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Zhan B, Wei W, Xie Z, Meng S, Bao X, He X, Xie X, Zhang M, Ye L, Jiang J, Yang S, Liang H. Machine learning-based prognostic prediction for hospitalized HIV/AIDS patients with cryptococcus infection in Guangxi, China. BMC Infect Dis 2024; 24:1121. [PMID: 39379851 PMCID: PMC11459777 DOI: 10.1186/s12879-024-10013-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 09/27/2024] [Indexed: 10/10/2024] Open
Abstract
OBJECTIVE To develop and validate a machine learning model for predicting mortality-associated prognostic factors in order to reduce in-hospital mortality rates among HIV/AIDS patients with Cryptococcus infection in Guangxi, China. METHODS This retrospective prognostic study included HIV/AIDS patients with cryptococcosis in the Fourth People's Hospital of Nanning from October 2011 to June 2019. