrics, Tygerberg Hospital, Stellenbosch University, Stellenbosch, South Africa
| | - Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, Pietermaritzburg, South Africa
- School of Clinical Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - John Black
- Department of Infectious Diseases, Livingstone Hospital, Port Elizabeth, South Africa
| | - David Boulware
- Department of Medicine, Centre for Infectious Diseases and Microbiology Translational Research, University of Minnesota, Minneapolis, United States
| | - Tom Boyles
- Anova Health Institute, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tom Chiller
- Mycotic Diseases Branch, US Centres for Disease Control and Prevention, Atlanta, United States
| | - Halima Dawood
- Department of Medicine, Grey's Hospital, Pietermaritzburg, South Africa
- Caprisa, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Sipho Dlamini
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
| | - Prudence Ive
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Infectious Diseases, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, Helen Joseph Hospital, Johannesburg, South Africa
| | - Joseph Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alan Karstaedt
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Infectious Diseases, Department of Internal Medicine, Charlotte Maxeke Johannesburg Hospital, Johannesburg, South Africa
| | - Matamela C Madua
- Department of Medicine, Rob Ferreira Hospital, Mbombela, South Africa
| | - Colin Menezes
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mahomed-Yunus S Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Zaaheera Motlekar
- Department of Medicine, Kimberley Provincial Hospital, Kimberley, South Africa
| | - Amir Shroufi
- Mycotic Diseases Branch, US Centres for Disease Control and Prevention, Atlanta, United States
| | - Sarah Lynn Stacey
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Merika Tsitsi
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gilles van Cutsem
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Ebrahim Variava
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Tshepong Hospital, Klerksdorp, South Africa
| | - Michelle Venter
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rachel Wake
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
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Pastick KA, Bangdiwala AS, Abassi M, Flynn AG, Morawski BM, Musubire AK, Eneh PC, Schutz C, Taseera K, Rhein J, Hullsiek KH, Nicol MR, Vidal JE, Nakasujja N, Meintjes G, Muzoora C, Meya DB, Boulware DR. Seizures in Human Immunodeficiency Virus-Associated Cryptococcal Meningitis: Predictors and Outcomes. Open Forum Infect Dis 2019; 6:ofz478. [PMID: 32042847 PMCID: PMC7001112 DOI: 10.1093/ofid/ofz478] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/02/2019] [Indexed: 01/24/2023] Open
Abstract
Background Seizures commonly occur in patients with cryptococcal meningitis, yet risk factors and outcomes related to seizures are not well described. Methods We performed post hoc analyses on participants prospectively enrolled in 3 separate human immunodeficiency virus (HIV)-associated cryptococcal meningitis clinical trials during 2010-2017. Documentation of seizures at presentation or during hospitalization and antiseizure medication receipt identified participants with seizures. We summarized participant characteristics by seizure status via Kruskal-Wallis and χ 2 tests. Cox proportional hazards models analyzed the relationship between seizures and mortality. We compared mean quantitative neurocognitive performance Z (QNPZ-8) scores, and individual domain z-scores, at 3-months using independent t tests. Results Among 821 HIV-infected cryptococcal meningitis participants, 28% (231 of 821) experienced seizures: 15.5% (127 of 821) experienced seizures at presentation, and 12.7% (104 of 821) experienced incident seizures. Participants with seizures at presentation had a significantly lower Glasgow coma scale ([GCS] <15; P < .001), CD4 count (<50 cells/mcL; P = .02), and higher cerebrospinal fluid (CSF) opening pressure (>25 cm H2O; P = .004) when compared with participants who never experienced seizures. Cerebrospinal fluid fungal burden was higher among those with seizures at presentation (125 000 Cryptococcus colony-forming units [CFU]/mL CSF) and with seizures during follow-up (92 000 CFU/mL) compared with those who never experienced seizures (36 000 CFU/mL, P < .001). Seizures were associated with increased 10-week mortality (adjusted hazard ratio = 1.45; 95% confidence interval, 1.11-1.89). Participants with seizures had lower neurocognitive function at 3 months (QNPZ-8 = -1.87) compared with those without seizures (QNPZ-8 = -1.36; P < .001). Conclusions Seizures were common in this HIV-associated cryptococcal meningitis cohort and were associated with decreased survival and neurocognitive function.
