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Zhu L, Maruvada R, Sapirstein A, Peters-Golden M, Kim KS. Cysteinyl leukotrienes as novel host factors facilitating Cryptococcus neoformans penetration into the brain. Cell Microbiol 2016; 19. [PMID: 27573789 DOI: 10.1111/cmi.12661] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/27/2016] [Accepted: 08/05/2016] [Indexed: 01/07/2023]
Abstract
Cryptococcus neoformas infection of the central nervous system (CNS) continues to be an important cause of mortality and morbidity, and a major contributing factor is our incomplete knowledge of the pathogenesis of this disease. Here, we provide the first direct evidence that C. neoformans exploits host cysteinyl leukotrienes (LTs), formed via LT biosynthetic pathways involving cytosolic phospholipase A2 α (cPLA2 α) and 5-lipoxygenase (5-LO) and acting via cysteinyl leukotriene type 1 receptor (CysLT1), for penetration of the blood-brain barrier. Gene deletion of cPLA2 α and 5-LO and pharmacological inhibition of cPLA2 α, 5-LO and CysLT1 were effective in preventing C. neoformans penetration of the blood-brain barrier in vitro and in vivo. A CysLT1 antagonist enhanced the efficacy of an anti-fungal agent in therapy of C. neoformans CNS infection in mice. These findings demonstrate that host cysteinyl LTs, dependent on the actions of cPLA2 α and 5-LO, promote C. neoformans penetration of the blood-brain barrier and represent novel targets for elucidating the pathogenesis and therapeutic development of C. neoformans CNS infection.
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Affiliation(s)
- Longkun Zhu
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Cell Biology and Medical Genetics/Center for Cell and Developmental Biology, School of Basic Medical Sciences Fujian Medical University, Fuzhou, Fujian, China
| | - Ravi Maruvada
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adam Sapirstein
- Department of Anesthesiology and Critical Care Medicine, Baltimore, MD, USA
| | - Marc Peters-Golden
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kwang Sik Kim
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Nyazika TK, Hagen F, Machiridza T, Kutepa M, Masanganise F, Hendrickx M, Boekhout T, Magombei-Majinjiwa T, Siziba N, Chin'ombe N, Mateveke K, Meis JF, Robertson VJ. Cryptococcus neoformans population diversity and clinical outcomes of HIV-associated cryptococcal meningitis patients in Zimbabwe. J Med Microbiol 2016; 65:1281-1288. [PMID: 27638836 DOI: 10.1099/jmm.0.000354] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
HIV and cryptococcal meningitis co-infection is a major public health problem in most developing countries. Cryptococcus neoformans sensu stricto is responsible for the majority of HIV-associated cryptococcosis cases in sub-Saharan Africa. Despite the available information, little is known about cryptococcal population diversity and its association with clinical outcomes in patients with HIV-associated cryptococcal meningitis in sub-Saharan Africa. In a prospective cohort, we investigated the prevalence and clinical outcome of Cryptococcusneoformans sensu stricto meningitis among HIV-infected patients in Harare, Zimbabwe, and compared the genotypic diversity of the isolates with those collected from other parts of Africa. Molecular typing was done using amplified fragment length polymorphism genotyping and microsatellite typing. The majority of patients with HIV-associated Cryptococcusneoformans sensu stricto meningitis in this cohort were males (n=33/55; 60.0 %). The predominant Cryptococcus neoformans sensu stricto genotype among the Zimbabwean isolates was genotype AFLP1/VNI (n=40; 72.7 %), followed by AFLP1A/VNB/VNII (n=8; 14.6 %), and AFLP1B/VNII was the least isolated (n=7; 12.7 %). Most of the isolates were mating-type α (n=51; 92.7 %), and only four (7.3 %) were mating-type a. Overall in-hospital mortality was 55.6 % (n=30), and no difference between infecting genotype and clinical outcome of patient (P=0.73) or CD4+ counts (P=0.79) was observed. Zimbabwean Cryptococcusneoformans sensu stricto genotypes demonstrated a high level of genetic diversity by microsatellite typing, and 51 genotypes within the main molecular types AFLP1/VNI, AFLP1A/VNB/VNII and AFLP1B/VNII were identified. This study demonstrates that Cryptococcusneoformans sensu stricto in Zimbabwe has a high level of genetic diversity when compared to other regional isolates.
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Affiliation(s)
- Tinashe K Nyazika
- Department of Medical Microbiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.,Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands.,Department of Chemical Pathology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands
| | - Tendai Machiridza
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Melody Kutepa
- Parirenyatwa Group of Hospitals, Causeway, Harare, Zimbabwe
| | | | - Marijke Hendrickx
- Section Mycology and Aerobiology, Scientific Institute of Public Health, Brussels, Belgium
| | - Teun Boekhout
- Department of Basidiomycetous & Yeast Research, CBS-KNAW Fungal Biodiversity Centre, Utrecht, The Netherlands
| | - Tricia Magombei-Majinjiwa
- Department of Medical Microbiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Nonthokozo Siziba
- Department of Medical Microbiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Nyasha Chin'ombe
- Department of Medical Microbiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Kudzanai Mateveke
- Research Support Centre, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands.,Radboudumc/CWZ Centre of Expertise in Mycology, Nijmegen, The Netherlands
| | - Valerie J Robertson
- Department of Medical Microbiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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253
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Mamuye AT, Bornstein E, Temesgen O, Blumberg HM, Kempker RR. Point-of-Care Testing for Cryptococcal Disease Among Hospitalized Human Immunodeficiency Virus-Infected Adults in Ethiopia. Am J Trop Med Hyg 2016; 95:786-792. [PMID: 27527636 DOI: 10.4269/ajtmh.15-0857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 06/28/2016] [Indexed: 01/05/2023] Open
Abstract
In a cross-sectional study among hospitalized human immunodeficiency virus (HIV)-infected patients in Ethiopia, we sought to determine the rates and predictors of cryptococcal disease and evaluate the test performance of a recently introduced point-of-care test for Cryptococcus neoformans detection in various biological samples. We tested serum, urine, and fingerstick blood samples from each patient with a cryptococcal antigen lateral flow assay (CRAG LFA; Immuno Mycologic Inc., Norman, OK). Cerebrospinal fluid was collected at the discretion of the treating physician. Logistic regression was used to identify risk factors for a positive test result. Agreement between different sample types was also assessed. Among 198 hospitalized HIV-infected patients with a median CD4 count of 93 cells/mm3, 18 patients (9.1%) had a positive serum CRAG LFA. Of these, 16 (8.1%) had confirmed cryptococcal meningitis (CM), all of whom had a positive fingerstick blood LFA result. There was a very high agreement between CRAG LFA tests in serum and fingerstick blood samples (κ = 0.97, 95% confidence interval [CI] = 0.91-1.00); this was higher than that between serum and urine samples (κ = 0.76, 95% CI = 0.58-0.93). A CD4 count < 100 cells/mm3 was significantly associated with a positive CRAG LFA. The absence of fever, headache, meningismus, and neck stiffness had a negative predictive value of 100% for CM. In addition to finding high rates of cryptococcal disease, our study demonstrated that the use of the LFA on fingerstick whole blood is less invasive, and an effective method for CM case finding among hospitalized patients with HIV.
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Affiliation(s)
- Admasu Tenna Mamuye
- Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Ethan Bornstein
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
| | - Obsie Temesgen
- Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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254
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Parkes-Ratanshi R, Achan B, Kwizera R, Kambugu A, Meya D, Denning DW. Cryptococcal disease and the burden of other fungal diseases in Uganda; Where are the knowledge gaps and how can we fill them? Mycoses 2016; 58 Suppl 5:85-93. [PMID: 26449512 DOI: 10.1111/myc.12387] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/21/2015] [Accepted: 05/21/2015] [Indexed: 01/11/2023]
Abstract
The HIV epidemic in Uganda has highlighted Cryptococcus and Candida infections as important opportunistic fungal infections. However, the burden of other fungal diseases is not well described. We aimed to estimate the burden of fungal infections in Uganda. All epidemiological papers of fungal diseases in Uganda were reviewed. Where there is no Ugandan data, global or East African data were used. Recurrent vaginal candidiasis is estimated to occur in 375 540 Uganda women per year; Candida in pregnant women affects up to 651,600 women per year. There are around 45,000 HIV-related oral and oesophageal candidosis cases per year. There are up to 3000 cases per year of post-TB chronic pulmonary aspergillosis. There are an estimated 40,392 people with asthma-related fungal conditions. An estimated 1,300,000 cases of tinea capitis occur in school children yearly in Uganda. There are approximately 800 HIV-positive adults with Pneumocystis jirovecii pneumonia (PJP) annually and up to 42 000 children with PJP per year. There are an estimated 4000 cryptococcal cases annually. There are an estimated 2.5 million fungal infections per year in Uganda. Cryptococcus and PJP cause around 28,000 deaths in adults and children per year. We propose replicating the model of research around cryptococcal disease to investigate and development management strategies for other fungal diseases in Uganda.
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Affiliation(s)
| | - B Achan
- Department of Microbiology, Makerere University, Kampala, Uganda
| | - R Kwizera
- Infectious Diseases Institute, Kampala, Uganda
| | - A Kambugu
- Infectious Diseases Institute, Kampala, Uganda
| | - D Meya
- Infectious Diseases Institute, Kampala, Uganda
| | - D W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, The University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, Manchester, UK
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Abstract
Cryptococcus neoformans is an encapsulated fungal pathogen that is remarkable for its tendency to cause meningoencephalitis, especially in patients with AIDS. While disease is less common in children than adults, it remains an important cause of morbidity and mortality among HIV-infected children without access to anti-retroviral therapy. This review highlights recent insights into both the biology and treatment of cryptococcosis with a special emphasis on the pediatric literature.
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Affiliation(s)
- Carol Kao
- Division of Pediatric Infectious Diseases, Children's Hospital at Montefiore, The Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA
| | - David L Goldman
- Division of Pediatric Infectious Diseases, Children's Hospital at Montefiore, The Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
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257
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Günthard HF, Saag MS, Benson CA, del Rio C, Eron JJ, Gallant JE, Hoy JF, Mugavero MJ, Sax PE, Thompson MA, Gandhi RT, Landovitz RJ, Smith DM, Jacobsen DM, Volberding PA. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2016 Recommendations of the International Antiviral Society-USA Panel. JAMA 2016; 316:191-210. [PMID: 27404187 PMCID: PMC5012643 DOI: 10.1001/jama.2016.8900] [Citation(s) in RCA: 477] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE New data and therapeutic options warrant updated recommendations for the use of antiretroviral drugs (ARVs) to treat or to prevent HIV infection in adults. OBJECTIVE To provide updated recommendations for the use of antiretroviral therapy in adults (aged ≥18 years) with established HIV infection, including when to start treatment, initial regimens, and changing regimens, along with recommendations for using ARVs for preventing HIV among those at risk, including preexposure and postexposure prophylaxis. EVIDENCE REVIEW A panel of experts in HIV research and patient care convened by the International Antiviral Society-USA reviewed data published in peer-reviewed journals, presented by regulatory agencies, or presented as conference abstracts at peer-reviewed scientific conferences since the 2014 report, for new data or evidence that would change previous recommendations or their ratings. Comprehensive literature searches were conducted in the PubMed and EMBASE databases through April 2016. Recommendations were by consensus, and each recommendation was rated by strength and quality of the evidence. FINDINGS Newer data support the widely accepted recommendation that antiretroviral therapy should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count. Recommended optimal initial regimens for most patients are 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (InSTI). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs. Recommendations for special populations and in the settings of opportunistic infections and concomitant conditions are provided. Reasons for switching therapy include convenience, tolerability, simplification, anticipation of potential new drug interactions, pregnancy or plans for pregnancy, elimination of food restrictions, virologic failure, or drug toxicities. Laboratory assessments are recommended before treatment, and monitoring during treatment is recommended to assess response, adverse effects, and adherence. Approaches are recommended to improve linkage to and retention in care are provided. Daily tenofovir disoproxil fumarate/emtricitabine is recommended for use as preexposure prophylaxis to prevent HIV infection in persons at high risk. When indicated, postexposure prophylaxis should be started as soon as possible after exposure. CONCLUSIONS AND RELEVANCE Antiretroviral agents remain the cornerstone of HIV treatment and prevention. All HIV-infected individuals with detectable plasma virus should receive treatment with recommended initial regimens consisting of an InSTI plus 2 NRTIs. Preexposure prophylaxis should be considered as part of an HIV prevention strategy for at-risk individuals. When used effectively, currently available ARVs can sustain HIV suppression and can prevent new HIV infection. With these treatment regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults.
