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Teixeira JC, de Oliveira VF, Gomes HR, Ribeiro SM, de Araujo EDMPA, da Cruz ICLV, Taborda M, Magri ASGK, Vidal JE, Nastri ACDSS, Silva GD, Magri MMC. Association between neuroimaging and clinical outcomes in individuals with central nervous system cryptococcosis. Mycoses 2024; 67:e13767. [PMID: 39004801 DOI: 10.1111/myc.13767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 06/19/2024] [Accepted: 07/06/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND The radiological manifestations of central nervous system (CNS) cryptococcosis are diverse and often subtle. There is heterogeneity on how different neuroimaging patterns impact prognosis. This study aims to assess the association between the neuroimaging and clinical outcomes of CNS cryptococcosis. METHODS All patients with CNS cryptococcosis between July 2017 and April 2023 who underwent brain magnetic resonance imaging (MRI) were included. The primary outcome was mortality during hospitalisation. Secondary outcomes were readmission, ventricular shunting, duration of hospitalisation and time to the first negative cerebrospinal fluid culture. We compared the outcomes for each of the five main radiological findings on the brain MRI scan. RESULTS We included 46 proven CNS cryptococcosis cases. The two main comorbidity groups were HIV infection (20, 43%) and solid organ transplantation (10, 22%), respectively. Thirty-nine patients exhibited at least one radiological abnormality (85%), with the most common being meningeal enhancement (34, 74%). The mortality rates occurred at 11% (5/46) during hospitalisation. We found no significant disparities in mortality related to distinct radiological patterns. The presence of pseudocysts was significantly associated with the need for readmission (p = .027). The ventricular shunting was significantly associated with the presence of pseudocysts (p = .005) and hydrocephalus (p = .044). CONCLUSION In this study, there is no association between brain MRI findings and mortality. Larger studies are needed to evaluate this important issue.
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Affiliation(s)
- Juliana Cavadas Teixeira
- Division of Infectious and Parasitic Diseases, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Vítor Falcão de Oliveira
- Division of Infectious and Parasitic Diseases, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Hélio Rodrigues Gomes
- Division of Neurology, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Suzana Mesquita Ribeiro
- Microbiology Section of Division Central Laboratory, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Isabela Carvalho Leme Vieira da Cruz
- Division of Infectious and Parasitic Diseases, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Mariane Taborda
- Division of Infectious and Parasitic Diseases, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Adriana Satie Gonçalves Kono Magri
- Division of Infectious and Parasitic Diseases, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José Ernesto Vidal
- Division of Infectious and Parasitic Diseases, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Department of Neurology, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
| | | | - Guilherme Diogo Silva
- Division of Neurology, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcello Mihailenko Chaves Magri
- Division of Infectious and Parasitic Diseases, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Alves MJ, Cruz KS, Alves GSB, Grisolia ME, Menescal VVF, do Nascimento IS, Menescal LSF, Pinheiro SB, da Silva FA, Trilles L, de Souza JVB, Lazera MDS, Jackisch-Matsuura AB. Antifungal susceptibility and multilocus sequence typing (MLST) of Cryptococcus neoformans complex from HIV-associated cryptococcal meningitis patients in Manaus, Amazonas, Brazil. Braz J Microbiol 2024:10.1007/s42770-024-01378-y. [PMID: 38755408 DOI: 10.1007/s42770-024-01378-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024] Open
Abstract
Cryptococcus neoformans is primarily responsible for cases of cryptococcal meningitis in individuals with HIV/AIDS. This study evaluated the susceptibility of C. neoformans obtained from individuals with cryptococcal meningitis associated with HIV/AIDS in Manaus, Amazonas, Brazil, against the action of the antifungals amphotericin B, flucytosine, fluconazole, itraconazole and posaconazole and analyzed it using Multilocus Sequence Typing (MLST) in order to identify the Sequence Types (STs). We analyzed 30 isolates of C. neoformans, from 24 HIV/AIDS patients diagnosed with cryptococcosis from 2017 to 2019 in a reference hospital, in addition to 3 environmental isolates: 1 isolate obtained in the home of a patient and 2 isolates obtained from neighboring homes of patients. 86.6% (n = 26/30) of the clinical isolates were identified as C. neoformans VNI ST93, 6.6% (n = 2/30) as C. neoformans VNI ST5, 3.3% (n = 1/30) as C. neoformans VNI ST32 and 3.3% (n = 1/30) as C. neoformans VNB ST232. The environmental isolates were identified as C. neoformans VNI ST93 (n = 3/3). 96.6% (n = 29/30) isolates were sensitive to amphotericin B, though there was variation in the MIC. 60% (n = 18/30) presented a MIC above the proposed epidemiological cutoff values for one or more antifungals. All environmental isolates were sensitive to the tested antifungals. The MLST showed that there is an important relationship between C. neoformans VNI ST93 and individuals with HIV/AIDS, including in the environmental isolates analyzed. C. neoformans VNB ST232 was observed for the first time in Amazonas. Amphotericin B was proven to be the best drug, but fluconazole and posaconazole also showed relevant action.
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Affiliation(s)
- Marla Jalene Alves
- Laboratório de Diversidade Microbiana da Amazônia com importância para a Saúde, Instituto Leônidas e Maria Deane - FIOCRUZ, Manaus, Amazonas, Brazil
- Programa de Pós-Graduação em Medicina Tropical, Convenio ILMD/IOC - FIOCRUZ, Manaus, Amazonas, Brazil
| | - Katia Santana Cruz
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Laboratório de Micologia Médica, Manaus, Amazonas, Brazil
| | - Gleica Soyan Barbosa Alves
- Instituto de Ciências Exatas e Tecnologia, Universidade Federal do Amazonas - UFAM, Itacoatiara, Amazonas, Brazil
| | - Maria Eduarda Grisolia
- Laboratório de Diversidade Microbiana da Amazônia com importância para a Saúde, Instituto Leônidas e Maria Deane - FIOCRUZ, Manaus, Amazonas, Brazil
| | - Victoria Violeta Fernandes Menescal
- Laboratório de Diversidade Microbiana da Amazônia com importância para a Saúde, Instituto Leônidas e Maria Deane - FIOCRUZ, Manaus, Amazonas, Brazil
| | - Izabella Sadalla do Nascimento
- Laboratório de Diversidade Microbiana da Amazônia com importância para a Saúde, Instituto Leônidas e Maria Deane - FIOCRUZ, Manaus, Amazonas, Brazil
| | | | - Silviane Bezerra Pinheiro
- Laboratório de Micologia, Instituto Nacional de Pesquisas da Amazônia (INPA), Manaus, Amazonas, Brazil
- Pós-Graduação em Genética, Conservação e Biologia Evolutiva, Instituto Nacional de Pesquisas da Amazônia (INPA), Manaus, Amazonas, Brazil
| | - Felipe Almeida da Silva
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Luciana Trilles
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | | | - Marcia Dos Santos Lazera
- Programa de Pós-Graduação em Medicina Tropical, Convenio ILMD/IOC - FIOCRUZ, Manaus, Amazonas, Brazil
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Ani Beatriz Jackisch-Matsuura
- Laboratório de Diversidade Microbiana da Amazônia com importância para a Saúde, Instituto Leônidas e Maria Deane - FIOCRUZ, Manaus, Amazonas, Brazil.
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Melhem MSC, Leite Júnior DP, Takahashi JPF, Macioni MB, Oliveira LD, de Araújo LS, Fava WS, Bonfietti LX, Paniago AMM, Venturini J, Espinel-Ingroff A. Antifungal Resistance in Cryptococcal Infections. Pathogens 2024; 13:128. [PMID: 38392866 PMCID: PMC10891860 DOI: 10.3390/pathogens13020128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Antifungal therapy, especially with the azoles, could promote the incidence of less susceptible isolates of Cryptococcus neoformans and C. gattii species complexes (SC), mostly in developing countries. Given that these species affect mostly the immunocompromised host, the infections are severe and difficult to treat. This review encompasses the following topics: 1. infecting species and their virulence, 2. treatment, 3. antifungal susceptibility methods and available categorical endpoints, 4. genetic mechanisms of resistance, 5. clinical resistance, 6. fluconazole minimal inhibitory concentrations (MICs), clinical outcome, 7. environmental influences, and 8. the relevance of host factors, including pharmacokinetic/pharmacodynamic (PK/PD) parameters, in predicting the clinical outcome to therapy. As of now, epidemiologic cutoff endpoints (ECVs/ECOFFs) are the most reliable antifungal resistance detectors for these species, as only one clinical breakpoint (amphotericin B and C. neoformans VNI) is available.
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Affiliation(s)
- Marcia S C Melhem
- Graduate Program in Sciences, Secretary of Health, São Paulo 01246-002, SP, Brazil
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Graduate Program in Tropical Diseases, State University of São Paulo, Botucatu 18618-687, SP, Brazil
| | | | - Juliana P F Takahashi
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Pathology Division, Adolfo Lutz Institute, São Paulo 01246-002, SP, Brazil
| | | | | | - Lisandra Siufi de Araújo
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Wellington S Fava
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Lucas X Bonfietti
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Anamaria M M Paniago
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - James Venturini
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Ana Espinel-Ingroff
- Central Public Health Laboratory-LACEN, Campo Grande 79074-460, MS, Brazil
- VCU Medical Center, Richmond, VA 23284, USA
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Vidal JE, Oliveira FG, Vieira M, Pereira L, Lucas Junior RM, Guedes BF, Magri MC, Boulware DR. Finger-Prick Whole Blood Cryptococcal Antigen Lateral Flow Assay for the Diagnosis of Cryptococcosis in HIV-Negative Patients: A Case Series Study in Two Tertiary Centers in São Paulo, Brazil. J Fungi (Basel) 2023; 9:1140. [PMID: 38132741 PMCID: PMC10744370 DOI: 10.3390/jof9121140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 12/23/2023] Open
Abstract
Cryptococcosis in HIV-negative patients can be an opportunistic or endemic disease. There are no published studies on the use of the finger-prick whole blood (point-of-care) cryptococcal antigen lateral flow assay (CrAg LFA) for diagnosing cryptococcosis in HIV-negative patients. We conducted a case series study of HIV-negative patients with cryptococcosis in two centers in São Paulo, Brazil. The objectives were to identify the sensitivity of a finger-prick whole blood CrAg LFA and to describe the main characteristics of this population. We identified 30 HIV-negative patients with cryptococcosis [19 (63%), male; median age, 47 years]. Ten (33%) patients were immunosuppressed, ten (33%) had other comorbidities, and ten (33%) were apparently immunocompetent and without comorbidities. The distribution of the sites of cryptococcosis was as follows: the central nervous system, 90% (n = 27); pulmonary, 43% (n = 13); and other extrapulmonary sites, 40% (n = 12). The sensitivity of the finger-prick whole blood CrAg LFA for the diagnosis of cryptococcosis was 97% (29/30). Among 26 participants with cryptococcal meningitis, the sensitivity of testing cerebrospinal fluid was as follows: CrAg latex agglutination, 77% (20/26); CrAg LFA, 96% (25/26); and culture, 81% (21/26). Culture speciation identified Cryptococcus gattii in 16 (62%) cases, and all had a positive finger-prick whole blood CrAg LFA. This test presented high sensitivity to the diagnosis of cryptococcosis in HIV-negative patients, including those caused by C. gattii.