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Affiliation(s)
- Katelyn A Pastick
- University of Minnesota, Minneapolis, Minnesota, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Mahsa Abassi
- University of Minnesota, Minneapolis, Minnesota, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Charlotte Schutz
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kabanda Taseera
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joshua Rhein
- University of Minnesota, Minneapolis, Minnesota, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Jose E Vidal
- Instituto de Infectologia Emilio Ribas, São Paulo, São Paulo, Brazil.,Divisão de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Graeme Meintjes
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B Meya
- University of Minnesota, Minneapolis, Minnesota, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
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137
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Abstract
PURPOSE OF REVIEW Defective cell-mediated immunity is a major risk factor for cryptococcosis, a fatal disease if untreated. Cryptococcal meningitis (CM), the main presentation of disseminated disease, occurs through hematogenous spread to the brain from primary pulmonary foci, facilitated by yeast virulence factors. We revisit remarkable recent improvements in the prevention, diagnosis and management of CM. RECENT FINDINGS Cryptococcal antigen (CrAg), main capsular polysaccharide of Cryptococcus spp. is detectable in blood and cerebrospinal fluid of infected patients with point of care lateral flow assays. Recent World Health Organization guidelines recommend 7-day amphotericin B plus flucytosine, then 7-day high dose (1200 mg/day) fluconazole for induction treatment of HIV-associated CM. Management of raised intracranial pressure, a consequence of CM, should rely mainly on daily therapeutic lumbar punctures until normalisation. In HIV-associated CM, following introduction of antifungal therapy, (re)initiation of antiretroviral therapy should be delayed by 4-6 weeks to prevent immune reconstitution inflammatory syndrome, common in CM. CM is a fatal disease whose diagnosis has recently been simplified. Treatment should always include antifungal combination therapy and management of raised intracranial pressure. Screening for immune deficiency should be mandatory in all patients with cryptococcosis.
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138
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Laboratory-Reflex Cryptococcal Antigen Screening Is Associated With a Survival Benefit in Tanzania. J Acquir Immune Defic Syndr 2019; 80:205-213. [PMID: 30422904 DOI: 10.1097/qai.0000000000001899] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cryptococcal antigen (CrAg) screening in persons with advanced HIV/AIDS is recommended to prevent death. Implementing CrAg screening only in outpatients may underestimate the true CrAg prevalence and decrease its potential impact. Our previous 12-month survival/retention in CrAg-positive persons not treated with fluconazole was 0%. METHODS HIV testing was offered to all antiretroviral therapy-naive outpatients and hospitalized patients in Ifakara, Tanzania, followed by laboratory-reflex CrAg screening for CD4 <150 cells/μL. CrAg-positive individuals were offered lumbar punctures, and antifungals were tailored to the presence/absence of meningitis. We assessed the impact on survival and retention-in-care using multivariate Cox-regression models. RESULTS We screened 560 individuals for CrAg. The median CD4 count was 61 cells/μL (interquartile range 26-103). CrAg prevalence was 6.1% (34/560) among individuals with CD4 ≤150 and 7.5% among ≤100 cells/μL. CrAg prevalence was 2.3-fold higher among hospitalized participants than in outpatients (12% vs 5.3%, P = 0.02). We performed lumbar punctures in 94% (32/34), and 31% (10/34) had cryptococcal meningitis. Mortality did not differ significantly between treated CrAg-positive without meningitis and CrAg-negative individuals (7.3 vs 5.4 deaths per 100 person-years, respectively, P = 0.25). Independent predictors of 6-month death/lost to follow-up were low CD4, cryptococcal meningitis (adjusted hazard ratio 2.76, 95% confidence interval: 1.31 to 5.82), and no antiretroviral therapy initiation (adjusted hazard ratio 3.12, 95% confidence interval: 2.16 to 4.50). CONCLUSIONS Implementing laboratory-reflex CrAg screening among outpatients and hospitalized individuals resulted in a rapid detection of cryptococcosis and a survival benefit. These results provide a model of a feasible, effective, and scalable CrAg screening and treatment strategy integrated into routine care in sub-Saharan Africa.