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Affiliation(s)
- Huldrych F Günthard
- University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | | | | | - Carlos del Rio
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | - Joseph J Eron
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | | | - Jennifer F Hoy
- Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Paul E Sax
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston
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258
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Ellis R, Letendre SL. Update and New Directions in Therapeutics for Neurological Complications of HIV Infections. Neurotherapeutics 2016; 13:471-6. [PMID: 27383150 PMCID: PMC4965416 DOI: 10.1007/s13311-016-0454-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The pace of therapeutic developments in HIV presents unique challenges to the neurologist caring for patients. Combination antiretroviral therapy (cART) is remarkably effective in suppressing viral replication, preventing, and often even reversing disease progression. Still, not every patient benefits from cART for a variety of reasons, ranging from the cost of therapy and the burden of lifelong daily treatment to side effects and inadequate access to medical care. Treatment failure inevitably leads to disease progression and opportunistic complications. Many of these complications, even those that are treatable, produce permanent neurological disability. With ART, immune recovery itself may paradoxically lead to severe neurological disease; strategies for managing so-called immune reconstitution inflammatory syndrome are beginning to show benefits. Effective cART may nevertheless leave in its wake persistent neurocognitive impairment. Treatments for persistent impairment despite virologic suppression and good immune recovery are being tested but are not yet proven. As we shall see, these treatments target several proposed mechanisms including cerebral small vessel disease, which is highly prevalent in HIV. Most recently, an ambitious initiative has been undertaken to develop interventions to eradicate HIV. This will require elimination of all infectious forms of viral nucleic acid throughout the body. The influence of these interventions on the brain remains to be characterized. Meanwhile, clinical investigators continue to develop antiretroviral treatments that optimize effectiveness, convenience, and tolerability, while minimizing long-term toxicities.
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Affiliation(s)
- Ronald Ellis
- University of California San Diego, San Diego, CA, USA.
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259
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Crabtree-Ramírez B, Caro-Vega Y, Shepherd BE, Grinsztejn B, Wolff M, Cortes CP, Padgett D, Carriquiry G, Fink V, Jayathilake K, Person AK, McGowan C, Sierra-Madero J. Time to HAART Initiation after Diagnosis and Treatment of Opportunistic Infections in Patients with AIDS in Latin America. PLoS One 2016; 11:e0153921. [PMID: 27271083 PMCID: PMC4896474 DOI: 10.1371/journal.pone.0153921] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/06/2016] [Indexed: 12/02/2022] Open
Abstract
Background Since 2009, earlier initiation of highly active antiretroviral therapy (HAART) after an opportunistic infection (OI) has been recommended based on lower risks of death and AIDS-related progression found in clinical trials. Delay in HAART initiation after OIs may be an important barrier for successful outcomes in patients with advanced disease. Timing of HAART initiation after an OI in “real life” settings in Latin America has not been evaluated. Methods Patients in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) ≥18 years of age at enrolment, from 2001–2012 who had an OI before HAART initiation were included. Patients were divided in an early HAART (EH) group (those initiating within 4 weeks of an OI) and a delayed HAART (DH) group (those initiating more than 4 weeks after an OI). All patients with an AIDS-defining OI were included. In patients with more than one OI the first event reported was considered. Calendar trends in the proportion of patients in the EH group (before and after 2009) were estimated by site and for the whole cohort. Factors associated with EH were estimated using multivariable logistic regression models. Results A total of 1457 patients had an OI before HAART initiation and were included in the analysis: 213 from Argentina, 686 from Brazil, 283 from Chile, 119 from Honduras and 156 from Mexico. Most prevalent OI were Tuberculosis (31%), followed by Pneumocystis pneumonia (24%), Invasive Candidiasis (16%) and Toxoplasmosis (9%). Median time from OI to HAART initiation decreased significantly from 5.7 (interquartile range [IQR] 2.8–12.1) weeks before 2009 to 4.3 (IQR 2.0–7.1) after 2009 (p<0.01). Factors associated with starting HAART within 4 weeks of OI diagnosis were lower CD4 count at enrolment (p-<0.001), having a non-tuberculosis OI (p<0.001), study site (p<0.001), and more recent years of OI diagnosis (p<0.001). Discussion The time from diagnosis of an OI to HAART initiation has decreased in Latin America coinciding with the publication of evidence of its benefit. We found important heterogeneity between sites which may reflect differences in clinical practices, local guidelines, and access to HAART. The impact of the timing of HAART initiation after OI on patient survival in this “real life” context needs further evaluation.
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Affiliation(s)
- Brenda Crabtree-Ramírez
- Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico
- * E-mail:
| | - Yanink Caro-Vega
- Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico
| | - Bryan E. Shepherd
- Vanderbilt University, Department of Biostatistics, Nashville, TN, United States of America
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| | - Marcelo Wolff
- Universidad de Chile- Fundación Arriarán, Santiago, Chile
| | | | - Denis Padgett
- Instituto Hondureño de Seguro Social and Hospital Escuela Universitario, Tegucigalpa, Honduras
| | | | - Valeria Fink
- Fundación Huésped, Investigaciones Clínicas, Buenos Aires, Argentina
| | - Karu Jayathilake
- Vanderbilt University, Department of Medicine, Nashville, TN, United States of America
| | - Anna K. Person
- Vanderbilt University, Department of Medicine, Nashville, TN, United States of America
| | - Catherine McGowan
- Vanderbilt University, Department of Medicine, Nashville, TN, United States of America
| | - Juan Sierra-Madero
- Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico
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260
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Phe K, Cadle RM, Guervil DJ, Guzman OE, Lockwood AM, Perez KK, Vuong NN, Aitken SL. Significant publications on infectious diseases pharmacotherapy in 2014. Am J Health Syst Pharm 2016; 72:1380-92. [PMID: 26246295 DOI: 10.2146/ajhp150112] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE The most important articles on infectious diseases (ID) pharmacotherapy published in the peer-reviewed literature in 2014, as nominated and selected by panels of pharmacists and others with ID expertise, are summarized. SUMMARY Members of the Houston Infectious Diseases Network were asked to nominate articles published in 2014 from prominent peer-reviewed journals that were felt to have a major impact in the field of ID pharmacotherapy. A list of 19 nominated articles on general ID-related topics and 9 articles specifically related to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) was compiled. In a national online survey, members of the Society of Infectious Diseases Pharmacists (SIDP) were asked to select from the list 10 general ID articles believed to have made a significant contribution to the field of ID pharmacotherapy and 1 article contributing to HIV/AIDS pharmacotherapy. Of the 291 SIDP members surveyed, 134 (46%) and 56 (19%) participated in the selection of general ID-related articles and HIV/AIDS-related articles, respectively. The 11 highest-ranked papers (10 general ID-related articles, 1 HIV/AIDS-related article) are summarized here. CONCLUSION With the vast number of articles published each year, it is difficult to remain up-to-date on current, significant ID pharmacotherapy publications. This review of significant publications in 2014 may be helpful by lessening this burden.
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Affiliation(s)
- Kady Phe
- Kady Phe, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX. Richard M. Cadle, Pharm.D., BCPS (AQ-ID), FASHP, is Clinical Pharmacy Manager and Residency Program Director, Pharmacy Practice (Postgraduate Year 1) and Infectious Disease (Postgraduate Year 2) Programs, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. David J. Guervil, Pharm.D., is Clinical Pharmacy Specialist-Infectious Diseases, Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston. Oscar E. Guzman, Pharm.D., BCPS, is Clinical Director, Infectious Diseases and Critical Care, Cardinal Health, Innovative Delivery Solutions, Houston. Ashley M. Lockwood, Pharm.D., is Postgraduate Year 2 Infectious Diseases Pharmacy Resident, Department of Pharmacy, Houston Methodist Hospital, Houston. Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist, Infectious Diseases, Departments of Pharmacy and Pathology and Genomic Medicine, Houston Methodist Hospital, and Assistant Professor of Health Sciences and Assistant Clinical Member, Institute for Academic Medicine, Houston Methodist Research Institute, Houston. Nancy N. Vuong, Pharm.D., MBIOT, BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy. Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Infectious Diseases, Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston
| | - Richard M Cadle
- Kady Phe, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX. Richard M. Cadle, Pharm.D., BCPS (AQ-ID), FASHP, is Clinical Pharmacy Manager and Residency Program Director, Pharmacy Practice (Postgraduate Year 1) and Infectious Disease (Postgraduate Year 2) Programs, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. David J. Guervil, Pharm.D., is Clinical Pharmacy Specialist-Infectious Diseases, Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston. Oscar E. Guzman, Pharm.D., BCPS, is Clinical Director, Infectious Diseases and Critical Care, Cardinal Health, Innovative Delivery Solutions, Houston. Ashley M. Lockwood, Pharm.D., is Postgraduate Year 2 Infectious Diseases Pharmacy Resident, Department of Pharmacy, Houston Methodist Hospital, Houston. Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist, Infectious Diseases, Departments of Pharmacy and Pathology and Genomic Medicine, Houston Methodist Hospital, and Assistant Professor of Health Sciences and Assistant Clinical Member, Institute for Academic Medicine, Houston Methodist Research Institute, Houston. Nancy N. Vuong, Pharm.D., MBIOT, BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy. Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Infectious Diseases, Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston
| | - David J Guervil
- Kady Phe, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX. Richard M. Cadle, Pharm.D., BCPS (AQ-ID), FASHP, is Clinical Pharmacy Manager and Residency Program Director, Pharmacy Practice (Postgraduate Year 1) and Infectious Disease (Postgraduate Year 2) Programs, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. David J. Guervil, Pharm.D., is Clinical Pharmacy Specialist-Infectious Diseases, Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston. Oscar E. Guzman, Pharm.D., BCPS, is Clinical Director, Infectious Diseases and Critical Care, Cardinal Health, Innovative Delivery Solutions, Houston. Ashley M. Lockwood, Pharm.D., is Postgraduate Year 2 Infectious Diseases Pharmacy Resident, Department of Pharmacy, Houston Methodist Hospital, Houston. Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist, Infectious Diseases, Departments of Pharmacy and Pathology and Genomic Medicine, Houston Methodist Hospital, and Assistant Professor of Health Sciences and Assistant Clinical Member, Institute for Academic Medicine, Houston Methodist Research Institute, Houston. Nancy N. Vuong, Pharm.D., MBIOT, BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy. Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Infectious Diseases, Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston
| | - Oscar E Guzman
- Kady Phe, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX. Richard M. Cadle, Pharm.D., BCPS (AQ-ID), FASHP, is Clinical Pharmacy Manager and Residency Program Director, Pharmacy Practice (Postgraduate Year 1) and Infectious Disease (Postgraduate Year 2) Programs, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. David J. Guervil, Pharm.D., is Clinical Pharmacy Specialist-Infectious Diseases, Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston. Oscar E. Guzman, Pharm.D., BCPS, is Clinical Director, Infectious Diseases and Critical Care, Cardinal Health, Innovative Delivery Solutions, Houston. Ashley M. Lockwood, Pharm.D., is Postgraduate Year 2 Infectious Diseases Pharmacy Resident, Department of Pharmacy, Houston Methodist Hospital, Houston. Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist, Infectious Diseases, Departments of Pharmacy and Pathology and Genomic Medicine, Houston Methodist Hospital, and Assistant Professor of Health Sciences and Assistant Clinical Member, Institute for Academic Medicine, Houston Methodist Research Institute, Houston. Nancy N. Vuong, Pharm.D., MBIOT, BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy. Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Infectious Diseases, Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston
| | - Ashley M Lockwood
- Kady Phe, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX. Richard M. Cadle, Pharm.D., BCPS (AQ-ID), FASHP, is Clinical Pharmacy Manager and Residency Program Director, Pharmacy Practice (Postgraduate Year 1) and Infectious Disease (Postgraduate Year 2) Programs, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. David J. Guervil, Pharm.D., is Clinical Pharmacy Specialist-Infectious Diseases, Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston. Oscar E. Guzman, Pharm.D., BCPS, is Clinical Director, Infectious Diseases and Critical Care, Cardinal Health, Innovative Delivery Solutions, Houston. Ashley M. Lockwood, Pharm.D., is Postgraduate Year 2 Infectious Diseases Pharmacy Resident, Department of Pharmacy, Houston Methodist Hospital, Houston. Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist, Infectious Diseases, Departments of Pharmacy and Pathology and Genomic Medicine, Houston Methodist Hospital, and Assistant Professor of Health Sciences and Assistant Clinical Member, Institute for Academic Medicine, Houston Methodist Research Institute, Houston. Nancy N. Vuong, Pharm.D., MBIOT, BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy. Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Infectious Diseases, Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston
| | - Katherine K Perez
- Kady Phe, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX. Richard M. Cadle, Pharm.D., BCPS (AQ-ID), FASHP, is Clinical Pharmacy Manager and Residency Program Director, Pharmacy Practice (Postgraduate Year 1) and Infectious Disease (Postgraduate Year 2) Programs, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. David J. Guervil, Pharm.D., is Clinical Pharmacy Specialist-Infectious Diseases, Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston. Oscar E. Guzman, Pharm.D., BCPS, is Clinical Director, Infectious Diseases and Critical Care, Cardinal Health, Innovative Delivery Solutions, Houston. Ashley M. Lockwood, Pharm.D., is Postgraduate Year 2 Infectious Diseases Pharmacy Resident, Department of Pharmacy, Houston Methodist Hospital, Houston. Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist, Infectious Diseases, Departments of Pharmacy and Pathology and Genomic Medicine, Houston Methodist Hospital, and Assistant Professor of Health Sciences and Assistant Clinical Member, Institute for Academic Medicine, Houston Methodist Research Institute, Houston. Nancy N. Vuong, Pharm.D., MBIOT, BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy. Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Infectious Diseases, Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston
| | - Nancy N Vuong
- Kady Phe, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX. Richard M. Cadle, Pharm.D., BCPS (AQ-ID), FASHP, is Clinical Pharmacy Manager and Residency Program Director, Pharmacy Practice (Postgraduate Year 1) and Infectious Disease (Postgraduate Year 2) Programs, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. David J. Guervil, Pharm.D., is Clinical Pharmacy Specialist-Infectious Diseases, Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston. Oscar E. Guzman, Pharm.D., BCPS, is Clinical Director, Infectious Diseases and Critical Care, Cardinal Health, Innovative Delivery Solutions, Houston. Ashley M. Lockwood, Pharm.D., is Postgraduate Year 2 Infectious Diseases Pharmacy Resident, Department of Pharmacy, Houston Methodist Hospital, Houston. Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist, Infectious Diseases, Departments of Pharmacy and Pathology and Genomic Medicine, Houston Methodist Hospital, and Assistant Professor of Health Sciences and Assistant Clinical Member, Institute for Academic Medicine, Houston Methodist Research Institute, Houston. Nancy N. Vuong, Pharm.D., MBIOT, BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy. Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Infectious Diseases, Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston
| | - Samuel L Aitken
- Kady Phe, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX. Richard M. Cadle, Pharm.D., BCPS (AQ-ID), FASHP, is Clinical Pharmacy Manager and Residency Program Director, Pharmacy Practice (Postgraduate Year 1) and Infectious Disease (Postgraduate Year 2) Programs, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. David J. Guervil, Pharm.D., is Clinical Pharmacy Specialist-Infectious Diseases, Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston. Oscar E. Guzman, Pharm.D., BCPS, is Clinical Director, Infectious Diseases and Critical Care, Cardinal Health, Innovative Delivery Solutions, Houston. Ashley M. Lockwood, Pharm.D., is Postgraduate Year 2 Infectious Diseases Pharmacy Resident, Department of Pharmacy, Houston Methodist Hospital, Houston. Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist, Infectious Diseases, Departments of Pharmacy and Pathology and Genomic Medicine, Houston Methodist Hospital, and Assistant Professor of Health Sciences and Assistant Clinical Member, Institute for Academic Medicine, Houston Methodist Research Institute, Houston. Nancy N. Vuong, Pharm.D., MBIOT, BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy. Samuel L. Aitken, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Infectious Diseases, Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston.
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Immune Reconstitution Inflammatory Syndrome in Invasive Fungal Infections: What We Know and What We Need to Know? CURRENT CLINICAL MICROBIOLOGY REPORTS 2016. [DOI: 10.1007/s40588-016-0033-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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262
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Brief Report: Effects of Tenofovir and Amphotericin B Deoxycholate Coadministration on Kidney Function in Patients Treated for Cryptococcal Meningitis. J Acquir Immune Defic Syndr 2016; 71:65-9. [PMID: 26334743 DOI: 10.1097/qai.0000000000000812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The effect of tenofovir and amphotericin coadministration on kidney function is poorly characterized. We measured creatinine during induction therapy and at 4 weeks after diagnosis in Ugandans undergoing cryptococcal meningitis therapy and classified as not receiving antiretroviral therapy (ART), receiving nontenofovir ART or receiving tenofovir-based ART. Longitudinal creatinine changes and grade 2-4 creatinine adverse events were evaluated across groups. Creatinine concentrations were similar across ART groups. At 4 weeks after diagnosis, creatinine was 0.25 mg/dL higher than at diagnosis, but similar across groups. Adverse event incidence was also similar across ART groups. Tenofovir and amphotericin coadministration did not increase the risk of kidney dysfunction.
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263
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Opportunistic Neurologic Infections in Patients with Acquired Immunodeficiency Syndrome (AIDS). Curr Neurol Neurosci Rep 2016; 16:10. [PMID: 26747443 DOI: 10.1007/s11910-015-0603-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Infections of the central nervous system (CNS) in individuals with human immunodeficiency virus (HIV) remain a substantial cause of morbidity and mortality despite the introduction of highly active antiretroviral therapy (HAART) especially in the resource-limited regions of the world. Diagnosis of these infections may be challenging because findings on cerebrospinal fluid (CSF) analysis and brain imaging are nonspecific. While brain biopsy provides a definitive diagnosis, it is an invasive procedure associated with a relatively low mortality rate, thus less invasive modalities have been studied in recent years. Diagnosis, therefore, can be established based on a combination of a compatible clinical syndrome, radiologic and CSF findings, and understanding of the role of HIV in these infections. The most common CNS opportunistic infections are AIDS-defining conditions; thus, treatment of these infections in combination with HAART has greatly improved survival.
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264
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Tugume L, Morawski BM, Abassi M, Bahr NC, Kiggundu R, Nabeta HW, Hullsiek KH, Taseera K, Musubire AK, Schutz C, Muzoora C, Williams DA, Rolfes MA, Meintjes G, Rhein J, Meya DB, Boulware DR. Prognostic implications of baseline anaemia and changes in haemoglobin concentrations with amphotericin B therapy for cryptococcal meningitis. HIV Med 2016; 18:13-20. [PMID: 27126930 DOI: 10.1111/hiv.12387] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Anaemia represents a common toxicity with amphotericin B-based induction therapy in HIV-infected persons with cryptococcal meningitis. We sought to examine the impact of amphotericin-related anaemia on survival. METHODS We used data from Ugandan and South African trial participants to characterize the variation of haemoglobin concentrations from diagnosis to 12 weeks post-diagnosis. Anaemia severity was classified based on the haemoglobin concentration at cryptococcal meningitis diagnosis, and nadir haemoglobin values during amphotericin induction. Cox proportional hazard models were used to estimate 2- and 10-week mortality risk. We also estimated 10-week mortality risk among participants with nadir haemoglobin < 8.5 g/dL during amphotericin induction and who survived ≥ 2 weeks post-enrolment. RESULTS The median haemoglobin concentration at meningitis diagnosis was 11.5 g/dL [interquartile range (IQR) 9.7-13 g/dL; n = 311] with a mean decline of 4.2 g/dL [95% confidence interval (CI) -4.6 to -3.8; P < 0.001; n = 148] from diagnosis to nadir value among participants with baseline haemoglobin ≥ 8.5 g/dL. The median haemoglobin concentration was 8.1 g/dL (IQR 6.5-9.5 g/dL) at 2 weeks, increasing to 9.4 g/dL (IQR 8.2-10.9 g/dL) by 4 weeks and continuing to increase to 12 weeks. Among participants with haemoglobin < 8.5 g/dL at diagnosis, mortality risk was elevated at 2 weeks [hazard ratio (HR) 2.7; 95% CI 1.5-4.9; P < 0.01] and 10 weeks (HR 1.8; 95% CI 1.1-2.2; P = 0.03), relative to those with haemoglobin ≥ 8.5 g/dL. New-onset anaemia occurring with amphotericin therapy did not have a statistically significant association with 10-week mortality (HR 2.0; 95% CI 0.5-9.1; P = 0.4). CONCLUSIONS Amphotericin induced significant haemoglobin declines, which were mostly transient and did not impact 10-week mortality. Individuals with moderate to life-threatening anaemia at baseline had a higher mortality risk at 2 and 10 weeks post-enrolment.
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Affiliation(s)
- L Tugume
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - B M Morawski
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - M Abassi
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - N C Bahr
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Center for Infectious Diseases & Microbiology Translational Research, University of Minnesota, Minneapolis, MN, USA
| | - R Kiggundu
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - H W Nabeta
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - K H Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - K Taseera
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - A K Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - C Schutz
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - C Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - D A Williams
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - M A Rolfes
- Epidemiologic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - G Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Imperial College London, London, UK
| | - J Rhein
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - D B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Department of Medicine, Faculty of Health Sciences, Makerere University, Kampala, Uganda
| | - D R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Center for Infectious Diseases & Microbiology Translational Research, University of Minnesota, Minneapolis, MN, USA
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265
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Henderson D, Sims-Williams HP, Wilhelm T, Sims-Williams H, Bhagani S, Thorne L. Neurosurgery and human immunodeficiency virus in the era of combination antiretroviral therapy: a review. J Neurosurg 2016; 126:897-907. [PMID: 27081898 DOI: 10.3171/2016.1.jns151194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Human immunodeficiency virus (HIV) is a global health problem. It renders the central nervous system susceptible to infectious and noninfectious diseases. HIV-positive individuals may present to neurosurgical services with brain lesions of unknown etiology. The differential diagnosis in these cases is broad, including opportunistic infections and malignancies, and investigation should be tailored accordingly. Opportunistic infections of the central nervous system can be complicated by hydrocephalus, and the management is pathogen dependent. Patients may also present to a neurosurgical service with conditions unrelated to their HIV status. This review outlines important conditions that cause brain lesions and hydrocephalus. It addresses the issues of diagnosis and intervention in HIV-positive patients in the era of combination antiretroviral therapy, while not ignoring the potential for opportunistic central nervous system infection in undiagnosed patients. The care of HIV-positive patients presenting to neurosurgical services requires a multidisciplinary approach, which is reflected in the authorship of this review, as well as in the guidance given.
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Affiliation(s)
| | | | | | | | | | - Lewis Thorne
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
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266
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The 2015 Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections in HIV-Infected Koreans: Guidelines for Opportunistic Infections. Infect Chemother 2016; 48:54-60. [PMID: 27104018 PMCID: PMC4835437 DOI: 10.3947/ic.2016.48.1.54] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Indexed: 12/11/2022] Open
Abstract
The Committee for Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections of the Korean Society for AIDS was founded in 2011. The first edition of the Korean guidelines was published in 2012. The guideline recommendations contain important information for physicians working with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in the clinical field. It has become necessary to revise the guidelines due to new data in this field. These guidelines aim to provide up-to-date, comprehensive information regarding the treatment and prevention of opportunistic infections in HIV-infected Koreans. These guidelines deal with several common opportunistic infections, including pneumocystis pneumonia, tuberculosis, cryptococcal meningitis, etc. A brief summary of the revised guidelines is provided below. Recommendations are rated using the same system used in the previous guidelines.
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267
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Merry M, Boulware DR. Cryptococcal Meningitis Treatment Strategies Affected by the Explosive Cost of Flucytosine in the United States: A Cost-effectiveness Analysis. Clin Infect Dis 2016; 62:1564-8. [PMID: 27009249 DOI: 10.1093/cid/ciw151] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 02/10/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In the United States, cryptococcal meningitis causes approximately 3400 hospitalizations and approximately 330 deaths annually. The US guidelines recommend treatment with amphotericin B plus flucytosine for at least 2 weeks, followed by fluconazole for a minimum of 8 weeks. Due to generic drug manufacturer monopolization, flucytosine currently costs approximately $2000 per day in the United States, with a 2-week flucytosine treatment course costing approximately $28 000. The daily flucytosine treatment cost in the United Kingdom is approximately $22. Cost-effectiveness analysis was performed to determine the value of flucytosine relative to alternative regimens. METHODS We estimated the incremental cost-effectiveness ratio (ICER) of 3 cryptococcal induction regimens: (1) amphotericin B deoxycholate for 4 weeks; (2) amphotericin and flucytosine (100 mg/kg/day) for 2 weeks; and (3) amphotericin and fluconazole (800 mg/day) for 2 weeks. Costs of care were calculated using 2015 US prices and the medication costs. Survival estimates were derived from a randomized trial and scaled relative to published US survival data. RESULTS Cost estimates were $83 227 for amphotericin monotherapy, $75 121 for amphotericin plus flucytosine, and $44 605 for amphotericin plus fluconazole. The ICER of amphotericin plus flucytosine was $23 842 per quality-adjusted life-year. CONCLUSIONS Flucytosine is currently cost-effective in the United States despite a dramatic increase in price in recent years. Combination therapy with amphotericin and flucytosine is the most attractive treatment strategy for cryptococcal meningitis, though the rising price may be creating access issues that will exacerbate if the trend of profiteering continues.
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Affiliation(s)
- Matthew Merry
- Department of Medicine, University of Minnesota, Minneapolis
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268
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Tenforde MW, Wake R, Leeme T, Jarvis JN. HIV-Associated Cryptococcal Meningitis: Bridging the Gap Between Developed and Resource-Limited Settings. CURRENT CLINICAL MICROBIOLOGY REPORTS 2016; 3:92-102. [PMID: 27257597 PMCID: PMC4845086 DOI: 10.1007/s40588-016-0035-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Cryptococcal meningitis is a major cause of HIV-associated morbidity and mortality worldwide. Most cases occur in low-income countries, where over half of patients die within 10 weeks of diagnosis compared to as few as 10 % of patients from developed countries. A host of factors, spanning the HIV care continuum, are responsible for this gap in treatment outcomes between developed and resource-limited settings. We explore factors responsible for this outcomes gap and describe low-cost, highly effective measures that can be implemented immediately to improve outcomes in resource-limited settings. We also explore health-system challenges that must be addressed to reduce mortality further, recent research in disease prevention, and novel short-course treatment regimens that, if efficacious, could be implemented in resource-limited settings where the cost of standard treatment regimens is currently prohibitive.