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Affiliation(s)
- José E. Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil;
- Laboratório de Investigação Médica (LIM 49) da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Fernanda Gurgel Oliveira
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil; (F.G.O.); (M.V.); (L.P.); (R.M.L.J.)
| | - Marcela Vieira
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil; (F.G.O.); (M.V.); (L.P.); (R.M.L.J.)
| | - Luisa Pereira
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil; (F.G.O.); (M.V.); (L.P.); (R.M.L.J.)
| | - Rodovaldo M. Lucas Junior
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil; (F.G.O.); (M.V.); (L.P.); (R.M.L.J.)
| | - Bruno Fukelman Guedes
- Departamento de Neurologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil;
| | - Marcello Chaves Magri
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil;
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
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Damasceno LS, Cézar RC, Canuto MCDS, Barbosa Neto JDP, Leitão TDMJS. Cryptococcal meningoencephalitis: Risk factors associated to death in a hospital in Northeastern Brazil. J Mycol Med 2023; 33:101407. [PMID: 37295283 DOI: 10.1016/j.mycmed.2023.101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/14/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Cryptococcosis is an opportunistic systemic mycosis caused by pathogenic encapsulated yeasts of the genus Cryptococcus. The objective of the present study was to evaluate the risk factors associated with death of patients diagnosed with meningitis due to Cryptococcus spp. METHODS This retrospective cohort study included patients admitted to the São José Hospital (SJH) with Cryptococcal Meningoencephalitis (CM) who were diagnosed between 2010 and 2018. Data collection was carried out by reviewing the patients' medical records. Death during hospitalization was considered the primary outcome. RESULTS From 2010 to 2018, 21,519 patients were admitted to the HSJ, 124 of whom were hospitalized due to CM. The CM incidence rate was 5.8 cases/103 hospitalizations. We included 112 patients in the study. Male patients were the most affected (82.1%), and the median age was 37 years [IQR: 29-45]. HIV coinfection occurred in 79.4% of the patients. Fever (65.2%) and headache (88.4%) were the most frequent symptoms. Greater cellularity in the CSF was the most related factor to CM in non-HIV individuals (p < 0.05). Death during hospitalization occurred in 28.6% (n = 32) of the patients. The independent risk factors associated with death during the hospitalization were women (p = 0.009), age > 35 years (p = 0.046), focal neurological deficits (p = 0.013), altered mental status (p = 0.018) and HIV infection (p = 0.040). The twelve-month survival was lower in HIV-positive patients (p < 0.05). CONCLUSION Early diagnosis, optimal treatment, and clinical follow-up strategies, especially in HIV patients, should be prioritized.
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Affiliation(s)
- Lisandra Serra Damasceno
- Departamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil; Hospital São José de Doenças Infecciosas, Fortaleza, Ceará, Brazil.
| | - Renan Carrasco Cézar
- Departamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | | | | | - Terezinha do Menino Jesus Silva Leitão
- Departamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil; Hospital São José de Doenças Infecciosas, Fortaleza, Ceará, Brazil
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Silva GD, Guedes BF, Junqueira IR, Gomes HR, Vidal JE. Diagnostic and therapeutic approach to chronic meningitis in Brazil: a narrative review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1167-1177. [PMID: 36577417 PMCID: PMC9797267 DOI: 10.1055/s-0042-1758645] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic meningitis (CM) is characterized by neurological symptoms associated with the evidence of cerebrospinal fluid pleocytosis lasting > 4 weeks. Studies on the management of CM in Brazil are scarce. OBJECTIVE To critically review the literature on CM and propose a rational approach in the Brazilian scenario. METHODS Narrative literature review discussing the epidemiology, clinical evaluation, basic and advanced diagnostic testing, and empirical and targeted therapy for the most relevant causes of CM. The present review was contextualized with the local experience of the authors. In addition, we propose an algorithm for the management of CM in Brazil. RESULTS In Brazil, tuberculosis and cryptococcosis are endemic and should always be considered in CM patients. In addition to these diseases, neurosyphilis and other endemic conditions should be included in the differential diagnosis, including neurocysticercosis, Baggio-Yoshinari syndrome, and endemic mycosis. After infectious etiologies, meningeal carcinomatosis and autoimmune diseases should be considered. Unbiased and targeted methods should be used based on availability and clinical and epidemiological data. CONCLUSION We propose a rational approach to CM in Brazil, considering the epidemiological scenario, systematizing the etiological investigation, and evaluating the timely use of empirical therapies.
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Affiliation(s)
- Guilherme Diogo Silva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.,Address for correspondence Guilherme Diogo Silva
| | - Bruno Fukelmann Guedes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Ióri Rodrigues Junqueira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Hélio Rodrigues Gomes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - José Ernesto Vidal
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Doenças Infecciosas, São Paulo SP, Brazil.,Instituto de Infectologia Emílio Ribas, Departamento de Neurologia, São Paulo SP, Brazil.
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Prevalence and Associated Factors of Cryptococcal Antigenemia in HIV-Infected Patients with CD4 < 200 Cells/µL in São Paulo, Brazil: A Bayesian Analysis. J Fungi (Basel) 2022; 8:jof8121284. [PMID: 36547617 PMCID: PMC9786117 DOI: 10.3390/jof8121284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Cryptococcosis is a severe life-threatening disease and a major cause of mortality in people with advanced AIDS and CD4 ≤ 100 cells/µL. Considering the knowledge gap regarding the benefits of routine application of antigenemia tests in HIV-infected patients with 100−200 CD4 cells/µL for the prevention of cryptococcal meningitis (CM), we aimed to evaluate the prevalence of positive antigenemia through lateral flow assay (LFA) and associated factors in HIV-infected patients with CD4 < 200 cells/µL. Our findings of 3.49% of positive LFA (LFA+) patients with CD4 < 100 cells/µL and 2.24% with CD4 between 100−200 cells/µL have been included in a Bayesian analysis with 12 other studies containing similar samples worldwide. This analysis showed a proportion of 3.6% LFA+ patients (95% credible interval-Ci [2.5−5.7%]) with CD4 < 100 cells/µL and 1.1% (95%Ci [0.5−4.3%]) with CD4 between 100−200 cells/µL, without statistical difference between these groups. The difference between mortality rates in LFA+ and negative LFA groups was e = 0.05013. Cryptococcoma and CM were observed in the LFA+ group with 100−200 and <100 CD4 cells/µL, respectively. Considering the benefits of antifungal therapy for LFA+ patients, our data reinforced the recommendation to apply LFA as a routine test in patients with 100−200 CD4 cells/µL aiming to expand cost-effectiveness studies in this group.
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Yonekura TDS, Macedo SD, Moya FG, Vidal JE. Chronic disseminated cryptococcosis without meningeal involvement in a severely immunosuppressed HIV-infected patient successfully treated with fluconazole. Med Mycol Case Rep 2022; 38:30-32. [PMID: 36345352 PMCID: PMC9636007 DOI: 10.1016/j.mmcr.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/15/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
Abstract
A 43-year-old female with advanced HIV infection presented with two chronic skin lesions. Cutaneous cryptococcosis was confirmed and pulmonary cryptococcosis was suspected. The patient was neurologically asymptomatic and the cerebrospinal fluid cryptococcal antigen lateral flow assay was negative. She received oral fluconazole and had resolution of the skin lesions and significant improvement of the lung lesions. We report a person with AIDS with chronic disseminated cryptococcosis without meningeal involvement successfully treated with oral fluconazole.
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Affiliation(s)
| | - Soraya Devi Macedo
- Instituto de Infectologia Emilio Ribas, Av. Dr. Arnaldo 165, São Paulo, 01246-900, Brazil
| | - Fernanda Gonçalves Moya
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Av. Doutor Enéas Carvalho Aguiar 255, 05403-000, São Paulo, Brazil,Instituto de Assistência Médica ao Servidor Público Estadual, R. Pedro de Toledo 1800, 04039-000, São Paulo, Brazil
| | - José Ernesto Vidal
- Instituto de Infectologia Emilio Ribas, Av. Dr. Arnaldo 165, São Paulo, 01246-900, Brazil,Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Av. Doutor Enéas Carvalho Aguiar 255, 05403-000, São Paulo, Brazil,Instituto de Medicina Tropical da Universidade de São Paulo, São Paulo, Brazil,Corresponding author. Instituto de Infectologia Emilio Ribas, Av. Dr. Arnaldo 165, São Paulo, 01246-900, Brazil.
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Cryptococcus spp. and Cryptococcosis: focusing on the infection in Brazil. Braz J Microbiol 2022; 53:1321-1337. [PMID: 35486354 PMCID: PMC9433474 DOI: 10.1007/s42770-022-00744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 03/25/2022] [Indexed: 11/02/2022] Open
Abstract
Cryptococcosis is a global fungal infection caused by the Cryptococcus neoformans/Cryptococcus gattii yeast complex. This infection is acquired by inhalation of propagules such as basidiospores or dry yeast, initially causing lung infections with the possibility of progressing to the meninges. This infection mainly affects immunocompromised HIV and transplant patients; however, immunocompetent patients can also be affected. This review proposes to evaluate cryptococcosis focusing on studies of this mycosis in Brazilian territory; moreover, recent advances in the understanding of its virulence mechanism, animal models in research are also assessed. For this, literature review as realized in PubMed, Scielo, and Brazilian legislation. In Brazil, cryptococcosis has been identified as one of the most lethal fungal infections among HIV patients and C. neoformans VNI and C. gattii VGII are the most prevalent genotypes. Moreover, different clinical settings published in Brazil were described. As in other countries, cryptococcosis is difficult to treat due to a limited therapeutic arsenal, which is highly toxic and costly. The presence of a polysaccharide capsule, thermo-tolerance, production of melanin, biofilm formation, mechanisms for iron use, and morphological alterations is an important virulence mechanism of these yeasts. The introduction of cryptococcosis as a compulsory notification disease could improve data regarding incidence and help in the management of these infections.
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Li M, Liu J, Deng X, Gan Q, Wang Y, Xu X, Jiang Y, Peng F. Triple therapy combined with ventriculoperitoneal shunts can improve neurological function and shorten hospitalization time in non-HIV cryptococcal meningitis patients with increased intracranial pressure. BMC Infect Dis 2020; 20:844. [PMID: 33198666 PMCID: PMC7667777 DOI: 10.1186/s12879-020-05510-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Abstract
Background Raised intracranial pressure (ICP) and insufficient antifungal regimens are the two main factors result to unsatisfactory outcomes in non-HIV cryptococcal meningitis (CM) patients. In this study, we try to discuss that whether triple therapy of amphotericin B (AmB), fluconazole, 5-flucytosine (5-FC) plus ventriculoperitoneal shunts (VPS) is superior to AmB, 5-FC, fluconazole plus intermittent lumbar puncture in induction therapy in non-HIV CM patients with increased ICP. Methods We reviewed 66 clinical records from non-HIV CM patients with increased ICP. The demographic and clinical characteristics, BMRC staging, cerebrospinal fluid profiles (CSF), brain magnetic resonance imaging, treatment, and outcomes of these individuals were retrospectively analyzed. All non-HIV CM patients with increased ICP (≥ 25 cmH2O) were divided into two groups, including 27 patients treated with triple antifungal agents and 39 patients treated with the same triple therapy plus VPS. Results Triple therapy plus VPS group had more satisfactory outcomes, more CSF sterilization at 10 weeks follow-up, lower CSF opening pressure, lower BMRC staging scores one week after VPS, less CSF C. neoformans counts and CSF culture positive. Besides, these patients had shorter hospital stay than triple therapy group. Conclusions Triple antifungal agents combined with VPS could effectively reduce ICP, had faster rate of clearance of C. neoformans counts, more improved neurological function, shorten hospitalization time and better outcomes in non-HIV CM patients with increased ICP. Our study indicated that triple therapy plus early VPS may be an optimal treatment for non-HIV CM patients with increased ICP.