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Oseso LN, Chiao EY, Bender Ignacio RA. Evaluating Antiretroviral Therapy Initiation in HIV-Associated Malignancy: Is There Enough Evidence to Inform Clinical Guidelines? J Natl Compr Canc Netw 2019; 16:927-932. [PMID: 30099368 DOI: 10.6004/jnccn.2018.7057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Katende A, Mbwanji G, Faini D, Nyuri A, Kalinjuma AV, Mnzava D, Hullsiek KH, Rhein J, Weisser M, Meya DB, Boulware DR, Letang E. Short-course amphotericin B in addition to sertraline and fluconazole for treatment of HIV-associated cryptococcal meningitis in rural Tanzania. Mycoses 2019; 62:1127-1132. [PMID: 31461550 DOI: 10.1111/myc.12995] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cryptococcal meningitis accounts for 15% of all AIDS mortality globally. Most cases in low- and middle-income countries are treated with fluconazole monotherapy, which is associated with a high mortality. New available therapies are needed. Short-course amphotericin B has been shown to be a safe and efficient therapeutic option. Sertraline has in vitro fungicidal activity against Cryptococcus and bi-directional synergy with fluconazole. METHODS We conducted an open-label clinical trial to assess the safety and efficacy of sertraline 400 mg/day and fluconazole 1200 mg/day (n = 28) vs sertraline, fluconazole and additional 5 days of amphotericin B deoxycholate 0.7-1 mg/kg (n = 18) for cryptococcal meningitis. RESULTS Two-week survival was 64% (18/28) without amphotericin and 89% (16/18) with amphotericin, and 10-week survival was 21% (6/28) vs 61% (11/18), respectively (P = .012). The cerebrospinal fluid (CSF) Cryptococcus clearance rate was 0.264 log10 colony-forming units (CFU)/mL of CSF/day (95% CI: 0.112-0.416) without amphotericin and 0.473 log10 CFU/mL/day (95% CI: 0.344-0.60) with short-course amphotericin (P = .03). Sertraline was discontinued in one participant due to side effects. Four participants receiving amphotericin B experienced hypokalemia <2.4 mEq/L. CONCLUSIONS Short-course amphotericin substantially increased CSF clearance and 10-week survival. Adjunctive sertraline improved 2-week CSF fungal clearance but did not improve 10-week mortality compared with published data using fluconazole 1200 mg/day monotherapy (early fungicidal activity 0.15 log10 CFU/mL/day).
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Affiliation(s)
- Andrew Katende
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania
| | - Gladys Mbwanji
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania
| | - Diana Faini
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania.,Muhimbili University of Health and Allied sciences, Dar es Salaam, Tanzania
| | - Amina Nyuri
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania
| | | | - Dorcas Mnzava
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania
| | - Katherine H Hullsiek
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Joshua Rhein
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Maja Weisser
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - David B Meya
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda.,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Emilio Letang
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.,Service of Infectious Diseases, Hospital del Mar, Hospital del Mar Research Institute (IMIM), Barcelona, Spain
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Abstract
PURPOSE OF REVIEW This article describes the clinical presentation, diagnostic approach (including the use of novel diagnostic platforms), and treatment of select infectious and noninfectious etiologies of chronic meningitis. RECENT FINDINGS Identification of the etiology of chronic meningitis remains challenging, with no cause identified in at least one-third of cases. Often, several serologic, CSF, and neuroimaging studies are indicated, although novel diagnostic platforms including metagenomic deep sequencing may hold promise for identifying organisms. Infectious etiologies are more common in those at risk for disseminated disease, specifically those who are immunocompromised because of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), transplantation, or immunosuppressant medications. An important step in identifying the etiology of chronic meningitis is assembling a multidisciplinary team of individuals, including those with specialized expertise in ophthalmology, dermatology, rheumatology, and infectious diseases, to provide guidance regarding diagnostic procedures. SUMMARY Chronic meningitis is defined as inflammation involving the meninges that lasts at least 4 weeks and is associated with a CSF pleocytosis. Chronic meningitis has numerous possible infectious and noninfectious etiologies, making it challenging to definitively diagnose patients. Therefore, a multifaceted approach that combines history, physical examination, neuroimaging, and laboratory analysis, including novel diagnostic platforms, is needed. This article focuses on key aspects of the evaluation of and approach to patients with chronic meningitis. Specific infectious etiologies and differential diagnoses of subacute and chronic meningitis, including noninfectious etiologies, are addressed.