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Affiliation(s)
- Mark W. Tenforde
- />Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA USA
- />University of Washington Medical Center, 1959 NE Pacific Street, Health Sciences Division #356423, Seattle, WA 98195 USA
| | - Rae Wake
- />Institute of Infection and Immunity, St. George’s University of London, London, UK
- />Centre for Opportunistic, Tropical and Hospital Infections, National Institute for Communicable Diseases, Johannesburg, South Africa
- />National Institute for Communicable Diseases, 1 Modderfontein Road, Sandringham, Johannesburg, 2131 South Africa
| | - Tshepo Leeme
- />Botswana-UPenn Partnership, Gaborone, Botswana
| | - Joseph N. Jarvis
- />Botswana-UPenn Partnership, Gaborone, Botswana
- />Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- />Department of Clinical Research, Faculty of Infectious Diseases and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
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269
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Oladele RO, Akanmu AS, Nwosu AO, Ogunsola FT, Richardson MD, Denning DW. Cryptococcal Antigenemia in Nigerian Patients With Advanced Human Immunodeficiency Virus: Influence of Antiretroviral Therapy Adherence. Open Forum Infect Dis 2016; 3:ofw055. [PMID: 27186581 PMCID: PMC4866571 DOI: 10.1093/ofid/ofw055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/07/2016] [Indexed: 11/12/2022] Open
Abstract
Background. Cryptococcal meningitis has a high mortality in human immunodeficiency virus (HIV)-infected persons in Africa. This is preventable with early screening and preemptive therapy. We evaluated the prevalence of cryptococcal disease by antigen testing, possible associated factors, and outcomes in HIV-infected patients being managed in a tertiary hospital in Lagos, Nigeria. Methods. Sera were collected from 214 consenting HIV-infected participants with CD4+ counts <250 cells/mm3, irrespective of their antiretroviral therapy (ART) status, between November 2014 and May 2015. A cryptococcal antigen (CrAg) lateral flow assay was used for testing. Pertinent clinical data were obtained from patients and their case notes. Results. Of the 214 participants, females (124; 57.9%) outnumbered males. Mean age was 41.3 ± 9.4 (standard deviation) years. The majority (204; 95.3%) were ART experienced. The median CD4+ cell count was 160 cells/mm3 (interquartile range, 90–210). The overall seroprevalence of cryptococcal antigenemia was 8.9% (19 of 214); 6 of 61 (9.8%) in those with CD4+ cell counts <100 cells/mm3, 4 of 80 (5.0%) in the 100–200 group, and 9 of 73 (12.3%) in 200–250 cells/mm3 group. Among ART-naive patients, 1 of 10 (10%) was CrAg positive. Twenty-seven of 214 (12.6%) had associated oral thrush. Potential baseline meningitis symptoms (3 of 214 [1.4%] experienced neck pain or stiffness and 21 of 214 [9.8%] experienced headache) were common in the study group, but the result was not statistically significant in relation to CrAg positivity. Two of 19 (10.5%) CrAg-positive patients died, 10 of 19 (52.6%) were lost to follow up, and 7 of 19 (36.8%) were alive. Empirical fluconazole was routinely given to those with low CD4 counts <100 cells/mm3, which was unrelated to CrAg positivity (P = .018). Conclusions. We report a prevalence of 8.9% cryptococcal antigenemia in a setting where first-line antifungals are not readily available. We recommend CrAg screening for HIV-infected patients, even for patients on ART.
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Affiliation(s)
- Rita O Oladele
- The University of Manchester, United Kingdom; College of Medicine of University of Lagos
| | - Alani S Akanmu
- US President's Emergency Plan for AIDS Relief Clinic , Lagos University Teaching Hospital
| | - Augustina O Nwosu
- AIDS Prevention Initiative in Nigeria, Central Laboratory , College of Medicine of University of Lagos , Nigeria
| | | | - Malcolm D Richardson
- The University of Manchester, United Kingdom; National Aspergillosis Centre and Mycology Reference Centre Manchester, University Hospital of South Manchester and Manchester Academic Health Science Centre, United Kingdom
| | - David W Denning
- The University of Manchester, United Kingdom; National Aspergillosis Centre and Mycology Reference Centre Manchester, University Hospital of South Manchester and Manchester Academic Health Science Centre, United Kingdom
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270
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Iribarren JA, Rubio R, Aguirrebengoa K, Arribas JR, Baraia-Etxaburu J, Gutiérrez F, Lopez Bernaldo de Quirós JC, Losa JE, Miró JM, Moreno S, Pérez Molina J, Podzamczer D, Pulido F, Riera M, Rivero A, Sanz Moreno J, Amador C, Antela A, Arazo P, Arrizabalaga J, Bachiller P, Barros C, Berenguer J, Caylá J, Domingo P, Estrada V, Knobel H, Locutura J, López Aldeguer J, Llibre JM, Lozano F, Mallolas J, Malmierca E, Miralles C, Miralles P, Muñoz A, Ocampo A, Olalla J, Pérez I, Pérez Elías MJ, Pérez Arellano JL, Portilla J, Ribera E, Rodríguez F, Santín M, Sanz Sanz J, Téllez MJ, Torralba M, Valencia E, Von Wichmann MA. Prevention and treatment of opportunistic infections and other coinfections in HIV-infected patients: May 2015. Enferm Infecc Microbiol Clin 2016; 34:516.e1-516.e18. [PMID: 26976381 DOI: 10.1016/j.eimc.2016.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/04/2016] [Indexed: 01/04/2023]
Abstract
Despite the huge advance that antiretroviral therapy represents for the prognosis of infection by the human immunodeficiency virus (HIV), opportunistic infections (OIs) continue to be a cause of morbidity and mortality in HIV-infected patients. OIs often arise because of severe immunosuppression resulting from poor adherence to antiretroviral therapy, failure of antiretroviral therapy, or unawareness of HIV infection by patients whose first clinical manifestation of AIDS is an OI. The present article updates our previous guidelines on the prevention and treatment of various OIs in HIV-infected patients, namely, infections by parasites, fungi, viruses, mycobacteria, and bacteria, as well as imported infections. The article also addresses immune reconstitution inflammatory syndrome.
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271
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Jarvis JN, Harrison TS. Forgotten but not gone: HIV-associated cryptococcal meningitis. THE LANCET. INFECTIOUS DISEASES 2016; 16:756-758. [PMID: 26971080 DOI: 10.1016/s1473-3099(16)00128-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 02/23/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Joseph N Jarvis
- Botswana-UPenn Partnership, PO Box AC 157 ACH, Gaborone, Botswana; Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Thomas S Harrison
- Institute of Infection and Immunity, St. George's University of London, London, UK
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Rhein J, Morawski BM, Hullsiek KH, Nabeta HW, Kiggundu R, Tugume L, Musubire A, Akampurira A, Smith KD, Alhadab A, Williams DA, Abassi M, Bahr NC, Velamakanni SS, Fisher J, Nielsen K, Meya DB, Boulware DR. Efficacy of adjunctive sertraline for the treatment of HIV-associated cryptococcal meningitis: an open-label dose-ranging study. THE LANCET. INFECTIOUS DISEASES 2016; 16:809-818. [PMID: 26971081 PMCID: PMC4927382 DOI: 10.1016/s1473-3099(16)00074-8] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 12/17/2022]
Abstract
Background Cryptococcus is the most common cause of adult meningitis in Africa. We evaluated the activity of adjunctive sertraline, previously demonstrated to have in vitro and in vivo activity against Cryptococcus. Methods We enrolled 172 HIV-infected Ugandans with cryptococcal meningitis from August 2013 through August 2014 into an open-label dose-finding study to assess safety and microbiologic efficacy. Sertraline 100–400mg/day was added to standard therapy of amphotericin + fluconazole 800mg/day. We evaluated early fungicidal activity via Cryptococcus cerebrospinal fluid (CSF) clearance rate, sertraline pharmacokinetics, and in vitro susceptibility. Findings Participants receiving any sertraline dose averaged a CSF clearance rate of −0·37 (95%CI: −0·41, −0·33) colony forming units (CFU)/mL/day. Incidence of paradoxical immune reconstitution inflammatory syndrome (IRIS) was 5% (2/43) and relapse was 0% through 12-weeks. Sertraline reached steady state concentrations in plasma by day 7, with median steady-state concentrations of 201 ng/mL (IQR, 90–300; n=49) with 200mg/day and 399 ng/mL (IQR, 279–560; n=30) with 400mg/day. Plasma concentrations reached 83% of steady state levels by day 3. The median projected steady state brain tissue concentration at 200mg/day was 3·7 (IQR, 2·0–5·7) mcg/mL and 6·8 (IQR, 4·6–9·7) mcg/mL at 400mg/day. Minimum inhibitory concentrations were ≤2 mcg/mL for 27% (35/128), ≤4 mcg/mL for 84% (108/128), ≤6 mcg/mL for 91% (117/128), and ≤8 mcg/mL for 100% of 128 Cryptococcus isolates. Interpretation Sertraline had faster cryptococcal CSF clearance, decreased IRIS, and decreased relapse compared with historical experiences. Sertraline reaches therapeutic levels in a clinical setting. This inexpensive and off-patent oral medication is a promising adjunctive antifungal therapy. Funding National Institutes of Health, Grand Challenges Canada.
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Affiliation(s)
- Joshua Rhein
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda.
| | | | | | - Henry W Nabeta
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Reuben Kiggundu
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Abdu Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | | | - Ali Alhadab
- University of Minnesota, Minneapolis, MN, USA
| | - Darlisha A Williams
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Mahsa Abassi
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Nathan C Bahr
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | | | | | - David B Meya
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
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273
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Beardsley J, Wolbers M, Kibengo FM, Ggayi ABM, Kamali A, Cuc NTK, Binh TQ, Chau NVV, Farrar J, Merson L, Phuong L, Thwaites G, Van Kinh N, Thuy PT, Chierakul W, Siriboon S, Thiansukhon E, Onsanit S, Supphamongkholchaikul W, Chan AK, Heyderman R, Mwinjiwa E, van Oosterhout JJ, Imran D, Basri H, Mayxay M, Dance D, Phimmasone P, Rattanavong S, Lalloo DG, Day JN. Adjunctive Dexamethasone in HIV-Associated Cryptococcal Meningitis. N Engl J Med 2016; 374:542-54. [PMID: 26863355 PMCID: PMC4778268 DOI: 10.1056/nejmoa1509024] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cryptococcal meningitis associated with human immunodeficiency virus (HIV) infection causes more than 600,000 deaths each year worldwide. Treatment has changed little in 20 years, and there are no imminent new anticryptococcal agents. The use of adjuvant glucocorticoids reduces mortality among patients with other forms of meningitis in some populations, but their use is untested in patients with cryptococcal meningitis. METHODS In this double-blind, randomized, placebo-controlled trial, we recruited adult patients with HIV-associated cryptococcal meningitis in Vietnam, Thailand, Indonesia, Laos, Uganda, and Malawi. All the patients received either dexamethasone or placebo for 6 weeks, along with combination antifungal therapy with amphotericin B and fluconazole. RESULTS The trial was stopped for safety reasons after the enrollment of 451 patients. Mortality was 47% in the dexamethasone group and 41% in the placebo group by 10 weeks (hazard ratio in the dexamethasone group, 1.11; 95% confidence interval [CI], 0.84 to 1.47; P=0.45) and 57% and 49%, respectively, by 6 months (hazard ratio, 1.18; 95% CI, 0.91 to 1.53; P=0.20). The percentage of patients with disability at 10 weeks was higher in the dexamethasone group than in the placebo group, with 13% versus 25% having a prespecified good outcome (odds ratio, 0.42; 95% CI, 0.25 to 0.69; P<0.001). Clinical adverse events were more common in the dexamethasone group than in the placebo group (667 vs. 494 events, P=0.01), with more patients in the dexamethasone group having grade 3 or 4 infection (48 vs. 25 patients, P=0.003), renal events (22 vs. 7, P=0.004), and cardiac events (8 vs. 0, P=0.004). Fungal clearance in cerebrospinal fluid was slower in the dexamethasone group. Results were consistent across Asian and African sites. CONCLUSIONS Dexamethasone did not reduce mortality among patients with HIV-associated cryptococcal meningitis and was associated with more adverse events and disability than was placebo. (Funded by the United Kingdom Department for International Development and others through the Joint Global Health Trials program; Current Controlled Trials number, ISRCTN59144167.).
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Affiliation(s)
- Justin Beardsley
- From the Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Vietnam (J.B., M.W., J.F., L.M., G.T., J.N.D.), Hospital for Tropical Diseases (N.T.K.C., N.V.V.C.), Cho Ray Hospital (T.Q.B., L.P.), Ho Chi Minh City, and the National Hospital for Tropical Diseases (N.V.K.) and Bach Mai Hospital (P.T.T.), Hanoi - all in Vietnam; Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford (J.B., M.W., J.F., L.M., G.T., M.M., D.D., J.N.D.), University College London, London (R.H.), and Liverpool School of Tropical Medicine, Liverpool (D.G.L.) - all in the United Kingdom; MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda (F.M.K., A.-B.M.G., A.K.); Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok (W.C.), Ubon Sappasithiprasong Hospital, Ubon (S.S., W.S.), and Udon Thani Hospital, Udon Thani (E.T., S.O.) - all in Thailand; Dignitas International, Zomba (A.K.C., E.M., J.J.O.), and Malawi-Liverpool-Wellcome Trust, Clinical Research Programme (R.H., D.G.L.), and University of Malawi College of Medicine (R.H., J.J.O.), Blantyre - all in Malawi; Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); Cipto Mangunkusumo Hospital (D.I.) and Eijkman Oxford Clinical Research Unit (H.B.) - both in Jakarta, Indonesia; and Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital (M.M., D.D., P.P., S.R.), and University of Health Sciences (M.M.) - both in Vientiane, Laos
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274
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Yeung VA, Azzam R, Dendle C, Graham M, Woolley IJ, Korman TM. Cryptococcemia in primary HIV infection. Int J STD AIDS 2016; 27:1231-1233. [PMID: 26868159 DOI: 10.1177/0956462416632139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/19/2016] [Indexed: 11/16/2022]
Abstract
Opportunistic infections have been reported infrequently in primary HIV infection. We report a case of cryptococcemia in primary HIV infection. To our knowledge there has not been such a case reported. Our case highlights the need for clinicians to be wary of other opportunistic infections, including cryptococcosis, in primary HIV infection.