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Affiliation(s)
- Min Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Xuhui Deng
- Department of Neurology, Yuebei People' Hospital, Shaoguan, 5120264, Guangdong, China
| | - Qingzhou Gan
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Yijie Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Xiaofeng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
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11
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Chesdachai S, Engen NW, Rhein J, Tugume L, Kiiza Kandole T, Abassi M, Ssebambulidde K, Kasibante J, Williams DA, Skipper CP, Hullsiek KH, Musubire AK, Rajasingham R, Meya DB, Boulware DR. Baseline Serum C-Reactive Protein Level Predicts Mortality in Cryptococcal Meningitis. Open Forum Infect Dis 2020; 7:ofaa530. [PMID: 33335936 PMCID: PMC7727340 DOI: 10.1093/ofid/ofaa530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/23/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND C-reactive protein (CRP) is an acute phase protein produced by the liver in response to systemic inflammation. CRP is a helpful surrogate biomarker used for following the progression and resolution of infection. We aimed to determine the association of baseline CRP level and the temporal change in CRP over time with cryptococcal meningitis outcome. METHODS We reviewed 168 prospectively enrolled HIV-infected Ugandans with confirmed first-episode cryptococcal meningitis. Baseline plasma CRP collected within 5 days of meningitis diagnosis was categorized into quartiles. We compared baseline CRP with 18-week survival using time-to-event analysis. RESULTS Of 168 participants, the baseline first quartile of serum CRP was <29.0 mg/L, second quartile 29.0-49.5 mg/L, third quartile 49.6-83.6 mg/L, and fourth quartile >83.6 mg/L. Baseline CD4 count, HIV viral load, and cerebrospinal fluid results did not differ by CRP quartile. Participants with CRP >49.5 mg/L more likely presented with Glasgow Coma Scale (GCS) <15 (P = .03). The 18-week mortality rate was 55% (46/84) in the highest 2 quartile CRP groups (>49.5 mg/L), 41% (17/42) in the mid-range CRP group (29.0-49.5 mg/L), and 14% (6/42) in the low-CRP group (<29.0 mg/L; P < .001). After adjustment for possible confounding factors including GCS <15, CRP remained significantly associated with mortality (adjusted hazard ratio, 1.084 per 10 mg/L; 95% CI, 1.031-1.139; P = .0016). CONCLUSIONS Higher baseline CRP is associated with increased mortality in HIV-infected individuals with first-episode cryptococcal meningitis. CRP could be a surrogate marker for undiagnosed coinfections or may reflect immune dysregulation, leading to worse outcomes in persons with advanced AIDS and concomitant cryptococcal meningitis.
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Affiliation(s)
- Supavit Chesdachai
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA,Correspondence: Supavit Chesdachai, MD, 420 Delaware Street SE, MMC 284, Minneapolis, MN 55455 ()
| | - Nicole W Engen
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tadeo Kiiza Kandole
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathy H Hullsiek
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abdu K Musubire
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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12
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Kamali Kakhki R, Najafzadeh MJ, Kachuei R, Ghazvini K. Targeting novel genes for simultaneous detection of five fungal and bacterial agents from BAL samples using multiplex PCR assay. Eur J Clin Microbiol Infect Dis 2020; 39:1535-1542. [PMID: 32253622 DOI: 10.1007/s10096-020-03879-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/24/2020] [Indexed: 12/26/2022]
Abstract
The main purpose of our study was to evaluate multiplex PCR assay targeting novel genes for detection of five fungal and bacterial agents in BAL samples; because many fungi and bacteria that cause respiratory infections have similar clinical symptoms, diagnosing and differentiating them are therefore essential to controlling and treating them. A total of 100 BAL specimens from a mycobacterium and mycology laboratory were collected from patients suspected of having TB or other respiratory diseases. Novel DNA targets for Aspergillus, Nocardia, Cryptococcus, and Streptomyces were found using modified comparative genomic analysis. Afterward, the primers were designed based on novel targets, and the sensitivity and specificity of the newly designed primers were evaluated. These primers, along with specific primers for M. tuberculosis (SDR), were used in a multiplex PCR assay. The results showed the culture test to be more sensitive than the PCR assay in detecting M. tuberculosis. However, in the detection of Aspergillus, the PCR assay was more sensitive than the culture test. We also found one positive culture and two positive PCR assays for Nocardiosis. Cryptococcal infections and Streptomyces associated with lung diseases were not identified by the culture test nor by the PCR assay. The multiplex PCR is one of the cheapest molecular diagnostic tests readily available for BAL samples in clinical laboratories. This assay can be used for early reports of the causative agents and for treating patients with appropriate drugs at an early stage.
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Affiliation(s)
- Reza Kamali Kakhki
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Javad Najafzadeh
- Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Kachuei
- Molecular Biology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| | - Kiarash Ghazvini
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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13
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Silva AP, Zenatti CT, Figueiredo-Mello C, Negra MD, Levin AS, Boulware DR, Vidal JE. Should we perform the serum cryptococcal antigen test in people living with HIV hospitalized due to a community-acquired pneumonia episode? Int J STD AIDS 2020; 31:345-350. [PMID: 32089092 DOI: 10.1177/0956462419847161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Community-acquired pneumonia (CAP) is a common cause of hospitalization among people living with human immunodeficiency virus (PLWH), particularly those with severe immunosuppression. Pulmonary disease due to cryptococcosis is uncommonly reported and likely under-diagnosed. There is scarce information about cryptococcal antigen (CrAg) prevalence in PLWH with CAP. The objectives of this study were to identify among PLWH who were hospitalized with CAP: (i) the prevalence of serum CrAg positivity, (ii) the proportion with asymptomatic vs. symptomatic cryptococcosis; and (iii) the prevalence of serum CrAg positivity in CD4+ T-cell count <100 cells/mm3. We performed a sub-analysis of a prospective cohort of hospitalized adults enrolled into a randomized clinical trial testing therapy for CAP. We included 202 participants who had serum CrAg testing performed. We found a 3.5% prevalence of serum CrAg-positivity overall, being higher (5.7%) in CD4+ T-cell count <100 cells/mm3. Overall, asymptomatic and symptomatic cryptococcosis were present in 2.0% and 1.5%, respectively. This study identifies a target population for CrAg testing: PLWH hospitalized with diagnosis of CAP, particularly those with CD4+ T-cell count <100 cells/mm3 where the number needed to test was 18 to detect 1 CrAg-positive person. This approach may facilitate the detection of asymptomatic cryptococcal infection and allow a timely diagnosis of symptomatic cryptococcal disease.
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Affiliation(s)
- Adriana Paulino Silva
- Deparment of Infectious Diseases, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
| | | | - Claudia Figueiredo-Mello
- Deparment of Infectious Diseases, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil.,Department of Infectious Diseases, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marinella Della Negra
- Deparment of Infectious Diseases, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - José Ernesto Vidal
- Department of Infectious Diseases, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Department of Neurology, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil.,Laboratório de Investigação Médica - 49, Instituto de Medicina Tropical, Universidade de São Paulo, São Paulo, Brazil
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14
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Chagas OJ, Buccheri R, de Souza Carvalho Melhem M, Szeszs W, dos Anjos Martins M, de Oliveira L, Marcusso R, Santos DW. Usefulness of Yeast Cell Counting and Lack of Clinical Correlation of the Antifungal Susceptibility Testing Results in Management of Aids-associated Cryptococcal Meningitis. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00368-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Maybruck BT, Lam WC, Specht CA, Ilagan MXG, Donlin MJ, Lodge JK. The Aminoalkylindole BML-190 Negatively Regulates Chitosan Synthesis via the Cyclic AMP/Protein Kinase A1 Pathway in Cryptococcus neoformans. mBio 2019; 10:e02264-19. [PMID: 31848271 PMCID: PMC6918072 DOI: 10.1128/mbio.02264-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/31/2019] [Indexed: 02/06/2023] Open
Abstract
Cryptococcus neoformans can cause fatal meningoencephalitis in patients with AIDS or other immunocompromising conditions. Current antifungals are suboptimal to treat this disease; therefore, novel targets and new therapies are needed. Previously, we have shown that chitosan is a critical component of the cryptococcal cell wall and is required for survival in the mammalian host and that chitosan deficiency results in rapid clearance from the mammalian host. We had also identified several specific proteins that were required for chitosan biosynthesis, and we hypothesize that screening for compounds that inhibit chitosan biosynthesis would identify additional genes/proteins that influence chitosan biosynthesis. To identify these compounds, we developed a robust and novel cell-based flow cytometry screening method to identify small-molecule inhibitors of chitosan production. We screened the ICCB Known Bioactives library and identified 8 compounds that reduced chitosan in C. neoformans We used flow cytometry-based counterscreens and confirmatory screens, followed by a biochemical secondary screen to refine our primary screening hits to 2 confirmed hits. One of the confirmed hits that reduced chitosan content was the aminoalkylindole BML-190, a known inverse agonist of mammalian cannabinoid receptors. We demonstrated that BML-190 likely targets the C. neoformans G-protein-coupled receptor Gpr4 and, via the cyclic AMP (cAMP)/protein kinase A (PKA) signaling pathway, contributes to an intracellular accumulation of cAMP that results in decreased chitosan. Our discovery suggests that this approach could be used to identify additional compounds and pathways that reduce chitosan biosynthesis and could lead to potential novel therapeutics against C. neoformansIMPORTANCECryptococcus neoformans is a fungal pathogen that kills ∼200,000 people every year. The cell wall is an essential organelle that protects fungi from the environment. Chitosan, the deacetylated form of chitin, has been shown to be an essential component of the cryptococcal cell wall during infection of a mammalian host. In this study, we screened a set of 480 compounds, which are known to have defined biological activities, for activity that reduced chitosan production in C. neoformans Two of these compounds were confirmed using an alternative method of measuring chitosan, and one of these was demonstrated to impact the cAMP signal transduction pathway. This work demonstrates that the cAMP pathway regulates chitosan biosynthesis in C. neoformans and validates that this screening approach could be used to find potential antifungal agents.
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Affiliation(s)
- Brian T Maybruck
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Woei C Lam
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles A Specht
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ma Xenia G Ilagan
- Department of Biochemistry and Molecular Biophysics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maureen J Donlin
- Department of Biochemistry and Molecular Biology, Saint Louis University, St. Louis, Missouri, USA
| | - Jennifer K Lodge
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
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16
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Alves Soares E, Lazera MDS, Wanke B, de Faria Ferreira M, Carvalhaes de Oliveira RV, Oliveira AG, Coutinho ZF. Mortality by cryptococcosis in Brazil from 2000 to 2012: A descriptive epidemiological study. PLoS Negl Trop Dis 2019; 13:e0007569. [PMID: 31356603 PMCID: PMC6687200 DOI: 10.1371/journal.pntd.0007569] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/08/2019] [Accepted: 06/21/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cryptococcosis is a neglected and predominantly opportunistic mycosis that, in Brazil, poses an important public health problem, due to its late diagnosis and high lethality. METHODS The present study analysed cryptococcosis mortality in Brazil from January 2000 to December 2012, based on secondary data (Mortality Information System/SIM-DATASUS and IBGE). RESULTS Out of 5,755 recorded deaths in which cryptococcosis was mentioned as one of the morbid states that contributed to death, two distinct groups emerged: 1,121 (19.5%) registered cryptococcosis as the basic cause of death, and 4,634 (80.5%) registered cryptococcosis associated with risk factors, mainly AIDS (75%), followed by other host risks (5.5%). The mortality rate by cryptococcosis as the basic cause was 6.19/million inhabitants, whereas the mortality rate by cryptococcosis as an associated cause was 25.19/million inhabitants. Meningitis was the predominant clinical form (80%), males were the more affected (69%), and 39.5 years old was the mean age. The highest mortality rate due to cryptococcosis as basic cause occurred in the state of Mato Grosso (10.96/million inhabitants). Mortality rates due to cryptococcosis as associated cause were highest in the states of Santa Catarina (70.41/million inhabitants) and Rio Grande do Sul (64.40/million inhabitants), both in the South Region. Southeast, Northeast and South showed significant time trends in mortality rates. CONCLUSIONS This study is relevant because it shows the magnitude of cryptococcosis mortality linked to AIDS and removes the invisibility of a particular non-AIDS-related disease, accounting for almost 20% of all cryptococcosis deaths. It can also contribute to control and surveillance programs, beyond highlighting the urgent prioritization of early diagnosis and proper treatment to reduce the unacceptable mortality rate of this neglected mycosis in Brazil.