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Mussini C, Roncaglia E, Borghi V, Rusconi S, Nozza S, Cattelan AM, Segala D, Bonfanti P, Di Biagio A, Barchi E, Focà E, Degli Antoni A, Bonora S, Francisci D, Limonta S, Antinori A, D’Ettorre G, Maggiolo F. A prospective randomized trial on abacavir/lamivudine plus darunavir/ritonavir or raltegravir in HIV-positive drug-naïve patients with CD4<200 cells/uL (the PRADAR study). PLoS One 2019; 14:e0222650. [PMID: 31560700 PMCID: PMC6764686 DOI: 10.1371/journal.pone.0222650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/02/2019] [Indexed: 01/11/2023] Open
Abstract
Background Very few data are available on treatment in HIV Late presenter population that still represents a clinical challenge. Methods Prospective, multicenter, randomized open-label, 2 arm, phase-3 trial comparing the 48-week virological response of two different regimens: abacavir/lamivudine + darunavir/r vs abacavir/lamivudine + raltegravir in antiretroviral naive with CD4+ counts < 200/mm3 and a viral load (VL)<500,000 copies/mL. The primary Endpoint was the proportion of patients with undetectable viremia (VL<50 copies/mL) after 48 weeks. The planned sample size for this trial was 350 patients. Results In 3 years, 53 patients were screened and 46 enrolled: 22 randomized to raltegravir and 24 to darunavir/r; 7 patients were excluded, 4 because of a VL >500,000 copies/mL and 3 for HLAB5701 positivity. The snapshot analysis at 48 weeks showed a virologic success of 77.3% in raltegravir and 66.7% in darunavir/r. Time to starting treatment was 34.5 days in raltegravir and 53 days in darunavir/r. At the as treated analysis, the median CD4 counts at 48 weeks was 297 cells/μL in raltegravir and 239 cells/μL in darunavir/r. No difference in total cholesterol, while triglycerides were higher in the darunavir/r arm. No statistical analyses were performed due to the low number of patients enrolled. Conclusions Late presenter patients are frequent but very difficult to enroll in clinical trials, especially in western countries. These regimens and the conditions of many patients could not allow the test and treat strategy. The rate of virologic success was higher than 65% in both arms with a median CD4 cell count >200/μL at week 48. Trial registration EUDRACT number: 2011-005973-21
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Affiliation(s)
- Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
- * E-mail:
| | - Enrica Roncaglia
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Vanni Borghi
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Rusconi
- Clinic of Infectious Diseases, DIBIC Luigi Sacco, University of Milan, Milan, Italy
| | - Silvia Nozza
- Clinic of Infectious Diseases, University Vita e Salute, San Raffaele Hospital, Milan, Italy
| | | | - Daniela Segala
- Clinic of Infectious Diseases, Sant’Anna Hospital, Ferrara, Italy
| | - Paolo Bonfanti
- Department of Infectious Diseases, Lecco Hospital, Lecco, Italy
| | | | - Enrico Barchi
- Department of Infectious Diseases, Santa Maria Nuova Hospital, Reggio Emilia, Italy
| | - Emanuele Focà
- Clinic of Infectious Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | | | - Stefano Bonora
- Clinic of Infectious Diseases, University of Torino, Torino, Italy
| | - Daniela Francisci
- Clinic of Infectious Diseases, University of Perugia, Perugia, Italy
| | - Silvia Limonta
- Clinic of Infectious Diseases, DIBIC Luigi Sacco, University of Milan, Milan, Italy
| | - Andrea Antinori
- National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | | | - Franco Maggiolo
- Department of Infectious Diseases, Bergamo Hospital, Bergamo, Italy
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Ross AJ, Ndayishimiye E. A review of the management and outcome of patients admitted with cryptococcal meningitis at a regional hospital in KwaZulu-Natal province. S Afr Fam Pract (2004) 2019. [DOI: 10.1080/20786190.2019.1607480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Andrew J Ross
- Department of Family Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Egide Ndayishimiye
- Prince Mshiyeni Memorial Hospital, Master of Public Health (MPH), University of KwaZulu-Natal, Durban, South Africa