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Affiliation(s)
- Victor Au Yeung
- Monash Infectious Diseases, Monash Health, Monash University, Australia
| | - Rula Azzam
- Monash Infectious Diseases, Monash Health, Monash University, Australia
| | - Claire Dendle
- Monash Infectious Diseases, Monash Health, Monash University, Australia
| | - Maryza Graham
- Monash Infectious Diseases, Monash Health, Monash University, Australia
| | - Ian J Woolley
- Monash Infectious Diseases, Monash Health, Monash University, Australia
| | - Tony M Korman
- Monash Infectious Diseases, Monash Health, Monash University, Australia
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275
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Meya DB, Manabe YC, Boulware DR, Janoff EN. The immunopathogenesis of cryptococcal immune reconstitution inflammatory syndrome: understanding a conundrum. Curr Opin Infect Dis 2016; 29:10-22. [PMID: 26658650 PMCID: PMC4689618 DOI: 10.1097/qco.0000000000000224] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Cryptococcal meningitis causes significant mortality among HIV-infected patients, despite antifungal therapy and use of antiretroviral therapy (ART). In patients with cryptococcal meningitis, ART is often complicated by immune reconstitution inflammatory syndrome (IRIS), manifesting as unmasking of previously unrecognized subclinical infection (unmasking CM-IRIS) or paradoxical worsening of symptoms in the central nervous system after prior improvement with antifungal therapy (paradoxical CM-IRIS). We review our current understanding of the pathogenesis of this phenomenon, focusing on unifying innate and adaptive immune mechanisms leading to the development of this often fatal syndrome. RECENT FINDINGS We propose that HIV-associated CD4 T-cell depletion, chemokine-driven trafficking of monocytes into cerebrospinal fluid in response to cryptococcal meningitis, and poor localized innate cytokine responses lead to inadequate cryptococcal killing and clearance of the fungus. Subsequent ART-associated recovery of T-cell signaling and restored cytokine responses, characterized by IFN-γ production, triggers an inflammatory response. The inflammatory response triggered by ART is dysregulated because of impaired homeostatic and regulatory mechanisms, culminating in the development of CM-IRIS. SUMMARY Despite our incomplete understanding of the immunopathogenesis of CM-IRIS, emerging data exploring innate and adaptive immune responses could be exploited to predict, prevent and manage CM-IRIS and associated morbid consequences.
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Affiliation(s)
- David B Meya
- Infectious Disease Institute, Makerere University, Uganda
- Dept of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, USA
- School of Medicine, College of Health Sciences, Makerere University
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - David R Boulware
- Dept of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, USA
| | - Edward N Janoff
- Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado Denver, Aurora, Colorado, USA; Denver Veterans Affairs Medical Center, Denver, CO
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276
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Asiimwe SB, Kanyesigye M, Bwana B, Okello S, Muyindike W. Predictors of dropout from care among HIV-infected patients initiating antiretroviral therapy at a public sector HIV treatment clinic in sub-Saharan Africa. BMC Infect Dis 2016; 16:43. [PMID: 26832737 PMCID: PMC4736127 DOI: 10.1186/s12879-016-1392-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/27/2016] [Indexed: 12/14/2022] Open
Abstract
Background In sub-Saharan Africa (SSA), antiretroviral therapy (ART) can prolong life for HIV-infected patients. However, patients initiating ART, especially in routine treatment programs, commonly dropout from care either due to death or loss to follow-up. Methods In a cohort of HIV-infected patients initiating ART at a public sector clinic in Uganda, we assessed predictors of dropout from care (a composite outcome combining death and loss to follow-up). From a large set of socio-demographic, clinical, and laboratory variables routinely collected at ART initiation, we selected those predicting dropout at P <0.1 in unadjusted analyses for inclusion into a multivariable proportional hazards regression model. We then used a stepwise backward selection procedure to identify variables which independently predicted dropout at P <0.05. Results Data from 5,057 patients were analyzed. The median age was 33 years (IQR 28 to 40) and 27.4 % had CD4+ T-cell counts <100 cells/μL at ART initiation. The median duration of follow-up was 24 months (IQR = 14 to 42, maximum follow-up = 64 months). Overall dropout was 26.9 % (established cumulative mortality = 2.3 %, loss to follow-up = 24.6 %), 5.6 % were transferred to other service providers, and 67.5 % were retained in care. A diagnosis of Kaposi’s sarcoma (hazard ratio (HR) = 3.3, 95 % CI 2.5 to 4.5); HIV-associated dementia (HR = 2.6, 95 % CI 1.5 to 4.6); history of cryptococcosis (HR = 2.2, 95 % CI 1.4 to 3.3); and reduced hemoglobin concentration (<11 g/dl versus ≥13.8 g/dl (HR = 1.9, 95 % CI 1.6 to 2.2) were strong predictors of dropout. Other independent predictors of dropout were: year of ART initiation; weight loss ≥10 %; reduced total lymphocyte count; chronic diarrhea; male sex; young age (≤28 years); and marital status. Conclusions Among HIV-infected patients initiating ART at a public sector clinic in SSA, biological factors that usually predict death were especially predictive of dropout. As most of the dropouts were lost to follow-up, this observation suggests that many losses to follow-up may have died. Future studies are needed to identify appropriate interventions that may improve both individual-level patient outcomes and outcome ascertainment among HIV-infected ART initiators in this setting.
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Affiliation(s)
- Stephen B Asiimwe
- Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. .,Department of Epidemiology and Biostatistics, University of California San Francisco, California, USA.
| | - Michael Kanyesigye
- Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda.
| | - Bosco Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Samson Okello
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Winnie Muyindike
- Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda.
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277
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Marais S, Meintjes G, Lesosky M, Wilkinson KA, Wilkinson RJ. Interleukin-17 mediated differences in the pathogenesis of HIV-1-associated tuberculous and cryptococcal meningitis. AIDS 2016; 30:395-404. [PMID: 26765934 PMCID: PMC4711381 DOI: 10.1097/qad.0000000000000904] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Mycobacterium tuberculosis and Cryptococcus neoformans are major causes of meningitis in HIV-1-infected patients. Identifying differences in the inflammatory profiles of HIV-1-associated tuberculous meningitis (TBM) and cryptococcal meningitis may inform differences in immunopathogenic mechanisms in these diseases. In this study we compared the clinical and inflammatory features of HIV-1-associated TBM, and cryptococcal meningitis. METHODS A prospective study of HIV-1-infected adults who presented with either TBM [antiretroviral therapy (ART)-naive] or cryptococcal meningitis (regardless of ART prescription). Clinical and laboratory findings and concentrations of 40 inflammatory mediators measured in cerebrospinal fluid (CSF, 33 paired with blood) were compared between TBM and cryptococcal meningitis patients regardless of ART prescription and between TBM and cryptococcal meningitis patients not receiving ART. RESULTS Clinical and laboratory findings were similar in TBM (n=34) and cryptococcal meningitis (n = 19; ART prescribed: n = 10, no ART prescribed: n = 9). Exceptions included a higher median CD4 cell count [interquartile: 113 (69-199) vs. 25 (8-49) cells/μl, P = 0.0001] and higher HIV-1 median viral load [plasma: 5.46 (4.82-5.89) vs. 4.87 (4.36-5.17) log10copies/ml, P = 0.037; CSF: 6.05 (5.43-6.56) vs. 5.56 (4.52-5.80) log10copies/ml, P = 0.03] in TBM vs. cryptococcal meningitis patients not receiving ART. CSF interleukin (IL)-17A was lower in TBM compared with cryptococcal meningitis [1.00 (0.25-2.35) vs. 9.31 (1.24-23.36) pg/ml, P-adjusted = 0.03]. CONCLUSION Despite presenting with higher peripheral CD4 cell counts, TBM patients also presented with higher HIV-1 viral loads compared with cryptococcal meningitis patients, suggesting a greater propensity of M. tuberculosis compared with C. neoformans to increase HIV-1 replication in vivo. CSF IL-17A was lower in TBM; its role in the immunopathogenesis of TBM and cryptococcal meningitis deserves further research.
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278
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Neurological immune reconstitution inflammatory response: riding the tide of immune recovery. Curr Opin Neurol 2016; 28:295-301. [PMID: 25887769 DOI: 10.1097/wco.0000000000000200] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This manuscript reviews current reports about clinical aspects of immune reconstitution inflammatory syndrome (IRIS), with a particular emphasis on IRIS in the setting of progressive multifocal leukoencephalopathy (PML) and to a lesser extent on cryptococcal meningitis and HIV. RECENT FINDINGS PML prognosis has been radically improved, as it has become possible to provide immune reconstitution, although some remaining morbidity and mortality results from excess inflammation. Similar pathologic responses are seen less often, but remain clinically important in cryptococcal meningitis, and HIV. Early diagnosis and active management of PML results in optimal outcomes with survival of 75% or higher in multiple recent series. These finding apply both to natalizumab and HIV-associated PML. Cryptococcal meningitis is frequently complicated by IRIS, and early treatment with antifungal therapy preceding HIV therapy provides optimal outcomes. HIV IRIS is reduced by early therapy, which is now recommended, but even on therapy, chronic dysregulated immune responses may play important roles in ongoing HIV-associated neurocognitive disease (HAND), which is common, as well as rare but more dramatic subacute encephalopathies. SUMMARY The clinician must actively monitor and treat both opportunistic infection and the inflammatory response that is essential to recovery but may itself augment disease and injury.
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279
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Treatment with adalimumab for severe immune reconstitution inflammatory syndrome in an HIV-infected patient presenting with cryptococcal meningitis. Med Mal Infect 2016; 46:154-6. [PMID: 26774857 DOI: 10.1016/j.medmal.2015.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/16/2015] [Indexed: 11/21/2022]
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280
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Abstract
Cryptococcosis is caused by the fungal genus Cryptococcus. Cryptococcosis, predominantly meningoencephalitis, emerged with the HIV pandemic, primarily afflicting HIV-infected patients with profound T-cell deficiency. Where in use, combination antiretroviral therapy has markedly reduced the incidence of and risk for disease, but cryptococcosis continues to afflict those without access to therapy, particularly in sub-Saharan Africa and Asia. However, cryptococcosis also occurs in solid organ transplant recipients and patients with other immunodeficiencies as well as those with no known immunodeficiency. This article reviews innate and adaptive immune responses to C. neoformans, with an emphasis on recent studies on the role of B cells, natural IgM and Fc gamma receptor polymorphisms in resistance to cryptococcosis.
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Affiliation(s)
- Soma Rohatgi
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
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281
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Wiesner DL, Smith KD, Kotov DI, Nielsen JN, Bohjanen PR, Nielsen K. Regulatory T Cell Induction and Retention in the Lungs Drives Suppression of Detrimental Type 2 Th Cells During Pulmonary Cryptococcal Infection. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2016; 196:365-74. [PMID: 26590316 PMCID: PMC4685009 DOI: 10.4049/jimmunol.1501871] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/26/2015] [Indexed: 12/18/2022]
Abstract
Lethal disease caused by the fungus Cryptococcus neoformans is a consequence of the combined failure to control pulmonary fungal replication and immunopathology caused by induced type 2 Th2 cell responses in animal models. In order to gain insights into immune regulatory networks, we examined the role of regulatory T (Treg) cells in suppression of Th2 cells using a mouse model of experimental cryptococcosis. Upon pulmonary infection with Cryptococcus, Treg cells accumulated in the lung parenchyma independently of priming in the draining lymph node. Using peptide-MHC class II molecules to identify Cryptococcus-specific Treg cells combined with genetic fate-mapping, we noted that a majority of the Treg cells found in the lungs were induced during the infection. Additionally, we found that Treg cells used the transcription factor, IFN regulatory factor 4, to dampen harmful Th2 cell responses, as well as mediate chemokine retention of Treg cells in the lungs. Taken together, induction and IFN regulatory factor 4-dependent localization of Treg cells in the lungs allow Treg cells to suppress the deleterious effects of Th2 cells during cryptococcal infection.
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Affiliation(s)
- Darin L Wiesner
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455
| | - Kyle D Smith
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455
| | - Dmitri I Kotov
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455; Center for Immunology, University of Minnesota, Minneapolis, MN 55455
| | - Judith N Nielsen
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC 27599; and
| | - Paul R Bohjanen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455; Center for Immunology, University of Minnesota, Minneapolis, MN 55455; Center for Infectious Diseases and Translational Research, University of Minnesota, Minneapolis, MN 55455
| | - Kirsten Nielsen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455; Center for Infectious Diseases and Translational Research, University of Minnesota, Minneapolis, MN 55455
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282
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Shahani L, Hamill RJ. Therapeutics targeting inflammation in the immune reconstitution inflammatory syndrome. Transl Res 2016; 167:88-103. [PMID: 26303886 DOI: 10.1016/j.trsl.2015.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/14/2015] [Accepted: 07/31/2015] [Indexed: 02/04/2023]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is characterized by improvement in a previously incompetent human immune system manifesting as worsening of clinical symptoms secondary to the ability of the immune system to now mount a vigorous inflammatory response. IRIS was first recognized in the setting of human immunodeficiency virus, and this clinical setting continues to be where it is most frequently encountered. Hallmarks of the pathogenesis of IRIS, independent of the clinical presentation and the underlying pathogen, include excessive activation of the immune system, with increased circulating effector memory T cells, and elevated levels of serum cytokines and inflammatory markers. Patients with undiagnosed opportunistic infections remain at risk for unmasking IRIS at the time of active antiretroviral therapy (ART) initiation. Systematic screening for opportunistic infections before starting ART is a key element to prevent this phenomenon. Appropriate management of IRIS requires prompt recognition of the syndrome and exclusion of alternative diagnoses, particularly underlying infections and drug resistance. Controlled studies supporting the use of pharmacologic interventions in IRIS are scare, and recommendations are based on case series and expert opinions. The only controlled trial published to date, showed reduction in morbidity in patients with paradoxical tuberculosis-related IRIS with the use of oral corticosteroids. There are currently limited data to recommend other anti-inflammatory or immunomodulatory therapies that are discussed in this review, and further research is needed. Ongoing research regarding the immune pathogenesis of IRIS will likely direct future rational therapeutic approaches and clinical trials.
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Affiliation(s)
- Lokesh Shahani
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Richard J Hamill
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Tex; Medical Care Line, Section of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
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283
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Rolfes MA, Rhein J, Schutz C, Taseera K, Nabeta HW, Huppler Hullsiek K, Akampuira A, Rajasingham R, Musubire A, Williams DA, Thienemann F, Bohjanen PR, Muzoora C, Meintjes G, Meya DB, Boulware DR. Cerebrospinal Fluid Culture Positivity and Clinical Outcomes After Amphotericin-Based Induction Therapy for Cryptococcal Meningitis. Open Forum Infect Dis 2015; 2:ofv157. [PMID: 26716103 PMCID: PMC4692307 DOI: 10.1093/ofid/ofv157] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/19/2015] [Indexed: 12/21/2022] Open
Abstract
Background. Amphotericin-based combination antifungal therapy reduces mortality from human immunodeficiency virus (HIV)-associated cryptococcal meningitis. However, 40%–50% of individuals have positive cerebrospinal fluid (CSF) fungal cultures at completion of 2 weeks of amphotericin induction therapy. Residual CSF culture positivity has historically been associated with poor clinical outcomes. We investigated whether persistent CSF fungemia was associated with detrimental clinical outcomes in a contemporary African cohort. Methods. Human immunodeficiency virus-infected individuals with cryptococcal meningitis in Uganda and South Africa received amphotericin (0.7–1.0 mg/kg per day) plus fluconazole (800 mg/day) for 2 weeks, followed by “enhanced consolidation” therapy with fluconazole 800 mg/day for at least 3 weeks or until cultures were sterile, and then 400 mg/day for 8 weeks. Participants were randomized to receive antiretroviral therapy (ART) either 1–2 or 5 weeks after diagnosis and observed for 6 months. Survivors were classified as having sterile or nonsterile CSF based on 2-week CSF cultures. Mortality, immune reconstitution inflammatory syndrome (IRIS), and culture-positive relapse were compared in those with sterile or nonsterile CSF using Cox regression. Results. Of 132 participants surviving 2 weeks, 57% had sterile CSF at 2 weeks, 23 died within 5 weeks, and 40 died within 6 months. Culture positivity was not significantly associated with mortality (adjusted 6-month hazard ratio, 1.2; 95% confidence interval, 0.6–2.3; P = .28). Incidence of IRIS or relapse was also not significantly related to culture positivity. Conclusions. Among patients, all treated with enhanced consolidation antifungal therapy and ART, residual cryptococcal culture positivity was not found to be associated with poor clinical outcomes.
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Affiliation(s)
- Melissa A Rolfes
- Department of Medicine , Medical School, University of Minnesota
| | - Joshua Rhein
- Department of Medicine , Medical School, University of Minnesota ; Infectious Diseases Institute, Makerere University , Kampala , Uganda
| | - Charlotte Schutz
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine , University of Cape Town , South Africa
| | - Kabanda Taseera
- Internal Medicine, Faculty of Medicine , Mbarara University of Science and Technology, Mbarara , Uganda
| | - Henry W Nabeta
- Infectious Diseases Institute, Makerere University , Kampala , Uganda
| | - Kathy Huppler Hullsiek
- Division of Biostatistics , School of Public Health, University of Minnesota , Minneapolis
| | - Andrew Akampuira
- Infectious Diseases Institute, Makerere University , Kampala , Uganda ; Department of Microbiology , College of Health Sciences, Makerere University , Kampala , Uganda
| | - Radha Rajasingham
- Department of Medicine , Medical School, University of Minnesota ; Infectious Diseases Institute, Makerere University , Kampala , Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Makerere University , Kampala , Uganda
| | - Darlisha A Williams
- Department of Medicine , Medical School, University of Minnesota ; Infectious Diseases Institute, Makerere University , Kampala , Uganda
| | - Friedrich Thienemann
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine , University of Cape Town , South Africa
| | - Paul R Bohjanen
- Department of Medicine , Medical School, University of Minnesota ; Infectious Diseases Institute, Makerere University , Kampala , Uganda
| | - Conrad Muzoora
- Internal Medicine, Faculty of Medicine , Mbarara University of Science and Technology, Mbarara , Uganda
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine , University of Cape Town , South Africa ; Department of Medicine , Imperial College London , United Kingdom
| | - David B Meya
- Department of Medicine , Medical School, University of Minnesota ; Infectious Diseases Institute, Makerere University , Kampala , Uganda ; School of Medicine, College of Health Sciences, Makerere University , Kampala , Uganda
| | - David R Boulware
- Department of Medicine , Medical School, University of Minnesota
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284
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Chang CC, Chen SCA. Colliding Epidemics and the Rise of Cryptococcosis. J Fungi (Basel) 2015; 2:jof2010001. [PMID: 29376920 PMCID: PMC5753082 DOI: 10.3390/jof2010001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/18/2015] [Accepted: 12/09/2015] [Indexed: 12/15/2022] Open
Abstract
Discovered more than 100 years ago as a human pathogen, the Cryptococcus neoformans–Cryptococcus gattii (C. neoformans–C. gattii) complex has seen a large global resurgence in its association with clinical disease in the last 30 years. First isolated in fermenting peach juice, and identified as a human pathogen in 1894 in a patient with bone lesions, this environmental pathogen has now found niches in soil, trees, birds, and domestic pets. Cryptococcosis is well recognized as an opportunistic infection and was first noted to be associated with reticuloendothelial cancers in the 1950s. Since then, advances in transplant immunology, medical science and surgical techniques have led to increasing numbers of solid organ transplantations (SOT) and hematological stem cell transplantations being performed, and the use of biological immunotherapeutics in increasingly high-risk and older individuals, have contributed to the further rise in cryptococcosis. Globally, however, the major driver for revivification of cryptococcosis is undoubtedly the HIV epidemic, particularly in Sub-Saharan Africa where access to care and antiretroviral therapy remains limited and advanced immunodeficiency, poverty and malnutrition remains the norm. As a zoonotic disease, environmental outbreaks of both human and animal cryptococcosis have been reported, possibly driven by climate change. This is best exemplified by the resurgence of C. gattii infection in Vancouver Island, Canada, and the Pacific Northwest of the United States since 1999. Here we describe how the colliding epidemics of HIV, transplantation and immunologics, climate change and migration have contributed to the rise of cryptococcosis.
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Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital, Monash University, Melbourne 3181, Australia.
- HIV Pathogenesis Programme, University of KwaZulu Natal, Durban 4001, South Africa.
| | - Sharon C-A Chen
- Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, University of Sydney, Sydney 2145, Australia.
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR-Pathology West, Westmead Hospital, Sydney 2145, Australia.
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285
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Douglas-Vail M, Bechamp T, Gohal S, Soegtrop R, Vitali S, Rugemalila J, Stone NRH. Reversible Deafness and Blindness in a Patient with Cryptococcal Meningitis in Tanzania. Infect Dis Rep 2015; 7:6173. [PMID: 26753085 PMCID: PMC4693333 DOI: 10.4081/idr.2015.6173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/16/2015] [Accepted: 10/17/2015] [Indexed: 11/22/2022] Open
Abstract
Cryptococcal meningitis is a common and devastating complication of advanced HIV, and is most prevalent in low resource settings in sub Saharan Africa. Raised intracranial pressure is one of the hallmarks of the disease, which can lead to visual and hearing loss and ultimately death. We present the case of a patient with visual and hearing impairment secondary to Cryptococcal meningitis successfully managed by serial cerebrospinal fluid drainage. This case highlights some of the challenges of managing this severe opportunistic infection in a low resource setting.
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Affiliation(s)
- Matt Douglas-Vail
- Schulich School of Medicine and Dentistry, Western University , Canada
| | - Taylor Bechamp
- Schulich School of Medicine and Dentistry, Western University , Canada
| | - Simran Gohal
- Schulich School of Medicine and Dentistry, Western University , Canada
| | - Robert Soegtrop
- Schulich School of Medicine and Dentistry, Western University , Canada
| | - Sarah Vitali
- Schulich School of Medicine and Dentistry, Western University , Canada
| | | | - Neil R H Stone
- Institute for Infection and Immunity, St. George's, University of London , UK
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286
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Abstract
Cryptococcosis is a globally distributed invasive fungal infection that is caused by species within the genus Cryptococcus which presents substantial therapeutic challenges. Although natural human-to-human transmission has never been observed, recent work has identified multiple virulence mechanisms that enable cryptococci to infect, disseminate within and ultimately kill their human host. In this Review, we describe these recent discoveries that illustrate the intricacy of host-pathogen interactions and reveal new details about the host immune responses that either help to protect against disease or increase host susceptibility. In addition, we discuss how this improved understanding of both the host and the pathogen informs potential new avenues for therapeutic development.
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287
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Boulware DR, von Hohenberg M, Rolfes MA, Bahr NC, Rhein J, Akampurira A, Williams DA, Taseera K, Schutz C, McDonald T, Muzoora C, Meintjes G, Meya DB, Nielsen K, Huppler Hullsiek K. Human Immune Response Varies by the Degree of Relative Cryptococcal Antigen Shedding. Open Forum Infect Dis 2015; 3:ofv194. [PMID: 26807426 PMCID: PMC4722283 DOI: 10.1093/ofid/ofv194] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 12/07/2015] [Indexed: 01/01/2023] Open
Abstract
Capsule shedding in cerebrospinal fluid is associated with inflammatory and Th2-mediated immune responses in HIV-infected individuals with cryptococcal meningitis. These findings provide important insight into the interactions that occur between the host immune system and the infecting strain of Cryptococcus. Background. Cerebrospinal fluid (CSF) cryptococcal glucuronoxylomannan antigen (CrAg) titers generally correlate with quantitative fungal culture burden; however, correlation is not precise. Some patients have higher CrAg titers with lower fungal burdens and vice versa. We hypothesized that the relative discordancy between CrAg titer and quantitative culture burden reflects the relative degree of CrAg shedding by Cryptococcus neoformans and is associated with human immune responses. Methods. One hundred ninety human immunodeficiency virus-infected individuals with cryptococcal meningitis were enrolled in Uganda and South Africa. We compared initial CSF CrAg titers relative to their CSF quantitative cultures to determine low (n = 58), intermediate (n = 68), or high (n = 64) CrAg shedders. We compared cytokines measured by Luminex multiplex assay on cryopreserved CSF and 10-week mortality across shedding groups using linear and logistic regression and distribution of genotypes by multilocus sequence typing. Results. The relative degree of CrAg shedding was positively associated with increasing CSF levels of the following: interleukin (IL)-6, IL-7, IL-8, and tumor necrosis factor-α (each P < 0.01), which are all secreted by antigen-presenting cells and negatively associated with vascular endothelial growth factor (P = .01). In addition, IL-5, IL-13, granulocyte colony-stimulating factor, and macrophage chemotactic protein were decreased in low-CrAg shedders compared with intermediate shedders (each P ≤ .01). Type 1 T-helper cells (Th1) cytokine responses and 10-week mortality did not differ between the shedding groups. Cryptococcal genotypes were equally distributed across shedding groups. Conclusions. Discordancy between CrAg shedding and expected shedding based on quantitative fungal burden is associated with detectable immunologic differences in CSF, primarily among secreted cytokines and chemokines produced by antigen-presenting cells and Th2.