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Affiliation(s)
- Emmanuel Alves Soares
- Natan Portela Institute of Tropical Diseases, State Secretary of Health of Piauí, Departament of infectious disease, Teresina-PI, Brasil
| | - Márcia dos Santos Lazera
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Department of Mycology, Rio de Janeiro-RJ, Brazil
| | - Bodo Wanke
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Department of Mycology, Rio de Janeiro-RJ, Brazil
| | - Marcela de Faria Ferreira
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Department of Mycology, Rio de Janeiro-RJ, Brazil
| | | | - Adeno Gonçalves Oliveira
- Natan Portela Institute of Tropical Diseases, State Secretary of Health of Piauí, Departament of infectious disease, Teresina-PI, Brasil
| | - Ziadir Francisco Coutinho
- Health Center Germano Sinval Farias, National School of Public Health/Oswaldo Cruz Foundation, Department of Public Health, Rio de Janeiro-RJ, Brazil
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17
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Álvarez-Moreno CA, González-Vélez AE, Colmenares-Mejía CC, Rincón-Ramírez KL, García-Buitrago JA, Rengifo-Bobadilla PA, Isaza-Ruget MA. The cost of hospital care for HIV patients in Colombia: an insurer's perspective. Int J STD AIDS 2019; 30:696-702. [PMID: 31046613 DOI: 10.1177/0956462419835636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to evaluate the cost derived from the hospitalization of people living with HIV (PLHIV) in Colombia between 2011 and 2015. This is an analysis of the direct cost of PLHIV hospitalization from the perspective of an insurer of the Colombian General Social Security System. The costs were calculated in Colombian pesos and corrected for inflation on the basis of the 2017 Consumer Price Index of the Bank of the Republic of Colombia. It was converted to US dollars at the Market Representative Exchange Rate of the same year. We analyzed 1129 hospitalizations in 612 PLHIV, of which 12% started with a diagnosis of HIV during the same hospitalization, with the majority in the AIDS stage (63%). The median overall cost of hospitalizations was US$1509 (25th and 75th percentiles: US$711-US$3254), being even higher in patients with AIDS and as the CD4 T lymphocyte count decreased. The cost derived from the medical care of PLHIV increases as the clinical control of the disease worsens, and it is a key indicator of the impact of the strategies implemented for the timely identification of the infection and subsequent management of the disease.
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18
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Guarana M, Vidal JE, Nucci M. Cryptococcosis in Patients with Hematologic Diseases. CURRENT FUNGAL INFECTION REPORTS 2018. [DOI: 10.1007/s12281-018-0332-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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19
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Nunes JDO, Tsujisaki RADS, Nunes MDO, Lima GME, Paniago AMM, Pontes ERJC, Chang MR. Cryptococcal meningitis epidemiology: 17 years of experience in a State of the Brazilian Pantanal. Rev Soc Bras Med Trop 2018; 51:485-492. [DOI: 10.1590/0037-8682-0050-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/21/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Marilene Rodrigues Chang
- Universidade Federal de Mato Grosso do Sul, Brazil; Universidade Federal de Mato Grosso do Sul, Brazil
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20
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Barletta J, Falak A, Pérez H. Cryptococcal meningitis: an unusual presentation of primary HIV infection. Int J STD AIDS 2018; 29:1247-1249. [PMID: 29966507 DOI: 10.1177/0956462418779312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute HIV infection presenting as severe opportunistic disease is a very uncommon event associated with more rapid HIV progression and higher mortality. We describe the case of a patient with cryptococcal meningitis in the setting of primary HIV infection.
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Affiliation(s)
- José Barletta
- Infectious Diseases Division, Hospital Juan A. Fernández, Buenos Aires, Argentina
| | - Adriana Falak
- Infectious Diseases Division, Hospital Juan A. Fernández, Buenos Aires, Argentina
| | - Héctor Pérez
- Infectious Diseases Division, Hospital Juan A. Fernández, Buenos Aires, Argentina
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21
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Vidal JE, Toniolo C, Paulino A, Colombo AL, Martins MDA, Meira CDS, Azevedo RGS, Pereira-Chioccola VL, Gomes HR, Lazera MDS, Oliveira ACPD, Boulware DR. Performance of cryptococcal antigen lateral flow assay in serum, cerebrospinal fluid, whole blood, and urine in HIV-infected patients with culture-proven cryptococcal meningitis admitted at a Brazilian referral center. Rev Inst Med Trop Sao Paulo 2018; 60:e1. [PMID: 29451598 PMCID: PMC5813664 DOI: 10.1590/s1678-9946201860001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/16/2017] [Indexed: 11/25/2022] Open
Abstract
Cryptococcal meningitis is the most common cause of opportunistic meningitis in HIV-infected patients in Brazil and causes unacceptable high mortality rates. In this study, HIV-infected patients with a first episode of culture-proven cryptococcal meningitis in cerebrospinal fluid (CSF) were prospectively included in order to evaluate sensitivity of cryptococcal antigen (CrAg) lateral flow assay (LFA) in serum, CSF, whole blood (fingerstick), and fresh urine. In addition, HIV-infected patients with other neurological confirmed diseases were included in order to evaluate the specificity of CrAg LFA in serum. Twenty patients with cryptococcal meningitis were included and in 19 of them, CrAg LFA in CSF, serum, and whole blood were positive (95% sensitivity). In 18 patients, India ink test was positive in CSF (90% sensitivity), and in 16 cases, CrAg LFA was positive in urine (80% sensitivity). Thirty-six HIV-infected patients with other neurological diseases had negative results of CrAg LFA in serum (100% specificity). In conclusion, CrAg LFA in serum, CSF, and whole blood showed high sensitivity and specificity. Whole blood CrAg LFA seems to be a good and reliable strategy to improve AIDS-related cryptococcal meningitis diagnosis in Brazil.
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Affiliation(s)
- José E Vidal
- Instituto de Infectologia Emilio Ribas, São Paulo, São Paulo, Brazil
| | - Carolina Toniolo
- Instituto de Infectologia Emilio Ribas, São Paulo, São Paulo, Brazil
| | - Adriana Paulino
- Instituto de Infectologia Emilio Ribas, São Paulo, São Paulo, Brazil
| | | | | | | | | | | | - Hélio Rodrigues Gomes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Marcia Dos Santos Lazera
- Instituto Nacional de Doenças Infecciosas, Fundação Fiocruz, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - David R Boulware
- University of Minnesota, Minneapolis, Minnesota, United States of America
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Chadli S, Aghrouch M, Taqarort N, Malmoussi M, Ouagari Z, Moustaoui F, Bourouache M, Oulkheir S. [Neuromeningeal cryptococcosis in patients infected with HIV at Agadir regional hospital, (Souss-Massa, Morocco)]. J Mycol Med 2017; 28:161-166. [PMID: 29132792 DOI: 10.1016/j.mycmed.2017.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 10/18/2017] [Accepted: 10/22/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Neuromeningeal cryptococcosis (NMC) is a severe and fatal opportunistic infection. Lethality is frequent in the absence of treatment, especially in the presence of HIV co-infection. OBJECTIVE To determine the prevalence, epidemiological, clinical, biological and therapeutic aspects as well as the evolution of NMC for patients infected with HIV. PATIENTS AND METHODS This is a retrospective study of 40 cases of neuromeningeal cryptococcosis diagnosed in HIV-infected patients. Data are collected for 7 years (from January 2010 to December 2016) in the registers of the parasitology laboratory and the infectious diseases department at the regional hospital center in Agadir. RESULTS A reduction in the prevalence of neuromeningeal cryptococcosis in HIV-infected patients was noted from 2010 to 2016 (3.66% to 0.83%). The overall prevalence of NMC was 1.53%. The mean age was 37±10 years old, with 90% of patients aged less than 45 years. The main clinical symptomatology was headache (75%). The main cytochemical abnormalities of cerebrospinal fluid analysis were hyperproteinorachy (60%), hypoglycorachy (63%) and lymphocytosis (50%). The mean CD4 cell count was 47/mm3. Patients were initially treated with amphotericin B, relayed with fluconazole. The overall lethality was 35%. CONCLUSION Neuromeningeal cryptococcosis is a serious opportunistic infection in patients HIV-infected, and the lethality rate remains unacceptable. Fighting NMC in HIV+ patients requires early diagnosis, increased access to antiretrovirals, rapid introduction of appropriate treatment and the prescription of effective systemic antifungals.
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Affiliation(s)
- S Chadli
- Institut supérieur des professions infirmières et techniques de santé (ISPITS), Agadir, Maroc.
| | - M Aghrouch
- Laboratoire des analyses médicales, centre hospitalier régional Hassan II, Agadir, Maroc
| | - N Taqarort
- Faculté polydisciplinaire de Taroudant, université Ibn Zohr, Agadir, Maroc
| | - M Malmoussi
- Service des maladies infectieuses, centre hospitalier régional Hassan II, Agadir, Maroc
| | - Z Ouagari
- Service des maladies infectieuses, centre hospitalier régional Hassan II, Agadir, Maroc
| | - F Moustaoui
- Laboratoire des analyses médicales, centre hospitalier régional Hassan II, Agadir, Maroc
| | - M Bourouache
- Faculté des sciences, université Ibn Zohr, Agadir, Maroc
| | - S Oulkheir
- Institut supérieur des professions infirmières et techniques de santé (ISPITS), Agadir, Maroc
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de Serpa Brandão RMS, Faria AR, de Andrade HM, Soares Martins LM, da Silva AS, do Monte SJH. Novel recombinant multiepitope proteins for the detection of anti-Cryptococcus antibodies. Future Microbiol 2017; 13:429-436. [PMID: 29125786 DOI: 10.2217/fmb-2017-0184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
AIM To produce and test recombinant multiepitope proteins as an alternative assay for the serological diagnosis of cryptococcosis. MATERIALS & METHODS Previously, synthetic peptides were used to detect anti-Cryptococcus antibodies, and in silico analyses showed that the union of peptides would improve the results. Here, the coding sequences of these peptides were assembled into synthetic genes. Four genes have been cloned and expressed in Escherichia coli, producing recombinant multiepitope proteins: proteins A, B, C and D. RESULTS All constructs yielded good results; however, protein D showed the best results, with a sensitivity of 88.57% and specificity of 100%. CONCLUSION The multiepitope proteins were shown to be potential antigens for the diagnosis of cryptococcosis in an attempt to detect anti-Cryptococcus antibodies.