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Chesdachai S, Rajasingham R, Nicol MR, Meya DB, Bongomin F, Abassi M, Skipper C, Kwizera R, Rhein J, Boulware DR. Minimum Inhibitory Concentration Distribution of Fluconazole against Cryptococcus Species and the Fluconazole Exposure Prediction Model. Open Forum Infect Dis 2019; 6:5550889. [PMID: 31420668 PMCID: PMC6767974 DOI: 10.1093/ofid/ofz369] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Fluconazole is lifesaving for treatment and prevention of cryptococcosis; however, optimal dosing is unknown. Initial fluconazole doses of 100mg to 2000mg/day have been used. Prevalence of fluconazole non-susceptible Cryptococcus is increasing over time, risking the efficacy of long-established standard dosing. Based on current minimum inhibitory concentration (MIC) distribution, we modeled fluconazole concentration and area under the curve (AUC) relative to MIC to propose a rational fluconazole dosing strategy. METHODS First, we conducted a systematic review using MEDLINE database for reports of fluconazole MIC distribution against clinical Cryptococcus isolates. Second, we utilized fluconazole concentrations from 92 Ugandans who received fluconazole 800mg/day coupled with fluconazole's known pharmacokinetics to predict plasma fluconazole concentrations for doses ranging from 100mg to 2000mg via linear regression. Third, the fluconazole AUC above MIC ratio were calculated using Monte Carlo simulation and using the MIC distribution elucidated during the systemic review. RESULTS We summarized 21 studies with 11,049 clinical Cryptococcus isolates. MICs were normally distributed with geometric mean of 3.4 μg/mL, median (MIC50) of 4 μg/mL, and 90th percentile (MIC90) of 16 μg/mL. The median MIC50 trended upwards from 4 μg/mL in 2000-2012 to 8 μg/mL in 2014-2018. Predicted sub-therapeutic fluconazole concentrations (below MIC) would occur in 40% with 100mg, 21% with 200mg, and 9% with 400mg. AUC/MIC ratio >100 would occur in 53% for 400mg, 74% for 800mg, 83% for 1200mg, and 88% for 1600mg. CONCLUSIONS Currently recommended fluconazole doses may be inadequate for cryptococcosis. Further clinical studies are needed for rational fluconazole dose selection.
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Affiliation(s)
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Melanie R Nicol
- College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Caleb Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Rhein J, Huppler Hullsiek K, Tugume L, Nuwagira E, Mpoza E, Evans EE, Kiggundu R, Pastick KA, Ssebambulidde K, Akampurira A, Williams DA, Bangdiwala AS, Abassi M, Musubire AK, Nicol MR, Muzoora C, Meya DB, Boulware DR. Adjunctive sertraline for HIV-associated cryptococcal meningitis: a randomised, placebo-controlled, double-blind phase 3 trial. THE LANCET. INFECTIOUS DISEASES 2019; 19:843-851. [PMID: 31345462 PMCID: PMC7041360 DOI: 10.1016/s1473-3099(19)30127-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Identifying new antifungals for cryptococcal meningitis is a priority given the inadequacy of current therapy. Sertraline has previously shown in vitro and in vivo activity against cryptococcus. We aimed to assess the efficacy and cost-effectiveness of adjunctive sertraline in adults with HIV-associated cryptococcal meningitis compared with placebo. METHODS In this double-blind, randomised, placebo-controlled trial, we recruited HIV-positive adults with cryptococcal meningitis from two hospitals in Uganda. Participants were randomly assigned (1:1) to receive standard therapy with 7-14 days of intravenous amphotericin B (0·7-1·0 mg/kg per day) and oral fluconazole (starting at 800 mg/day) with either adjunctive sertraline or placebo. Sertraline was administered orally or via nasogastric tube at a dose of 400 mg/day for 2 weeks, followed by 200 mg/day for 12 weeks, then tapered off over 3 weeks. The primary endpoint was 18-week survival, analysed by intention-to-treat. This study is registered with ClinicalTrials.gov, number NCT01802385. FINDINGS Between March 9, 2015, and May 29, 2017, we screened 842 patients with suspected meningitis and enrolled 460 of a planned 550 participants, at which point the trial was stopped for futility. Three patients in the sertraline group and three patients in the placebo group were lost to follow-up and therefore discontinued before study end. At 18 weeks, 120 (52%) of 229 patients in the sertraline group and 106 (46%) of 231 patients in the placebo group had died (hazard ratio 1·21, 95% CI 0·93-1·57; p=0·15). The fungal clearance rate from cerebrospinal fluid was similar between groups (0·43 -log10 CFU/mL per day [95% CI 0·37-0·50] in the sertraline group vs 0·47 -log10 CFU/mL per day [0·40-0·54] in the placebo group; p=0·59), as was occurrence of grade 4 or 5 adverse events (72 [31%] of 229 vs 75 [32%] of 231; p=0·98), most of which were associated with amphotericin B toxicity. INTERPRETATION Sertraline did not reduce mortality and should not be used to treat patients with HIV-associated cryptococcal meningitis. The reasons for sertraline inactivity appear to be multifactorial and might be associated with insufficient duration of therapeutic sertraline concentrations. FUNDING National Institutes of Health and Medical Research Council, Wellcome Trust.