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Affiliation(s)
- David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine; School of Public Health
| | | | - Melissa A Rolfes
- Division of Infectious Diseases and International Medicine, Department of Medicine; School of Public Health
| | - Nathan C Bahr
- Division of Infectious Diseases and International Medicine, Department of Medicine
| | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, Department of Medicine; Infectious Disease Institute, Makerere University
| | | | - Darlisha A Williams
- Division of Infectious Diseases and International Medicine, Department of Medicine; Infectious Disease Institute, Makerere University
| | | | - Charlotte Schutz
- Infectious Diseases Unit, GF Jooste Hospital; Department of Medicine, Faculty of Health Sciences; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Tami McDonald
- Department of Microbiology and Immunology , University of Minnesota , Minnesota
| | | | - Graeme Meintjes
- Infectious Diseases Unit, GF Jooste Hospital; Department of Medicine, Faculty of Health Sciences; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - David B Meya
- Division of Infectious Diseases and International Medicine, Department of Medicine; Infectious Disease Institute, Makerere University; Makerere University College of Health Sciences, Kampala
| | - Kirsten Nielsen
- Department of Microbiology and Immunology , University of Minnesota , Minnesota
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288
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Hedley L, Minton J, Wallis G, Waters L. Antiretroviral therapy options for treatment-naive patients with HIV-1. Br J Hosp Med (Lond) 2015; 76:C122-5. [PMID: 26255930 DOI: 10.12968/hmed.2015.76.8.c122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Lucy Hedley
- Senior Clinical Pharmacist - HIV and Infectious Diseases
| | - June Minton
- Lead Pharmacist - HIV and Infectious Diseases
| | - Gabriel Wallis
- Core Medical Trainee in the Department of Infectious and Tropical Diseases, University College London Hospital, London NW1 2BU
| | - Laura Waters
- Consultant Physician in HIV and Genitourinary Medicine in the Department of GU/HIV Medicine, Central and North West London, London
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289
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Curbelo J, Galván JM, Aspa J. Actualización sobre Aspergillus, Pneumocystis y otras micosis pulmonares oportunistas. Arch Bronconeumol 2015; 51:647-53. [DOI: 10.1016/j.arbres.2015.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 02/19/2015] [Accepted: 02/20/2015] [Indexed: 01/15/2023]
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290
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John CC, Carabin H, Montano SM, Bangirana P, Zunt JR, Peterson PK. Global research priorities for infections that affect the nervous system. Nature 2015; 527:S178-86. [PMID: 26580325 PMCID: PMC4697933 DOI: 10.1038/nature16033] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Infections that cause significant nervous system morbidity globally include viral (for example, HIV, rabies, Japanese encephalitis virus, herpes simplex virus, varicella zoster virus, cytomegalovirus, dengue virus and chikungunya virus), bacterial (for example, tuberculosis, syphilis, bacterial meningitis and sepsis), fungal (for example, cryptococcal meningitis) and parasitic (for example, malaria, neurocysticercosis, neuroschistosomiasis and soil-transmitted helminths) infections. The neurological, cognitive, behavioural or mental health problems caused by the infections probably affect millions of children and adults in low- and middle-income countries. However, precise estimates of morbidity are lacking for most infections, and there is limited information on the pathogenesis of nervous system injury in these infections. Key research priorities for infection-related nervous system morbidity include accurate estimates of disease burden; point-of-care assays for infection diagnosis; improved tools for the assessment of neurological, cognitive and mental health impairment; vaccines and other interventions for preventing infections; improved understanding of the pathogenesis of nervous system disease in these infections; more effective methods to treat and prevent nervous system sequelae; operations research to implement known effective interventions; and improved methods of rehabilitation. Research in these areas, accompanied by efforts to implement promising technologies and therapies, could substantially decrease the morbidity and mortality of infections affecting the nervous system in low- and middle-income countries.
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Affiliation(s)
- Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
| | - Hélène Carabin
- Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA
| | - Silvia M Montano
- Department of Bacteriology, US Naval Medical Research Unit No. 6, Lima, Peru
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joseph R Zunt
- Department of Epidemiology, University of Washington, Seattle, Washington 98195, USA
| | - Phillip K Peterson
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota 55455, USA
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291
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Bahr NC, Sarosi GA, Meya DB, Bohjanen PR, Richer SM, Swartzentruber S, Halupnick R, Jarrett D, Wheat LJ, Boulware DR. Seroprevalence of histoplasmosis in Kampala, Uganda. Med Mycol 2015; 54:295-300. [PMID: 26527637 DOI: 10.1093/mmy/myv081] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/03/2015] [Indexed: 11/13/2022] Open
Abstract
Histoplasmosis is endemic to the Midwestern United States, but cases have been reported nearly worldwide. A 1970 study found 3.8% skin test sensitivity to Histoplasma capsulatum in Uganda but no systemic study of histoplasmosis exposure has occurred since the onset of the human immunodeficiency virus (HIV) pandemic. This study investigated the seroprevalence of H. capsulatum and sought previously undetected cases of histoplasmosis in Kampala, Uganda. Serum, cerebrospinal fluid (CSF) and/or urine specimens were obtained from HIV-infected persons with suspected meningitis. Specimens were tested for H. capsulatum IgG and IgM by enzyme immune assay and Histoplasma antigen. 147 of the 257 subjects who were enrolled had cryptococcal meningitis. Overall, 1.3% (2/151) of subjects were serum Histoplasma IgG positive, and zero of 151 were IgM positive. Antigen was not detected in any serum (n = 57), urine (n = 37, or CSF (n = 63) samples. Both subjects with serum Histoplasma IgG positivity had cryptococcal meningitis. Histoplasma capsulatum IgG was detected at low levels in persons with HIV/AIDS in Kampala, Uganda. Histoplasmosis is not widespread in Uganda but microfoci do exist. There appears to be no cross-reactivity between Cryptococcus neoformans and Histoplasma antigen testing, and cryptococcosis appears to be at most, a rare cause of positive Histoplasma IgG.
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Affiliation(s)
- Nathan C Bahr
- Infectious Diseases Institute, Makerere University, Kampala, Uganda Department of Medicine, University of Minnesota, Minneapolis, Minnesota Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota
| | - George A Sarosi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda Department of Medicine, University of Minnesota, Minneapolis, Minnesota Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Paul R Bohjanen
- Infectious Diseases Institute, Makerere University, Kampala, Uganda Department of Medicine, University of Minnesota, Minneapolis, Minnesota Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Ryan Halupnick
- Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota
| | | | | | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota
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292
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Pettersen KD, Pappas PG, Chin-Hong P, Baxi SM. A paradoxical decline: intracranial lesions in two HIV-positive patients recovering from cryptococcal meningitis. BMJ Case Rep 2015; 2015:bcr-2015-212108. [PMID: 26475880 DOI: 10.1136/bcr-2015-212108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cryptococcal immune reconstitution inflammatory syndrome (C-IRIS) is an increasingly important manifestation among patients with HIV/AIDS, especially as the use of antiretroviral therapy (ART) is expanding worldwide. Cryptococcus and associated C-IRIS are common causes of meningitis. While intracranial lesions are common in HIV/AIDS, they are rarely due to cryptococcosis or C-IRIS. We describe two cases of paradoxical C-IRIS associated with the development of intracranial cryptococcomas in HIV/AIDS. Both patients had an initial episode of cryptococcal meningitis treated with antifungal therapy. At the time, they had initiated or modified ART with subsequent evidence of immune reconstitution. Two months later, they developed aseptic meningitis with intracranial lesions. After exhaustive work ups, both patients were diagnosed with paradoxical C-IRIS and biopsy confirmed intracranial cryptococcomas. We review the important clinical, diagnostic and therapeutic features of cryptococcomas associated with C-IRIS in HIV/AIDS.
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Affiliation(s)
- Kenneth D Pettersen
- Department of Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Peter G Pappas
- Department of Medicine, Division of Infectious Diseases, University of Alabama, Birmingham, Birmingham, Alabama, USA
| | - Peter Chin-Hong
- Department of Internal Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA
| | - Sanjiv M Baxi
- Department of Internal Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA
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293
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Eschke M, Piehler D, Schulze B, Richter T, Grahnert A, Protschka M, Müller U, Köhler G, Höfling C, Rossner S, Alber G. A novel experimental model of Cryptococcus neoformans-related immune reconstitution inflammatory syndrome (IRIS) provides insights into pathogenesis. Eur J Immunol 2015; 45:3339-50. [PMID: 26381487 DOI: 10.1002/eji.201545689] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 09/01/2015] [Accepted: 09/18/2015] [Indexed: 11/06/2022]
Abstract
Antiretroviral therapy (ART) has yielded major advances in fighting the HIV pandemic by restoring protective immunity. However, a significant proportion of HIV patients co-infected with the opportunistic fungal pathogen Cryptococcus neoformans paradoxically develops a life-threatening immune reconstitution inflammatory syndrome (IRIS) during antiretroviral therapy. Despite several clinical studies, the underlying pathomecha-nisms are poorly understood. Here, we present the first mouse model of cryptococcal IRIS that allows for a detailed analysis of disease development. Lymphocyte-deficient RAG-1(-/-) mice are infected with C. neoformans and 4 weeks later adoptively transferred with purified CD4(+) T cells. Reconstitution of CD4(+) T cells is sufficient to induce a severe inflammatory disease similar to clinical IRIS in C. neoformans-infected RAG-1(-/-) mice of different genetic backgrounds and immunological phenotypes (i.e. C57BL/6 and BALB/c). Multiorgan inflammation is accompanied by a systemic release of distinct proinflammatory cytokines, i.e. IFN-γ, IL-6, and TNF-α. IRIS development is characterized by infection-dependent activation of donor CD4(+) T cells, which are the source of IFN-γ. Interestingly, IFN-γ-mediated effects are not required for disease induction. Taken together, this novel mouse model of cryptococcal IRIS provides a useful tool to verify potential mechanisms of pathogenesis, revealing targets for diagnosis and therapeutic interventions.
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Affiliation(s)
- Maria Eschke
- Institute of Immunology/Molecular Pathogenesis, Center for Biotechnology and Biomedicine, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | - Daniel Piehler
- Institute of Immunology/Molecular Pathogenesis, Center for Biotechnology and Biomedicine, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | - Bianca Schulze
- Institute of Immunology/Molecular Pathogenesis, Center for Biotechnology and Biomedicine, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | - Tina Richter
- Institute of Immunology/Molecular Pathogenesis, Center for Biotechnology and Biomedicine, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | - Andreas Grahnert
- Institute of Immunology/Molecular Pathogenesis, Center for Biotechnology and Biomedicine, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | - Martina Protschka
- Institute of Immunology/Molecular Pathogenesis, Center for Biotechnology and Biomedicine, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | - Uwe Müller
- Institute of Immunology/Molecular Pathogenesis, Center for Biotechnology and Biomedicine, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | | | - Corinna Höfling
- Paul Flechsig Institute for Brain Research, Faculty of Medicine, University of Leipzig, Leipzig, Germany
| | - Steffen Rossner
- Paul Flechsig Institute for Brain Research, Faculty of Medicine, University of Leipzig, Leipzig, Germany
| | - Gottfried Alber
- Institute of Immunology/Molecular Pathogenesis, Center for Biotechnology and Biomedicine, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
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294
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Toxicity of Amphotericin B Deoxycholate-Based Induction Therapy in Patients with HIV-Associated Cryptococcal Meningitis. Antimicrob Agents Chemother 2015; 59:7224-31. [PMID: 26349818 PMCID: PMC4649151 DOI: 10.1128/aac.01698-15] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/31/2015] [Indexed: 11/20/2022] Open
Abstract
Amphotericin B deoxycholate (AmBd) is the recommended induction treatment for HIV-associated cryptococcal meningitis (CM). Its use is hampered by toxicities that include electrolyte abnormalities, nephrotoxicity, and anemia. Protocols to minimize toxicity are applied inconsistently. In a clinical trial cohort of AmBd-based CM induction treatment, a standardized protocol of preemptive hydration and electrolyte supplementation was applied. Changes in blood counts, electrolyte levels, and creatinine levels over 14 days were analyzed in relation to the AmBd dose, treatment duration (short course of 5 to 7 days or standard course of 14 days), addition of flucytosine (5FC), and outcome. In the 368 patients studied, the hemoglobin levels dropped by a mean of 1.5 g/dl (95% confidence interval [CI], 1.0 to 1.9 g/dl) following 7 days of AmBd and by a mean of 2.3 g/dl (95% CI, 1.1 to 3.6 g/dl) after 14 days. Serum creatinine levels increased by 37 μmol/liter (95% CI, 30 to 45 μmol/liter) by day 7 and by 49 μmol/liter (95% CI, 35 to 64μmol/liter) by day 14 of AmBd treatment. Overall, 33% of patients developed grade III/IV anemia, 5.6% developed grade III hypokalemia, 9.5% had creatinine levels that exceeded 220 μmol, and 6% discontinued AmBd prematurely. The addition of 5FC was associated with a slight increase in anemia but not neutropenia. Laboratory abnormalities stabilized or reversed during the second week in patients on short-course induction. Grade III/IV anemia (adjusted odds ratio [aOR], 2.2; 95% CI, 1.1 to 4.3; P = 0.028) and nephrotoxicity (aOR, 4.5; 95% CI, 1.8 to 11; P = 0.001) were risk factors for 10-week mortality. In summary, routine intravenous saline hydration and preemptive electrolyte replacement during AmBd-based induction regimens for HIV-associated CM minimized the incidence of hypokalemia and nephrotoxicity. Anemia remained a concerning adverse effect. The addition of flucytosine was not associated with increased neutropenia. Shorter AmBd courses were less toxic, with rapid reversibility.