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Affiliation(s)
- Rafael Melo Santos de Serpa Brandão
- Laboratório de Imunogenética e Biologia Molecular, Universidade Federal do Piauí, Campus Ministro Petrônio Portella Bloco SG-16, 64049-550, Teresina, Piauí, Brasil
| | - Angélica Rosa Faria
- Universidade Federal de Minas Gerais, Instituto de Ciências Biológicas, Departamento de Parasitologia, 31279-910, Belo Horizonte, Minas Gerais, Brasil
| | - Hélida Monteiro de Andrade
- Universidade Federal de Minas Gerais, Instituto de Ciências Biológicas, Departamento de Parasitologia, 31279-910, Belo Horizonte, Minas Gerais, Brasil
| | - Liline Maria Soares Martins
- Laboratório de Imunogenética e Biologia Molecular, Universidade Federal do Piauí, Campus Ministro Petrônio Portella Bloco SG-16, 64049-550, Teresina, Piauí, Brasil.,Universidade Estadual do Piauí, Centro de Ciências da Saúde, 64001-280, Teresina, Piauí, Brasil
| | - Adalberto Socorro da Silva
- Laboratório de Imunogenética e Biologia Molecular, Universidade Federal do Piauí, Campus Ministro Petrônio Portella Bloco SG-16, 64049-550, Teresina, Piauí, Brasil
| | - Semiramis Jamil Hadad do Monte
- Laboratório de Imunogenética e Biologia Molecular, Universidade Federal do Piauí, Campus Ministro Petrônio Portella Bloco SG-16, 64049-550, Teresina, Piauí, Brasil
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Feliciano LM, Ramos SDP, Szeszs MW, Martins MA, Bonfietti LX, Oliveira RA, Santos DCS, Fadul LH, Silva DF, Paula CR, Trilles L, Silva LEA, Ferreira-Paim K, Mora DJ, Andrade AA, Silva PR, Silva-Vergara ML, Roberto TN, Melhem MSC. Heteroresistance to Fluconazol in Clinical and Environmental Brazilian Strains of Cryptococcus neoformans/C. gattii Species Complex. CURRENT FUNGAL INFECTION REPORTS 2017. [DOI: 10.1007/s12281-017-0298-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Crabtree Ramírez B, Caro Vega Y, Shepherd BE, Le C, Turner M, Frola C, Grinsztejn B, Cortes C, Padgett D, Sterling TR, McGowan CC, Person A. Outcomes of HIV-positive patients with cryptococcal meningitis in the Americas. Int J Infect Dis 2017; 63:57-63. [PMID: 28807740 DOI: 10.1016/j.ijid.2017.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/02/2017] [Accepted: 08/06/2017] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is associated with substantial mortality in HIV-infected patients. Optimal timing of antiretroviral therapy (ART) in persons with CM represents a clinical challenge, and the burden of CM in Latin America has not been well described. Studies suggest that early ART initiation is associated with higher mortality, but data from the Americas are scarce. METHODS HIV-infected adults in care between 1985-2014 at participating sites in the Latin America (the Caribbean, Central and South America network (CCASAnet)) and the Vanderbilt Comprehensive Care Clinic (VCCC) and who had CM were included. Survival probabilities were estimated. Risk of death when initiating ART within the first 2 weeks after CM diagnosis versus initiating between 2-8 weeks was assessed using dynamic marginal structural models adjusting for site, age, sex, year of CM, CD4 count, and route of HIV transmission. FINDINGS 340 patients were included (Argentina 58, Brazil 138, Chile 28, Honduras 27, Mexico 34, VCCC 55) and 142 (42%) died during the observation period. Among 151 patients with CM prior to ART 56 (37%) patients died compared to 86 (45%) of 189 with CM after ART initiation (p=0.14). Patients diagnosed with CM after ART had a higher risk of death (p=0.03, log-rank test). The probability of survival was not statistically different between patients who started ART within 2 weeks of CM (7/24, 29%) vs. those initiating between 2-8 weeks (14/53, 26%) (p=0.96), potentially due to lack of power. INTERPRETATION In this large Latin-American cohort, patients with CM had very high mortality rates, especially those diagnosed after ART initiation. This study reflects the overwhelming burden of CM in HIV-infected patients in Latin America.
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Affiliation(s)
- B Crabtree Ramírez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Mexico City, Mexico.
| | - Y Caro Vega
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Mexico City, Mexico
| | - B E Shepherd
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - C Le
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - M Turner
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - C Frola
- Fundación Huésped, Buenos Aires, Argentina
| | - B Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - C Cortes
- Universidad de Chile, Fundación Arriarán, Santiago, Chile
| | - D Padgett
- Instituto Hondureño de Seguridad Social and Hospital Escuela, Tegucigalpa, Honduras
| | - T R Sterling
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - C C McGowan
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - A Person
- Vanderbilt University School of Medicine, Nashville, TN, United States
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Santos JRA, Ribeiro NQ, Bastos RW, Holanda RA, Silva LC, Queiroz ER, Santos DA. High-dose fluconazole in combination with amphotericin B is more efficient than monotherapy in murine model of cryptococcosis. Sci Rep 2017; 7:4661. [PMID: 28680034 PMCID: PMC5498649 DOI: 10.1038/s41598-017-04588-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/17/2017] [Indexed: 12/26/2022] Open
Abstract
Cryptococcus spp., the causative agents of cryptococcosis, are responsible for deaths of hundreds of thousands of people every year worldwide. The drawbacks of available therapeutic options are aggravated by the increased resistance of yeast to the drugs, resulting in inefficient therapy. Also, the antifungal 5FC is not available in many countries. Therefore, a combination of antifungal drugs may be an interesting option, but in vitro and theoretical data point to the possible antagonism between the main antifungals used to treat cryptococcosis, i.e., fluconazole (FLC), and amphotericin B (AMB). Therefore, in vivo studies are necessary to test the above hypothesis. In this study, the efficacy of FLC and AMB at controlling C. gattii infection was evaluated in a murine model of cryptococcosis caused by C. gattii. The infected mice were treated with FLC + AMB combinations and showed a significant improvement in survival as well as reduced morbidity, reduced lung fungal burden, and the absence of yeast in the brain when FLC was used at higher doses, according to the Tukey test and principal component analysis. Altogether, these results indicate that combinatorial optimization of antifungal therapy can be an option for effective control of cryptococcosis.
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Affiliation(s)
- Julliana Ribeiro Alves Santos
- Mestrado em Biologia Parasitária - Universidade CEUMA (UNICEUMA), São Luís, Maranhão, Brazil. .,Mestrado em Meio Ambiente - Universidade CEUMA (UNICEUMA), São Luís, Maranhão, Brazil.
| | - Noelly Queiroz Ribeiro
- Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Rafael Wesley Bastos
- Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Letícia Chagas Silva
- Mestrado em Meio Ambiente - Universidade CEUMA (UNICEUMA), São Luís, Maranhão, Brazil
| | - Estela Rezende Queiroz
- Departamento de Química, Universidade Federal de Lavras (UFLA), Campus 17 Universitário, Lavras- MG, Brazil
| | - Daniel Assis Santos
- Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Frola C, Guelfand L, Blugerman G, Szyld E, Kaufman S, Cahn P, Sued O, Pérez H. Prevalence of cryptococcal infection among advanced HIV patients in Argentina using lateral flow immunoassay. PLoS One 2017; 12:e0178721. [PMID: 28617817 PMCID: PMC5472272 DOI: 10.1371/journal.pone.0178721] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 05/17/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Globally, Latin America ranks third among regions with most cases of AIDS related cryptococcal meningitis. In 2009, a lateral flow immunoassay (LFA) for the detection of cryptococcal antigen (CrAg) was developed as a potential point-of-care test for diagnosis of cryptococcal infection. In 2011 World Health Organizations recommended on CrAg screening for HIV positive persons with CD4 below 100 cells/μL, followed by preemptive fluconazole treatment. However, in Argentina no formal recommendations for CrAg screening have been issued. METHODS HIV positive patients > = 18 years with advanced immunosuppression (CD4 counts ≤100 cells/μL within 3 months or WHO stage III/IV), who visited the hospital between April 1, 2014 and January 31, 2015, were included. The LFA was performed according to the manufacturer's instructions on all serum samples. When CrAg detection was positive, a lumbar puncture was performed to rule out cryptococcal meningitis. Patients without evidence of meningeal involvement were treated with preemptive oral fluconazole in ambulatory care. RESULTS We included 123 patients. Prevalence of CrAg-positivity was 8.1%. Among the 10 CrAg-positive patients, 6 had meningeal involvement detected through the CSF analysis (CSF India-ink testing, CSF CrAg and culture). The remaining 4 patients with positive CrAg received targeted preemptive treatment with oral fluconazole and were free of cryptococcal disease during the follow-up period. None of the 113 patients with a negative CrAg test result developed cryptococcal disease. CONCLUSIONS This is the first study in Argentina, to our knowledge, describing the prevalence of cryptococcosis and usefulness of CrAg screening. LFA provided early diagnosis to determine a high prevalence of CrAg in our hospital, and that screening for subclinical infection with preemptive antifungal treatment, prevented a substantial proportion of meningeal disease.
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Affiliation(s)
- Claudia Frola
- Service of Infectious Diseases, Juan A. Fernández Hospital, Buenos Aires, Argentina
- Clinical Research Department, Fundación Huésped, Buenos Aires, Argentina
| | - Liliana Guelfand
- Microbiology Laboratory, Juan A. Fernández Hospital, Buenos Aires, Argentina
| | - Gabriela Blugerman
- Service of Infectious Diseases, Juan A. Fernández Hospital, Buenos Aires, Argentina
| | - Edgardo Szyld
- Clinical Research Department, Fundación Huésped, Buenos Aires, Argentina
- Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Sara Kaufman
- Microbiology Laboratory, Juan A. Fernández Hospital, Buenos Aires, Argentina
| | - Pedro Cahn
- Clinical Research Department, Fundación Huésped, Buenos Aires, Argentina
| | - Omar Sued
- Clinical Research Department, Fundación Huésped, Buenos Aires, Argentina
| | - Héctor Pérez
- Service of Infectious Diseases, Juan A. Fernández Hospital, Buenos Aires, Argentina
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28
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Mora DJ, Ferreira-Paim K, Andrade-Silva LE, Bragine T, Rocha IH, Ribeiro BDM, Machado GH, Rodrigues Junior V, Silva-Teixeira DN, Meyer W, Silva-Vergara ML. Cytokine patterns in a prospective cohort of HIV-infected patients with cryptococcal meningitis following initiation of antifungal and antiretroviral therapy. PLoS One 2017; 12:e0176304. [PMID: 28486489 PMCID: PMC5423598 DOI: 10.1371/journal.pone.0176304] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/07/2017] [Indexed: 12/23/2022] Open
Abstract
Cryptococcal meningitis (CM) is a life-threatening infection in HIV-infected patients, especially in resource-limited settings. Cytokine patterns in the cerebrospinal fluid (CSF) and sera may be related to clinical outcomes. This study aimed to evaluate cytokine patterns in the CSF and sera of HIV-infected patients with CM as well as the cytokines produced by peripheral blood mononuclear cells (PBMCs) when stimulated with LPS and cryptococcal GXM. CSF and serum levels of IL-2, IL-4, IL-8, IL-10, IL-12p40, IL-17A, INF-γ, TNF-α and CXCL-10 were measured in HIV-infected patients with CM (CM+ HIV+) at various time points. Cytokine levels were evaluated in the PBMC culture supernatants and the baseline values were compared to those of HIV-infected patients without CM (CM- HIV+) and healthy controls (CM- HIV-). CSF cytokine levels at admission (n = 33) were higher than levels among the 23 survivors at week 2, but statistically significant differences were observed for IL-8 and IFN-γ (p<0.05). CSF and serum levels of IL-4 and IL-17A at week 10 (n = 16) were lower than the baseline values, whereas IL-2 levels increased compared to week 2 (p<0.05). At week 16 (n = 15), CSF and serum levels of IL-4, IL-10 and CXCL-10 were decreased compared to the baseline values (p<0.05). PBMCs from CM- HIV- individuals produced significantly higher levels of proinflammatory cytokines in response to LPS, with the exception of TNF-α, which showed higher levels among CM+ HIV+ patients. The PBMCs of CM patients produced higher levels of IL-4 than those of CM- HIV- patients in response to GXM stimulation, and levels progressively decreased during treatment (p<0.05). Then, a progressive shift in cytokine expression favoring a Th1 pattern was observed, which is crucial in controlling cryptococcal infection. A better understanding of the protective immune response against Cryptococcus neoformans will help to develop novel strategies to improve the outcomes of patients with cryptococcosis.