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Affiliation(s)
- Joshua Rhein
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Emily E. Evans
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Katelyn A. Pastick
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Darlisha A. Williams
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Mahsa Abassi
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K. Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B. Meya
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Abstract
PURPOSE OF REVIEW Widespread use of antiretroviral therapy (ART) has led to near-normal life expectancy in people with human immunodeficiency virus (HIV) infection. However, neurologic complications of HIV remain common; can affect any part of the neuraxis; and are due to direct effects of the virus, immunosuppression because of untreated HIV infection, aberrant immune responses in the setting of ART initiation, and ART toxicities. RECENT FINDINGS HIV-associated neurocognitive disorder (HAND) remains one of the most common neurologic complications of HIV encountered today, but milder forms predominate in people on ART. No specific treatments for HAND exist, but small trials and epidemiologic evidence suggest paroxetine, intranasal insulin, and maraviroc may have utility in its treatment; further trials of these agents are ongoing. Widespread ART use has decreased the incidence of central nervous system opportunistic infections, but prognosis often remains poor in those who develop opportunistic infections. High-titer positive serum cryptococcal antigen is strongly predictive of cryptococcal meningitis and provides a tool to enhance diagnosis in areas with limited resources. HIV is an independent risk factor for stroke, and accelerated aging associated with HIV infection results in neurologic diseases of older age occurring at much younger ages in individuals infected with HIV. Ongoing HIV replication in the CSF despite peripheral virologic suppression may contribute to the development of HAND and may not improve despite adjusting the ART regimen to increase central nervous system penetrance. SUMMARY Neurologists are likely to encounter patients infected with HIV in clinical practice. This article reviews the presentation, diagnosis, and management of the most common neurologic conditions associated with HIV infection and ART.
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147
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Skipper C, Abassi M, Boulware DR. Diagnosis and Management of Central Nervous System Cryptococcal Infections in HIV-Infected Adults. J Fungi (Basel) 2019; 5:jof5030065. [PMID: 31330959 PMCID: PMC6787675 DOI: 10.3390/jof5030065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/24/2022] Open
Abstract
Cryptococcal meningitis persists as a significant source of morbidity and mortality in persons with HIV/AIDS, particularly in sub-Saharan Africa. Despite increasing access to antiretrovirals, persons presenting with advanced HIV disease remains common, and Cryptococcus remains the most frequent etiology of adult meningitis. We performed a literature review and herein present the most up-to-date information on the diagnosis and management of cryptococcosis. Recent advances have dramatically improved the accessibility of timely and affordable diagnostics. The optimal initial antifungal management has been newly updated after the completion of a landmark clinical trial. Beyond antifungals, the control of intracranial pressure and mitigation of toxicities remain hallmarks of effective treatment. Cryptococcal meningitis continues to present challenging complications and continued research is needed.
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Affiliation(s)
- Caleb Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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148
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Longitudinal Changes in Cd4 +, Cd8 + T Cell Phenotype and Activation Marker Expression Following Antiretroviral Therapy Initiation among Patients with Cryptococcal Meningitis. J Fungi (Basel) 2019; 5:jof5030063. [PMID: 31319498 PMCID: PMC6787641 DOI: 10.3390/jof5030063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/18/2019] [Accepted: 06/26/2019] [Indexed: 11/26/2022] Open
Abstract
Despite improvement in the prognosis of HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) patients on antiretroviral therapy (ART), cryptococcal meningitis (CM) still causes 10–15% mortality among HIV-infected patients. The immunological impact of ART on the CD4+ and CD8+ T cell repertoire during cryptococcal co-infection is unclear. We determined longitudinal phenotypic changes in T cell subsets among patients with CM after they initiated ART. We hypothesized that ART alters the clonotypic phenotype and structural composition of CD4+ and CD8+ T cells during CM co-infection. For this substudy, peripheral blood mononuclear cells (PBMC) were isolated at four time points from CM patients following ART initiation during the parent study (ClinicalTrials.gov number, NCT01075152). Phenotypic characterization of CD4+ and CD8+ T cells was done using T cell surface marker monoclonal antibodies by flow cytometry. There was variation in the expression of immunophenotypic markers defining central memory (CD27+CD45R0+), effector memory (CD45R0+CD27–), immune activation (CD38+ and Human Leucocyte Antigen DR (HLA-DR+), and exhaustion (Programmed cell death protein one (PD-1) in the CD4+ T cell subset. In comparison to the CD4+ T cell population, the CD8+ central memory subset declined gradually with minimal increase in the effector memory subset. Both CD4+ and CD8+ T cell immune exhaustion and activation markers remained elevated over 12 weeks. The relative surge and decline in the expression of T cell surface markers outlines a variation in the differentiation of CD4+ T cells during ART treatment during CM co-infection.