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295
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Increased Antifungal Drug Resistance in Clinical Isolates of Cryptococcus neoformans in Uganda. Antimicrob Agents Chemother 2015; 59:7197-204. [PMID: 26324276 DOI: 10.1128/aac.01299-15] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 08/25/2015] [Indexed: 12/21/2022] Open
Abstract
Cryptococcal antigen screening is recommended among people living with AIDS when entering HIV care with a CD4 count of <100 cells/μl, and preemptive fluconazole monotherapy treatment is recommended for those with subclinical cryptococcal antigenemia. Yet, knowledge is limited of current antimicrobial resistance in Africa. We examined antifungal drug susceptibility in 198 clinical isolates collected from Kampala, Uganda, between 2010 and 2014 using the CLSI broth microdilution assay. In comparison with two previous studies from 1998 to 1999 that reported an MIC50 of 4 μg/ml and an MIC90 of 8 μg/ml prior to widespread human fluconazole and agricultural azole fungicide usage, we report an upward shift in the fluconazole MIC50 to 8 μg/ml and an MIC90 value of 32 μg/ml, with 31% of isolates with a fluconazole MIC of ≥ 16 μg/ml. We observed an amphotericin B MIC50 of 0.5 μg/ml and an MIC90 of 1 μg/ml, of which 99.5% of isolates (197 of 198 isolates) were still susceptible. No correlation between MIC and clinical outcome was observed in the context of amphotericin B and fluconazole combination induction therapy. We also analyzed Cryptococcus susceptibility to sertraline, with an MIC50 of 4 μg/ml, suggesting that sertraline is a promising oral, low-cost, available, novel medication and a possible alternative to fluconazole. Although the CLSI broth microdilution assay is ideal to standardize results, limit human bias, and increase assay capacity, such assays are often inaccessible in low-income countries. Thus, we also developed and validated an assay that could easily be implemented in a resource-limited setting, with similar susceptibility results (P = 0.52).
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296
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Williams DA, Kiiza T, Kwizera R, Kiggundu R, Velamakanni S, Meya DB, Rhein J, Boulware DR. Evaluation of fingerstick cryptococcal antigen lateral flow assay in HIV-infected persons: a diagnostic accuracy study. Clin Infect Dis 2015; 61:464-7. [PMID: 25838287 PMCID: PMC4503809 DOI: 10.1093/cid/civ263] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/25/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Cryptococcus neoformans is the most common cause of adult meningitis in sub-Saharan Africa. The cryptococcal antigen (CRAG) lateral flow assay (LFA) has simplified diagnosis as a point-of-care test approved for serum or cerebrospinal fluid (CSF). We evaluated the accuracy of the CRAG LFA using fingerstick whole blood compared with serum/plasma and CSF for diagnosing meningitis. METHODS From August 2013 to August 2014, CRAG LFA (IMMY, Norman, Oklahoma) tests were performed on fingerstick whole blood, plasma/serum, and CSF in 207 HIV-infected adults with suspected meningitis in Kampala, Uganda. Venous blood was also collected and centrifuged to obtain serum and/or plasma. CSF was tested after lumbar puncture. RESULTS Of 207 participants, 149 (72%) had fingerstick CRAG-positive results. There was 100% agreement between fingerstick whole blood and serum/plasma. Of the 149 fingerstick CRAG-positive participants, 138 (93%) had evidence of cryptococcal meningitis with a positive CSF CRAG. Eleven participants (5%) had isolated cryptococcal antigenemia with a negative CSF CRAG and culture, of whom 8 had CSF abnormalities (n = 3 lymphocytic pleocytosis, n = 5 elevated protein, n = 4 increased opening pressure). No persons with cryptococcal meningitis had negative fingersticks. CONCLUSIONS The 100% agreement between whole blood, serum, and plasma CRAG LFA results demonstrates that fingerstick CRAG is a reliable bedside diagnostic test. Using point-of-care CRAG testing simplifies screening large numbers of patients and enables physicians to prioritize on whom to measure CSF opening pressure using manometers.
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Affiliation(s)
| | | | | | | | | | - David B. Meya
- University of Minnesota, Minneapolis
- Infectious Diseases Institute
- College of Health Sciences, Department of Medicine, Makerere University,Kampala, Uganda
| | - Joshua Rhein
- University of Minnesota, Minneapolis
- Infectious Diseases Institute
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297
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Thakur KT, Mateyo K, Hachaambwa L, Kayamba V, Mallewa M, Mallewa J, Nwazor EO, Lawal T, Mallum CB, Atadzhanov M, Boulware DR, Birbeck GL, Siddiqi OK. Lumbar puncture refusal in sub-Saharan Africa: A call for further understanding and intervention. Neurology 2015; 84:1988-90. [PMID: 25964478 DOI: 10.1212/wnl.0000000000001561] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Kiran T Thakur
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA.
| | - Kondwelani Mateyo
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Lottie Hachaambwa
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Violet Kayamba
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Macpherson Mallewa
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Jane Mallewa
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Ernest O Nwazor
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Tope Lawal
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Chindo B Mallum
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Masharip Atadzhanov
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - David R Boulware
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Gretchen L Birbeck
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Omar K Siddiqi
- From the Division of Neuroinfectious Diseases and Neuroimmunology, Department of Neurology (K.T.T.), Johns Hopkins Hospital, Baltimore, MD; the Department of Internal Medicine (K.M., L.H., V.K., M.A., O.K.S.), University of Zambia School of Medicine, Lusaka, Zambia; the Department of Internal Medicine (L.H.), University of Maryland School of Medicine, Baltimore, MD; the Department of Pediatrics and Child Health, College of Medicine (M.M.), and the Department of Internal Medicine (J.M.), Queen Elizabeth Central Hospital, Blantyre, Malawi; the Neurology Unit, Department of Internal Medicine (E.O.N.), Federal Medical Center Owerri, Imo State, Nigeria; the Neurology Unit (T.L.), Department of Internal Medicine, Lagos University Teaching Hospital, Lagos State, Nigeria; the Neurology Unit, Department of Internal Medicine (C.B.M.), Jos University Teaching Hospital, Jos, Plateau State, Nigeria; the Division of Infectious Diseases & International Medicine, Department of Medicine (D.R.B.), University of Minnesota, Minneapolis; Epilepsy Division, Department of Neurology (G.L.B.), University of Rochester, NY; the Chikankata Epilepsy Care Team (G.L.B.), Mazabuka, Zambia; and the Global Neurology Program, Division of Neuroimmunology, Center for Virology and Vaccine Research, Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA
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Cryptococcus: Shedding New Light on an Inveterate Yeast. J Fungi (Basel) 2015; 1:115-129. [PMID: 29376903 PMCID: PMC5753104 DOI: 10.3390/jof1020115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/01/2015] [Accepted: 07/08/2015] [Indexed: 12/26/2022] Open
Abstract
Cryptococcus has emerged as a significant pathogen in immunocompromised patients. While the diagnostic testing and the antifungal treatment of cryptococcal infections have become firmly established in clinical practice, new developments and areas of ambiguity merit further consideration. These include the potential for donor transmission of Cryptococcus; cirrhosis-associated cryptococcosis, particularly during transplant candidacy; the utility of serum cryptococcal antigen testing of asymptomatic individuals in high-prevalence, poor-resource areas; pathogenesis and treatment of the immune reconstitution syndrome, specifically in relation to antiretroviral therapy and immunosuppressive medications; and new challenges posed by the emerging species of Cryptococcus gatti. In this article, we summarize the literature pertaining to these topics, focusing on recent progress.
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Beale MA, Sabiiti W, Robertson EJ, Fuentes-Cabrejo KM, O’Hanlon SJ, Jarvis JN, Loyse A, Meintjes G, Harrison TS, May RC, Fisher MC, Bicanic T. Genotypic Diversity Is Associated with Clinical Outcome and Phenotype in Cryptococcal Meningitis across Southern Africa. PLoS Negl Trop Dis 2015; 9:e0003847. [PMID: 26110902 PMCID: PMC4482434 DOI: 10.1371/journal.pntd.0003847] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/24/2015] [Indexed: 12/21/2022] Open
Abstract
Cryptococcal meningitis is a major cause of mortality throughout the developing world, yet little is known about the genetic markers underlying Cryptococcal virulence and patient outcome. We studied a cohort of 230 Cryptococcus neoformans (Cn) isolates from HIV-positive South African clinical trial patients with detailed clinical follow-up using multi-locus sequence typing and in vitro phenotypic virulence assays, correlating these data with clinical and fungal markers of disease in the patient. South African Cn displayed high levels of genetic diversity and locus variability compared to globally distributed types, and we identified 50 sequence types grouped within the main molecular types VNI, VNII and VNB, with 72% of isolates typed into one of seven 'high frequency' sequence types. Spatial analysis of patients’ cryptococcal genotype was not shown to be clustered geographically, which might argue against recent local acquisition and in favour of reactivation of latent infection. Through comparison of MLST genotyping data with clinical parameters, we found a relationship between genetic lineage and clinical outcome, with patients infected with the VNB lineage having significantly worse survival (n=8, HR 3.35, CI 1.51-7.20, p=0.003), and this was maintained even after adjustment for known prognostic indicators and treatment regimen. Comparison of fungal genotype with in vitro phenotype (phagocytosis, laccase activity and CSF survival) performed on a subset of 89 isolates revealed evidence of lineage-associated virulence phenotype, with the VNII lineage displaying increased laccase activity (p=0.001) and ex vivo CSF survival (p=0.0001). These findings show that Cryptococcus neoformans is a phenotypically heterogeneous pathogen, and that lineage plays an important role in cryptococcal virulence during human infection. Furthermore, a detailed understanding of the genetic diversity in Southern Africa will support further investigation into how genetic diversity is structured across African environments, allowing assessment of the risks different ecotypes pose to infection. Cryptococcus neoformans (Cn) is a yeast that commonly causes meningitis in HIV infected individuals in Africa, where it may account for up to 500,000 deaths every year. In this highly translational and multidisciplinary study, we used genetic analysis techniques to show that Cryptococcus found in Southern Africa represents a hotspot of genetic diversity. We combined this data with the results of microbiological techniques that assess the natural virulence traits that the yeast uses to survive and infect humans to further show that genetic diversity is associated with differences in cryptococcal phenotype. Finally, we analysed detailed clinical data on patients to investigate the clinical effects of infection with different lineages, and showed that one genetic lineage (VNB) is significantly associated with worse survival. Whilst much of our prior knowledge regarding the genetic basis of virulence is derived from studies on laboratory-adapted cryptococcal strains, our findings from this large and comprehensive MLST genotyping study of clinical isolates—linking genotype, phenotype, clinical presentation and outcome—provide direct insights into the contribution of pathogen lineage to virulence in human cryptococcal meningitis.
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Affiliation(s)
- Mathew A. Beale
- Institute of Infection and Immunity, St. George’s University London, London, United Kingdom
- Department of Infectious Disease Epidemiology, Imperial College School of Public Health, London, United Kingdom
| | - Wilber Sabiiti
- Institute of Infection and Immunity, St. George’s University London, London, United Kingdom
- School of Medicine University of St. Andrews, St. Andrews, United Kingdom
| | - Emma J. Robertson
- Institute of Infection and Immunity, St. George’s University London, London, United Kingdom
| | | | - Simon J. O’Hanlon
- Department of Infectious Disease Epidemiology, Imperial College School of Public Health, London, United Kingdom
| | - Joseph N. Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angela Loyse
- Institute of Infection and Immunity, St. George’s University London, London, United Kingdom
| | - Graeme Meintjes
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Thomas S. Harrison
- Institute of Infection and Immunity, St. George’s University London, London, United Kingdom
| | - Robin C. May
- Institute of Microbiology and Infection and the School of Biosciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre, University Hospitals of Birmingham National Health Service (NHS) Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Matthew C. Fisher
- Department of Infectious Disease Epidemiology, Imperial College School of Public Health, London, United Kingdom
- * E-mail: (MCF); (TB)
| | - Tihana Bicanic
- Institute of Infection and Immunity, St. George’s University London, London, United Kingdom
- * E-mail: (MCF); (TB)
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Tuffour J, Owusu-Mireku E, Ruf MT, Aboagye S, Kpeli G, Akuoku V, Pereko J, Paintsil A, Bonney K, Ampofo W, Pluschke G, Yeboah-Manu D. Challenges Associated with Management of Buruli Ulcer/Human Immunodeficiency Virus Coinfection in a Treatment Center in Ghana: A Case Series Study. Am J Trop Med Hyg 2015; 93:216-23. [PMID: 26055745 DOI: 10.4269/ajtmh.14-0571] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 03/13/2015] [Indexed: 11/07/2022] Open
Abstract
The synergy between Mycobacterium tuberculosis infection and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome is well established but not so in Buruli ulcer (BU). We screened confirmed BU cases for HIV infection and followed seven BU/HIV-coinfected patients. Management of BU/HIV was based on the World Health Organization guidelines and patient condition. The HIV positivity among BU patients (8.2%; 11/134) was higher compared with that of general patients attending the facility (4.8%; 718/14,863; P = 0.07) and that of pregnant women alone (2.5%; 279/11,125; P = 0.001). All seven BU/HIV-coinfected cases enrolled in the study presented with very large (category III) lesions with four having multiple lesions compared with 54.5% of category III lesions among HIV-negative BU patients. During the recommended BU treatment with streptomycin and rifampicin (SR) all patients developed immune infiltrates including CD4 T cells in their lesions. However, one patient who received antiretroviral therapy (ART) 1 week after beginning SR treatment developed four additional lesions during antibiotic treatment, while two out of the four who did not receive ART died. Further evidence is required to ascertain the most appropriate time to commence ART in relation to SR treatment to minimize paradoxical reactions.
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Affiliation(s)
- Joseph Tuffour
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Evelyn Owusu-Mireku
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Marie-Therese Ruf
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Samuel Aboagye
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Grace Kpeli
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Victor Akuoku
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Janet Pereko
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Albert Paintsil
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Kofi Bonney
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - William Ampofo
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Gerd Pluschke
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Dorothy Yeboah-Manu
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
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