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Affiliation(s)
- Delio José Mora
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
- * E-mail:
| | - Kennio Ferreira-Paim
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | | | - Thatiane Bragine
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | - Ivonete Helena Rocha
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | - Barbara de Melo Ribeiro
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | | | | | - David Nascimento Silva-Teixeira
- Institute of Health Sciences, Department of Clinical Medicine, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School-Westmead Hospital, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
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Rajasingham R, Smith RM, Park BJ, Jarvis JN, Govender NP, Chiller TM, Denning DW, Loyse A, Boulware DR. Global burden of disease of HIV-associated cryptococcal meningitis: an updated analysis. THE LANCET. INFECTIOUS DISEASES 2017; 17:873-881. [PMID: 28483415 DOI: 10.1016/s1473-3099(17)30243-8] [Citation(s) in RCA: 1288] [Impact Index Per Article: 184.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cryptococcus is the most common cause of meningitis in adults living with HIV in sub-Saharan Africa. Global burden estimates are crucial to guide prevention strategies and to determine treatment needs, and we aimed to provide an updated estimate of global incidence of HIV-associated cryptococcal disease. METHODS We used 2014 Joint UN Programme on HIV and AIDS estimates of adults (aged >15 years) with HIV and antiretroviral therapy (ART) coverage. Estimates of CD4 less than 100 cells per μL, virological failure incidence, and loss to follow-up were from published multinational cohorts in low-income and middle-income countries. We calculated those at risk for cryptococcal infection, specifically those with CD4 less than 100 cells/μL not on ART, and those with CD4 less than 100 cells per μL on ART but lost to follow-up or with virological failure. Cryptococcal antigenaemia prevalence by country was derived from 46 studies globally. Based on cryptococcal antigenaemia prevalence in each country and region, we estimated the annual numbers of people who are developing and dying from cryptococcal meningitis. FINDINGS We estimated an average global cryptococcal antigenaemia prevalence of 6·0% (95% CI 5·8-6·2) among people with a CD4 cell count of less than 100 cells per μL, with 278 000 (95% CI 195 500-340 600) people positive for cryptococcal antigen globally and 223 100 (95% CI 150 600-282 400) incident cases of cryptococcal meningitis globally in 2014. Sub-Saharan Africa accounted for 73% of the estimated cryptococcal meningitis cases in 2014 (162 500 cases [95% CI 113 600-193 900]). Annual global deaths from cryptococcal meningitis were estimated at 181 100 (95% CI 119 400-234 300), with 135 900 (75%; [95% CI 93 900-163 900]) deaths in sub-Saharan Africa. Globally, cryptococcal meningitis was responsible for 15% of AIDS-related deaths (95% CI 10-19). INTERPRETATION Our analysis highlights the substantial ongoing burden of HIV-associated cryptococcal disease, primarily in sub-Saharan Africa. Cryptococcal meningitis is a metric of HIV treatment programme failure; timely HIV testing and rapid linkage to care remain an urgent priority. FUNDING None.
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Affiliation(s)
- Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Rachel M Smith
- Mycotic Diseases Branch, Centers for Disease Control, Atlanta, GA, USA
| | - Benjamin J Park
- Mycotic Diseases Branch, Centers for Disease Control, Atlanta, GA, USA
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA; Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Nelesh P Govender
- National Institute for Communicable Diseases, Center for Healthcare-associated Infections, Antimicrobial Resistance and Mycoses, Johannesburg, South Africa; Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Tom M Chiller
- Mycotic Diseases Branch, Centers for Disease Control, Atlanta, GA, USA
| | - David W Denning
- University of Manchester, Manchester Academic Health Science Centre and the National Aspergillosis Centre, University Hospital of South Manchester, Manchester, UK
| | - Angela Loyse
- Cryptococcal Meningitis Group, Research Centre for Infection and Immunity, Division of Clinical Sciences, St George's University of London, London, UK
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Concha-Velasco F, González-Lagos E, Seas C, Bustamante B. Factors associated with early mycological clearance in HIV-associated cryptococcal meningitis. PLoS One 2017; 12:e0174459. [PMID: 28355252 PMCID: PMC5371305 DOI: 10.1371/journal.pone.0174459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 03/09/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The first-line combination therapy for HIV-associated cryptococcal meningitis (CM), a condition of high mortality particularly in the first two weeks of treatment, consists of amphotericin B plus flucytosine (5-FC). Given that 5-FC remains unavailable in many countries, the knowledge of factors influencing mycological clearance in patients treated with second-line therapy could contribute to effective management. OBJECTIVES To determine the factors associated with the clearance of Cryptococcus sp. from the cerebrospinal fluid by the second week of effective antifungal therapy (early mycological clearance) in HIV-associated CM. METHODS Retrospective cohort study based on secondary data corresponding to HIV-associated CM cases hospitalized at a tertiary health care center in Lima, Peru where 5-FC remains unavailable. Risk factors associated with early mycological clearance were analyzed by generalized linear regression models. RESULTS From January 2000 to December 2013, 234 individuals were discharged with a diagnosis of HIV-associated CM; in 215 we retrieved the required data. The inpatient mortality was 20% (43/215), 15 of them in the first two weeks of treatment. In the final model (157 cases), adjusted for age, previous episode of CM, ART use, type of antifungal treatment, raised intracranial pressure, frequency of therapeutic lumbar punctures, baseline fungal burden and treatment period, the factors associated with early mycological clearance were: Amphotericin B deoxycholate plus fluconazole as combination therapy (RR, 1.56; 95% CI, 1.14-2.14); severe baseline intracranial pressure (≥35 cm H2O) (RR, 0.57; 95% CI, 0.33-0.99); and baseline fungal burden over 4.5 log10 CFU/mL (RR, 0.61 95% CI: 0.39-0.95). CONCLUSIONS In a setting without access to first-line therapy for CM, the combination therapy with amphotericin B deoxycholate plus fluconazole was positively associated with early mycological clearance, while high fungal burden and severe baseline intracranial pressure were negatively associated, and thus related to failure.
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Affiliation(s)
- Fátima Concha-Velasco
- Instituto de Medicina Tropical “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Perú
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Perú
- * E-mail: ,
| | - Elsa González-Lagos
- Instituto de Medicina Tropical “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Perú
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Carlos Seas
- Instituto de Medicina Tropical “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Perú
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Perú
- Departamento de Enfermedades Infecciosas, Tropicales y Dermatológicas, Hospital Cayetano Heredia, Lima, Perú
| | - Beatriz Bustamante
- Instituto de Medicina Tropical “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Perú
- Departamento de Enfermedades Infecciosas, Tropicales y Dermatológicas, Hospital Cayetano Heredia, Lima, Perú
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Ferreira-Paim K, Andrade-Silva L, Fonseca FM, Ferreira TB, Mora DJ, Andrade-Silva J, Khan A, Dao A, Reis EC, Almeida MTG, Maltos A, Junior VR, Trilles L, Rickerts V, Chindamporn A, Sykes JE, Cogliati M, Nielsen K, Boekhout T, Fisher M, Kwon-Chung J, Engelthaler DM, Lazéra M, Meyer W, Silva-Vergara ML. MLST-Based Population Genetic Analysis in a Global Context Reveals Clonality amongst Cryptococcus neoformans var. grubii VNI Isolates from HIV Patients in Southeastern Brazil. PLoS Negl Trop Dis 2017; 11:e0005223. [PMID: 28099434 PMCID: PMC5242430 DOI: 10.1371/journal.pntd.0005223] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 12/01/2016] [Indexed: 12/16/2022] Open
Abstract
Cryptococcosis is an important fungal infection in immunocompromised individuals, especially those infected with HIV. In Brazil, despite the free availability of antiretroviral therapy (ART) in the public health system, the mortality rate due to Cryptococcus neoformans meningitis is still high. To obtain a more detailed picture of the population genetic structure of this species in southeast Brazil, we studied 108 clinical isolates from 101 patients and 35 environmental isolates. Among the patients, 59% had a fatal outcome mainly in HIV-positive male patients. All the isolates were found to be C. neoformans var. grubii major molecular type VNI and mating type locus alpha. Twelve were identified as diploid by flow cytometry, being homozygous (AαAα) for the mating type and by PCR screening of the STE20, GPA1, and PAK1 genes. Using the ISHAM consensus multilocus sequence typing (MLST) scheme, 13 sequence types (ST) were identified, with one being newly described. ST93 was identified from 81 (75%) of the clinical isolates, while ST77 and ST93 were identified from 19 (54%) and 10 (29%) environmental isolates, respectively. The southeastern Brazilian isolates had an overwhelming clonal population structure. When compared with populations from different continents based on data extracted from the ISHAM-MLST database (mlst.mycologylab.org) they showed less genetic variability. Two main clusters within C. neoformans var. grubii VNI were identified that diverged from VNB around 0.58 to 4.8 million years ago. The members of the Cryptococcus neoformans / Cryptococcus gattii species complex are the cause of cryptococcosis, a life-threatening human disease responsible for 624,000 deaths annually. Infection is acquired through inhalation of dehydrated yeast cells from environmental sources. After reaching the lungs, the fungus disseminates to the central nervous system causing meningoencephalitis. The majority of meningitis cases in HIV-infected patients are caused by C. neoformans, a species well studied in regions with a high prevalence of HIV infection, such as Asia and Africa. A similar high prevalence has been reported from Brazil however the epidemiology of these infections is less well understood. We studied clinical and environmental isolates from the southeast region of Brazil using MLST. The results that we obtained showed a clonal population structure of C. neoformans var. grubii VNI, with low variability when compared against populations from different continents. This lower variability is probably the result of multiple recent dispersal events from Africa to the Americas. The majority of clinical isolates were of one sequence type (ST93), which was also found in environmental samples. By expanding the analysis to isolates from around the globe, it was possible to identify two major groups among C. neoformans var. grubii VNI.
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Affiliation(s)
- Kennio Ferreira-Paim
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School-Westmead Hospital, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
- Infectious Disease Department, Triangulo Mineiro Federal University, Uberaba, Brazil
| | | | | | - Thatiana B. Ferreira
- Infectious Disease Department, Triangulo Mineiro Federal University, Uberaba, Brazil
| | - Delio J. Mora
- Infectious Disease Department, Triangulo Mineiro Federal University, Uberaba, Brazil
| | - Juliana Andrade-Silva
- Infectious Disease Department, Triangulo Mineiro Federal University, Uberaba, Brazil
| | - Aziza Khan
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School-Westmead Hospital, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
| | - Aiken Dao
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School-Westmead Hospital, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
| | - Eduardo C. Reis
- Infectious Disease Department, Faculty of Medicine of São José do Rio Preto, São José do Rio Preto, Brazil
| | - Margarete T. G. Almeida
- Infectious Disease Department, Faculty of Medicine of São José do Rio Preto, São José do Rio Preto, Brazil
| | - Andre Maltos
- Infectious Disease Department, Triangulo Mineiro Federal University, Uberaba, Brazil
| | - Virmondes R. Junior
- Infectious Disease Department, Triangulo Mineiro Federal University, Uberaba, Brazil
| | - Luciana Trilles
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Ariya Chindamporn
- Mycology Unit, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jane E. Sykes
- Department of Medicine and Epidemiology, University of California, Davis, United States of America
| | - Massimo Cogliati
- Laboratorio Micologia Medica, Dip. Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy
| | - Kirsten Nielsen
- Department of Microbiology and Immunology, Medical School, University of Minnesota, Minneapolis, Mississippi, United States of America
| | - Teun Boekhout
- Department of Yeast and Basidiomycete Research, CBS-KNAW Fungal Biodiversity Centre, Utrecht, The Netherlands
| | - Matthew Fisher
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, United Kingdom
| | - June Kwon-Chung
- Molecular Microbiology Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, Maryland, United States of America
| | - David M. Engelthaler
- Translational Genomics Research Institute, Flagstaff, Arizona, United States of America
| | - Marcia Lazéra
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School-Westmead Hospital, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
- * E-mail:
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Srichatrapimuk S, Sungkanuparph S. Integrated therapy for HIV and cryptococcosis. AIDS Res Ther 2016; 13:42. [PMID: 27906037 PMCID: PMC5127046 DOI: 10.1186/s12981-016-0126-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/16/2016] [Indexed: 12/27/2022] Open
Abstract
Cryptococcosis has been one of the most common opportunistic infections and causes of mortality among HIV-infected patients, especially in resource-limited countries. Cryptococcal meningitis is the most common form of cryptococcosis. Laboratory diagnosis of cryptococcosis includes direct microscopic examination, isolation of Cryptococcus from a clinical specimen, and detection of cryptococcal antigen. Without appropriate treatment, cryptococcosis is fatal. Early diagnosis and treatment is the key to treatment success. Treatment of cryptococcosis consists of three main aspects: antifungal therapy, intracranial pressure management for cryptococcal meningitis, and restoration of immune function with antiretroviral therapy (ART). Optimal integration of these three aspects is crucial to achieving successful treatment and reducing the mortality. Antifungal therapy consists of three phases: induction, consolidation, and maintenance. A combination of two drugs, i.e. amphotericin B plus flucytosine or fluconazole, is preferred in the induction phase. Fluconazole monotherapy is recommended during consolidation and maintenance phases. In cryptococcal meningitis, intracranial pressure rises along with CSF fungal burden and is associated with morbidity and mortality. Aggressive control of intracranial pressure should be done. Management options include therapeutic lumbar puncture, lumbar drain insertion, ventriculostomy, or ventriculoperitoneal shunt. Medical treatment such as corticosteroids, mannitol, and acetazolamide are ineffective and should not be used. ART has proven to have a great impact on survival rates among HIV-infected patients with cryptococcosis. The time to start ART in HIV-infected patients with cryptococcosis has to be deferred until 5 weeks after the start of antifungal therapy. In general, any effective ART regimen is acceptable. Potential drug interactions between antiretroviral agents and amphotericin B, flucytosine, and fluconazole are minimal. Of most potential clinical relevance is the concomitant use of fluconazole and nevirapine. Concomitant use of these two drugs should be cautious, and patients should be monitored closely for nevirapine-associated adverse events, including hepatotoxicity. Overlapping toxicities of antifungal and antiretroviral drugs and immune reconstitution inflammatory syndrome are not uncommon. Early recognition and appropriate management of these consequences can reinforce the successful integrated therapy in HIV-infected patients with cryptococcosis.