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149
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Gerstein AC, Jackson KM, McDonald TR, Wang Y, Lueck BD, Bohjanen S, Smith KD, Akampurira A, Meya DB, Xue C, Boulware DR, Nielsen K. Identification of Pathogen Genomic Differences That Impact Human Immune Response and Disease during Cryptococcus neoformans Infection. mBio 2019; 10:e01440-19. [PMID: 31311883 PMCID: PMC6635531 DOI: 10.1128/mbio.01440-19] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/10/2019] [Indexed: 12/18/2022] Open
Abstract
Patient outcomes during infection are due to a complex interplay between the quality of medical care, host immunity factors, and the infecting pathogen's characteristics. To probe the influence of pathogen genotype on human survival, immune response, and other parameters of disease, we examined Cryptococcus neoformans isolates collected during the Cryptococcal Optimal Antiretroviral Therapy (ART) Timing (COAT) Trial in Uganda. We measured human participants' survival, meningitis disease parameters, immunologic phenotypes, and pathogen in vitro growth characteristics. We compared those clinical data to whole-genome sequences from 38 C. neoformans isolates of the most frequently observed sequence type (ST), ST93, in our Ugandan participant population and to sequences from an additional 18 strains of 9 other sequence types representing the known genetic diversity within the Ugandan Cryptococcus clinical isolates. We focused our analyses on 652 polymorphisms that were variable among the ST93 genomes, were not in centromeres or extreme telomeres, and were predicted to have a fitness effect. Logistic regression and principal component analysis identified 40 candidate Cryptococcus genes and 3 hypothetical RNAs associated with human survival, immunologic response, or clinical parameters. We infected mice with 17 available KN99α gene deletion strains for these candidate genes and found that 35% (6/17) directly influenced murine survival. Four of the six gene deletions that impacted murine survival were novel. Such bedside-to-bench translational research identifies important candidate genes for future studies on virulence-associated traits in human Cryptococcus infections.IMPORTANCE Even with the best available care, mortality rates in cryptococcal meningitis range from 20% to 60%. Disease is often due to infection by the fungus Cryptococcus neoformans and involves a complex interaction between the human host and the fungal pathogen. Although previous studies have suggested genetic differences in the pathogen impact human disease, it has proven quite difficult to identify the specific C. neoformans genes that impact the outcome of the human infection. Here, we take advantage of a Ugandan patient cohort infected with closely related C. neoformans strains to examine the role of pathogen genetic variants on several human disease characteristics. Using a pathogen whole-genome sequencing approach, we showed that 40 C. neoformans genes are associated with human disease. Surprisingly, many of these genes are specific to Cryptococcus and have unknown functions. We also show deletion of some of these genes alters disease in a mouse model of infection, confirming their role in disease. These findings are particularly important because they are the first to identify C. neoformans genes associated with human cryptococcal meningitis and lay the foundation for future studies that may lead to new treatment strategies aimed at reducing patient mortality.
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Affiliation(s)
- Aleeza C Gerstein
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katrina M Jackson
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tami R McDonald
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Yina Wang
- Public Health Research Institute, Rutgers University, Newark, New Jersey, USA
| | - Benjamin D Lueck
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sara Bohjanen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kyle D Smith
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew Akampurira
- Infectious Diseases Institute and School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute and School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Chaoyang Xue
- Public Health Research Institute, Rutgers University, Newark, New Jersey, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kirsten Nielsen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota, USA
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150
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Affiliation(s)
- Damien K Ming
- Academic Clinical Fellow, Department of Infection and Immunity, Imperial College London, London W12 0HS
| | - Thomas S Harrison
- Professor of Infectious Diseases and Medicine, Institute of Infection and Immunity, St George's University of London, London
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