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Vidal JE, Toniolo C, Paulino A, Colombo A, Dos Anjos Martins M, da Silva Meira C, Pereira-Chioccola VL, Figueiredo-Mello C, Barros T, Duarte J, Fonseca F, Alves Cunha M, Mendes C, Ribero T, Dos Santos Lazera M, Rajasingham R, Boulware DR. Asymptomatic cryptococcal antigen prevalence detected by lateral flow assay in hospitalised HIV-infected patients in São Paulo, Brazil. Trop Med Int Health 2016; 21:1539-1544. [PMID: 27699970 DOI: 10.1111/tmi.12790] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the prevalence of asymptomatic cryptococcal antigen (CRAG) using lateral flow assay (LFA) in hospitalised HIV-infected patients with CD4 counts <200 cells/μl. METHODS Hospitalised HIV-infected patients were prospectively recruited at Instituto de Infectologia Emilio Ribas, a tertiary referral hospital to HIV-infected patients serving the São Paulo State, Brazil. All patients were >18 years old without prior cryptococcal meningitis, without clinical suspicion of cryptococcal meningitis, regardless of antiretroviral (ART) status, and with CD4 counts <200 cells/μl. Serum CRAG was tested by LFA in all patients, and whole blood CRAG was tested by LFA in positive cases. RESULTS We enrolled 163 participants of whom 61% were men. The duration of HIV diagnosis was a median of 8 (range, 1-29) years. 26% were antiretroviral (ART)-naïve, and 74% were ART-experienced. The median CD4 cell count was 25 (range, 1-192) cells/μl. Five patients (3.1%; 95%CI, 1.0-7.0%) were asymptomatic CRAG-positive. Positive results cases were cross-verified by performing LFA in whole blood. CONCLUSIONS 3.1% of HIV-infected inpatients with CD4 <200 cells/μl without symptomatic meningitis had cryptococcal antigenemia in São Paulo, suggesting that routine CRAG screening may be beneficial in similar settings in South America. Our study reveals another targeted population for CRAG screening: hospitalised HIV-infected patients with CD4 <200 cells/μl, regardless of ART status. Whole blood CRAG LFA screening seems to be a simple strategy to prevention of symptomatic meningitis.
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Affiliation(s)
- José E Vidal
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil.,Faculdade de Medicina, Hospital das Clínicas, da Universidade de São Paulo, São Paulo, Brazil.,Instituto de Medicina Tropical da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | - Claudia Figueiredo-Mello
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Tiago Barros
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
| | | | | | | | - Clara Mendes
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
| | - Taiana Ribero
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
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Torres RG, Etchebehere RM, Adad SJ, Micheletti AR, Ribeiro BDM, Silva LEA, Mora DJ, Paim KF, Silva-Vergara ML. Cryptococcosis in Acquired Immunodeficiency Syndrome Patients Clinically Confirmed and/or Diagnosed at Necropsy in a Teaching Hospital in Brazil. Am J Trop Med Hyg 2016; 95:781-785. [PMID: 27458037 DOI: 10.4269/ajtmh.16-0148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/14/2016] [Indexed: 11/07/2022] Open
Abstract
Cryptococcosis occurs in acquired immunodeficiency syndrome (AIDS) patients with poor compliance to antiretroviral therapy or unaware of their human immunodeficiency virus status who present severe immunosuppression at admission. Consequently, high mortality rates are observed due to disseminated fungal infection. This report presents clinical and postmortem data of AIDS patients with cryptococcosis in a teaching hospital in Brazil. Retrospectively, medical and necropsy records of AIDS patients with cryptococcosis clinically confirmed and/or postmortem verified were reviewed. Clinical data were compared with those of patients presenting a good outcome to evaluate disseminated fungal infection and the agreement between clinical and postmortem diagnosis. At admission, most of the 45 patients with cryptococcal meningitis who died, presented more altered consciousness (P = 0.0047), intracranial increased pressure (P = 0.047), and severe malnutrition (P = 0.0006) than the survivors. Of 29 (64.4%) patients with cryptococcal meningitis, 23 died before week 2 on antifungal therapy, and the other six during the next 3 months. The remaining 16 (35.6%) cases had other diagnoses and died soon after. At necropsy, 31 (68.9%) presented disseminated infection involving two or more organs, whereas 14 (31.1%) cases had meningeal or pulmonary localized infection. The agreement of 64.4% between clinical and postmortem diagnosis was similar to some studies. However, other reports have shown figures ranging from 34% to 95%. Currently, a progressive worldwide decrease of autopsies is worrying because the role of postmortem examination is pivotal to verify or identify the death causes, which contributes to improve the quality of clinical diagnosis and medical training.
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Affiliation(s)
- Rafael Garcia Torres
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Minas Gerais, Brazil
| | | | - Sheila Jorge Adad
- Discipline of Special Pathology, Triângulo Mineiro Federal University, Minas Gerais, Brazil
| | - Adilha Rua Micheletti
- Discipline of Special Pathology, Triângulo Mineiro Federal University, Minas Gerais, Brazil
| | | | | | - Delio Jose Mora
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Minas Gerais, Brazil
| | - Kennio Ferreira Paim
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Minas Gerais, Brazil
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Samantaray S, Correia JN, Garelnabi M, Voelz K, May RC, Hall RA. Novel cell-based in vitro screen to identify small-molecule inhibitors against intracellular replication of Cryptococcus neoformans in macrophages. Int J Antimicrob Agents 2016; 48:69-77. [PMID: 27289450 PMCID: PMC4942879 DOI: 10.1016/j.ijantimicag.2016.04.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/07/2016] [Accepted: 04/16/2016] [Indexed: 01/08/2023]
Abstract
The fungal pathogen Cryptococcus neoformans poses a major threat to immunocompromised patients and is a leading killer of human immunodeficiency virus (HIV)-infected patients worldwide. Cryptococci are known to manipulate host macrophages and can either remain latent or proliferate intracellularly within the host phagocyte, a favourable niche that also renders them relatively insensitive to antifungal agents. Here we report an attempt to address this limitation by using a fluorescence-based drug screening method to identify potential inhibitors of intracellular proliferation of C. neoformans. The Prestwick Chemical Library(®) of FDA-approved small molecules was screened for compounds that limit the intracellular replication of a fluorescently-tagged C. neoformans reference strain (H99-GFP) in macrophages. Preliminary screening revealed 19 of 1200 compounds that could significantly reduce intracellular growth of the pathogen. Secondary screening and host cell cytotoxicity assays highlighted fendiline hydrochloride as a potential drug candidate for the development of future anticryptococcal therapies. Live cell imaging demonstrated that this Ca(2+) channel blocker strongly enhanced phagosome maturation in macrophages leading to improved fungal killing and reduced intracellular replication. Whilst the relatively high dose of fendiline hydrochloride required renders it unfit for clinical deployment against cryptococcosis, this study highlights a novel approach for identifying new lead compounds and unravels a pharmacologically promising scaffold towards the development of novel antifungal therapies for this neglected disease.
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Affiliation(s)
- Sweta Samantaray
- Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK
| | - Joao N Correia
- Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK
| | - Mariam Garelnabi
- Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK
| | - Kerstin Voelz
- Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK
| | - Robin C May
- Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK.
| | - Rebecca A Hall
- Institute of Microbiology and Infection, School of Biosciences, University of Birmingham, Birmingham, UK.
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Vidal JE. Preemptive Therapy for Cryptococcal Meningitis: A Valid Strategy for Latin America? J Fungi (Basel) 2016; 2:jof2020014. [PMID: 29376931 PMCID: PMC5753076 DOI: 10.3390/jof2020014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/11/2016] [Accepted: 05/16/2016] [Indexed: 11/16/2022] Open
Abstract
AIDS-related cryptococcal meningitis continues to cause a substantial burden of death in low and middle income countries. Better diagnostics allow detection of cryptococcosis in the asymptomatic phase and using these technologies to screen at-risk persons would likely reduce mortality. The World Health Organization recommends cryptococcal antigen screening among populations with a prevalence of cryptococcal antigenaemia (CRAG) > 3%. There is scarce data about CRAG prevalence in Latin America. Four studies (only one published as a full text) showed asymptomatic CRAG prevalence between 2.7% and 6.2% in several sub-sets of HIV-infected patients. The CRAG lateral flow assay (LFA) has several advantages over other techniques for actual implementation of a screening program. Although more studies are necessary to confirm available data, implementation of the CRAG screening strategy seems to be opportune in Latin America.
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Affiliation(s)
- José E Vidal
- Department of Neurology; Emilio Ribas Institute of Infectious Diseases; Av Doutor Arnaldo 165, Cerqueira César, São Paulo, CEP 05411-000, Brazil.
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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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Kumari S, Verma RK, Singh DP, Yadav R. Comparison of Antigen Detection and Nested PCR in CSF Samples of HIV Positive and Negative Patients with Suspected Cryptococcal Meningitis in a Tertiary Care Hospital. J Clin Diagn Res 2016; 10:DC12-5. [PMID: 27190801 DOI: 10.7860/jcdr/2016/18322.7619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/11/2016] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The cases of cryptococcal meningitis and other forms of cryptococcosis have increased in recent time and the present scenario of the condition with significant morbidity and mortality is actually posing a serious threat to the community, so an early and prompt diagnosis is necessary to prevent serious complications and thus improving the overall disease outcome. AIM Comparison of diagnostic efficacy of nested Polymerase Chain Reaction (PCR) with Latex Agglutination Test (LAT) in the Cerebro Spinal Fluid (CSF) samples of the cases of meningitis in HIV positive and negative cases. MATERIALS AND METHODS We have compared the diagnostic efficacy of Latex Agglutination Test (LAT) with nested Polymerase Chain Reaction (PCR) in 200 Cerebrospinal Fluid (CSF) samples, including 14 HIV positive also, in the cases of suspected cryptococcal meningitis. Nested PCR was done in all cases reporting positive by LAT and results were then compared with that of India ink and culture on Sabouraud Dextrose Agar (SDA), and the isolates were further identified by urease, nitrate and sugar assimilation tests. RESULTS Of the 200 cases, including 14 HIV positive, LAT was positive in 46 cases while 154 were negative. Out of these 46 LAT positive cases, nested PCR was positive in 40 cases only, while culture and India ink was positive in 38 and 33 cases respectively. Majority of the cases, 30 (65.2%) were between age group 21-50 years, while 2 (4.3%) in 0-20, and 14 (30.4%) in 51-80 years age group. CONCLUSION Although negative staining like India ink and nigrosin are most widely used techniques, but these suffer with subjective error. Rapid method like LAT is available but it always has the scope of false positive and negative results. In such cases nested PCR can help in establishing final diagnosis.
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Affiliation(s)
- Sunita Kumari
- Lecturer, Department of Microbiology, UPRIMS & R , Saifai, Etawah, (UP), India
| | - Rajesh Kumar Verma
- Associate Professor, Department of Microbiology, UPRIMS & R , Saifai, Etawah, (UP), India
| | | | - Ramakant Yadav
- Professor, Department of Neurology, UPRIMS & R , Saifai, Etawah, (UP), India
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Vidal JE, Boulware DR. LATERAL FLOW ASSAY FOR CRYPTOCOCCAL ANTIGEN: AN IMPORTANT ADVANCE TO IMPROVE THE CONTINUUM OF HIV CARE AND REDUCE CRYPTOCOCCAL MENINGITIS-RELATED MORTALITY. Rev Inst Med Trop Sao Paulo 2015; 57 Suppl 19:38-45. [PMID: 26465368 PMCID: PMC4711197 DOI: 10.1590/s0036-46652015000700008] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
AIDS-related cryptococcal meningitis continues to cause a substantial burden of death in low and middle income countries. The diagnostic use for detection of cryptococcal capsular polysaccharide antigen (CrAg) in serum and cerebrospinal fluid by latex agglutination test (CrAg-latex) or enzyme-linked immunoassay (EIA) has been available for over decades. Better diagnostics in asymptomatic and symptomatic phases of cryptococcosis are key components to reduce mortality. Recently, the cryptococcal antigen lateral flow assay (CrAg LFA) was included in the armamentarium for diagnosis. Unlike the other tests, the CrAg LFA is a dipstick immunochromatographic assay, in a format similar to the home pregnancy test, and requires little or no lab infrastructure. This test meets all of the World Health Organization ASSURED criteria (Affordable, Sensitive, Specific, User friendly, Rapid/robust, Equipment-free, and Delivered). CrAg LFA in serum, plasma, whole blood, or cerebrospinal fluid is useful for the diagnosis of disease caused by Cryptococcus species. The CrAg LFA has better analytical sensitivity for C. gattii than CrAg-latex or EIA. Prevention of cryptococcal disease is new application of CrAg LFA via screening of blood for subclinical infection in asymptomatic HIV-infected persons with CD4 counts < 100 cells/mL who are not receiving effective antiretroviral therapy. CrAg screening of leftover plasma specimens after CD4 testing can identify persons with asymptomatic infection who urgently require pre-emptive fluconazole, who will otherwise progress to symptomatic infection and/or die.
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Affiliation(s)
- Jose E Vidal
- Instituto de Infectologia Emílio Ribas, São Paulo, SP, Brasil
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Yao Y, Zhang JT, Yan B, Gao T, Xing XW, Tian CL, Huang XS, Yu SY. Voriconazole: a novel treatment option for cryptococcal meningitis. Infect Dis (Lond) 2015; 47:694-700. [PMID: 26100526 DOI: 10.3109/23744235.2015.1044260] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a relatively common opportunistic infection in patients with human immunodeficiency virus (HIV) infection and can also occur in patients with no underlying disease. The aim of this study was to evaluate the clinical manifestations, laboratory findings, diagnosis and misdiagnosis, treatment, and prognosis of CM at a tertiary care hospital. METHODS We performed a retrospective study of 55 patients at a tertiary care hospital from January 1, 1992 to December 31, 2013. All the patients had a definite diagnosis based on etiology. RESULTS All 55 patients had a positive cerebrospinal fluid (CSF) India ink staining result. The predominant change observed on magnetic resonance imaging (MRI) was leptomeningeal liner enhancement, which is also called 'lumbriciform-enhancing.' Only 15 patients were first diagnosed with CM, indicating a misdiagnosis rate of 72.7%. At the follow-up end point, 8 patients were cured, 33 had improved, and 14 had died. The overall response rate was 74.5%. The voriconazole group had a response rate of 100%, which was significantly higher than the other two groups. CONCLUSIONS Most CM patients in China were previously healthy without any potential risk factors. CM was easily misdiagnosed due to the lack of specificity of early clinical symptoms. Repeated CSF India ink staining should be performed to identify the pathogen. Voriconazole could be administered to the patients with CM, especially to patients who had a treatment failure with amphotericin B alone or accompanied by fluconazole.
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Affiliation(s)
- Yan Yao
- From the Department of Neurology, General Hospital of the People's Liberation Army , Beijing , China
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Mora DJ, Fortunato LR, Andrade-Silva LE, Ferreira-Paim K, Rocha IH, Vasconcelos RR, Silva-Teixeira DN, Nascentes GAN, Silva-Vergara ML. Cytokine profiles at admission can be related to outcome in AIDS patients with cryptococcal meningitis. PLoS One 2015; 10:e0120297. [PMID: 25799044 PMCID: PMC4370646 DOI: 10.1371/journal.pone.0120297] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/27/2015] [Indexed: 01/12/2023] Open
Abstract
Cryptococcal meningitis (CM) remains as common life-threatening AIDS-defining illness mainly in resource-limited settings. Previous reports suggested that baseline cytokine profiles can be associated to fungal burden and clinical outcome. This study aimed to evaluate the baseline cytokine profiles in AIDS patients with CM and its relation with the outcome at weeks 2 and 10. Thirty AIDS patients with CM diagnosed by cerebrospinal fluid (CSF) Cryptococcus neoformans positive culture, India ink stain and cryptococcal antigen test were prospectively evaluated. As controls, 56 HIV-infected patients without CM and 48 non-HIV individuals were included. Baseline CSF and sera levels of IL-2, IL-4, IL-8, IL-10, IL-12p40, IL-17A, INF-γ and TNF-α were measured by ELISA. Of 30 CM patients, 24 (80%) were male, median age of 38.1. The baseline CSF high fungal burden and positive blood culture were associated with a positive CSF culture at week 2 (p = 0.043 and 0.029). Most CSF and sera cytokines presented higher levels in CM patients than control subjects (p < 0.05). CSF levels of IL-8, IL-12p40, IL-17A, TNF-α, INF-γ and sera TNF-α were significantly higher among survivors at weeks 2 and 10 (p < 0.05). Patients with increased intracranial pression exhibited CSF IL-10 high levels and poor outcome at week 10 (p = 0.032). Otherwise, baseline CSF log10 IFN-γ and IL-17A were negatively correlated with fungal burden (r = -0.47 and -0.50; p = 0.0175 and 0.0094, respectively). The mortality rate was 33% (10/30) at week 2 and 57% (17/30) at week 10. The severity of CM and the advanced immunodeficiency at admission were related to a poor outcome in these patients. Otherwise, the predominant Th1 cytokines profile among survivors confirms its pivotal role to infection control and would be a prognostic marker in cryptococcal meningitis.
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Affiliation(s)
- Delio José Mora
- Infectious Diseases Unit, Internal Medicine Department, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
- * E-mail: (MLS-V); (DJM)
| | - Laila Rigolin Fortunato
- Infectious Diseases Unit, Internal Medicine Department, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | | | - Kennio Ferreira-Paim
- Infectious Diseases Unit, Internal Medicine Department, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | - Ivonete Helena Rocha
- Infectious Diseases Unit, Internal Medicine Department, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | - Rakel Rocha Vasconcelos
- Infectious Diseases Unit, Internal Medicine Department, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | | | | | - Mario León Silva-Vergara
- Infectious Diseases Unit, Internal Medicine Department, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
- * E-mail: (MLS-V); (DJM)
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Martins MDA, Brighente KBS, Matos TAD, Vidal JE, Hipólito DDCD, Pereira-Chioccola VL. Molecular diagnosis of cryptococcal meningitis in cerebrospinal fluid: comparison of primer sets for Cryptococcus neoformans and Cryptococcus gattii species complex. Braz J Infect Dis 2014; 19:62-7. [PMID: 25523072 PMCID: PMC9425233 DOI: 10.1016/j.bjid.2014.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 09/18/2014] [Accepted: 09/19/2014] [Indexed: 11/25/2022] Open
Abstract
Aim This study evaluated the use of polymerase chain reaction for cryptococcal meningitis diagnosis in clinical samples. Materials and methods The sensitivity and specificity of the methodology were evaluated using eight Cryptococcus neoformans/C. gattii species complex reference strains and 165 cerebrospinal fluid samples from patients with neurological diseases divided into two groups: 96 patients with cryptococcal meningitis and AIDS; and 69 patients with other neurological opportunistic diseases (CRL/AIDS). Two primer sets were tested (CN4–CN5 and the multiplex CNa70S–CNa70A/CNb49S–CNb-49A that amplify a specific product for C. neoformans and another for C. gattii). Results CN4–CN5 primer set was positive in all Cryptococcus standard strains and in 94.8% in DNA samples from cryptococcal meningitis and AIDS group. With the multiplex, no 448-bp product of C. gattii was observed in the clinical samples of either group. The 695 bp products of C. neoformans were observed only in 64.6% of the cryptococcal meningitis and AIDS group. This primer set was negative for two standard strains. The specificity based on the negative samples from the CTL/AIDS group was 98.5% in both primer sets. Conclusions These data suggest that the CN4/CN5 primer set was highly sensitive for the identification of C. neoformans/C. gattii species complex in cerebrospinal fluid samples from patients with clinical suspicion of cryptococcal meningitis.
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Affiliation(s)
- Marilena dos Anjos Martins
- Laboratório de Biologia Molecular de Parasitas e Fungos, Instituto Adolfo Lutz, Sao Paulo, SP, Brazil; Núcleo de Micologia, Instituto Adolfo Lutz, Sao Paulo, SP, Brazil
| | | | | | - Jose Ernesto Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, Sao Paulo, SP, Brazil
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de Oliveira RB, Atobe JH, Souza SA, de Castro Lima Santos DW. Epidemiology of Invasive Fungal Infections in Patients with Acquired Immunodeficiency Syndrome at a Reference Hospital for Infectious Diseases in Brazil. Mycopathologia 2014; 178:71-8. [DOI: 10.1007/s11046-014-9755-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 05/02/2014] [Indexed: 10/25/2022]
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Wen Y, Zhou Y, Wang W, Wang Y, Lu X, Sun CM, Cui W, Liu J, Geng WQ, Shang H, Liu P. Baseline factors associated with mortality within six months after admission among hospitalized HIV-1 patients in Shenyang, China. Intern Med 2014; 53:2455-61. [PMID: 25366003 DOI: 10.2169/internalmedicine.53.2502] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Short-term mortality rates remain high among critically ill human immunodeficiency virus-1 (HIV-1) patients though long-term mortality rates have dropped. Baseline risk factors for short-term mortality have not yet been determined in China. In this paper, we herein describe clinical characteristics, laboratory findings, causes of clinical deterioration, and risk factors associated with mortality among HIV-1 patients within six months after hospital admission. METHODS We carried out a prospective study of hospitalized patients in advanced stages of HIV infection. These patients started antiretroviral therapy three or four weeks after admission. Follow-up was conducted for a period of six months. We used a multivariate logistic-regression analysis to identify risk factors associated with mortality. RESULTS A total of 141 patients met our inclusion criteria. The mean age was 41 years. Fever and weight loss were the most common clinical manifestations of advanced HIV disease. Oral candidiasis, tuberculosis, cytomegaloviremia, and pneumocystis pneumonia were the most common opportunistic infections. Significantly decreased CD4+ T-cell counts, hypoalbuminemia, anemia, hyponatremia, as well as elevated C-reactive protein (CRP) and glutamic alanine transaminase levels were common laboratory test abnormalities. The mortality rate was 21.3%. The patients who died were more likely than the survivors to have low CD4+ T-cell counts as well as low creatinine, hemoglobin, albumin, and serum sodium levels while also having longer intervals of fever and higher CRP levels. A multivariate analysis demonstrated that the independent risk factors for mortality were active tuberculosis [odds ratio (OR): 2.681; 95% confidence interval (CI), 1.006-7.142; p=0.049], hyponatremia (OR: 3.027; 95% CI, 1.238-7.401; p=0.015), and being at clinical stage 4 (as defined by the World Health Organization) (OR: 9.492; 95% CI, 1.200-75.065; p=0.033) within the first six months of admission. CONCLUSION Special consideration should be given to patients who have active tuberculosis, are at clinical stage 4, and present with hyponatremia upon admission as these were found to be important factors associated with mortality within six months of hospital admission in HIV-1 patients.
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Affiliation(s)
- Ying Wen
- Department of Infectious Diseases, The First Affiliated Hospital, China Medical University, China
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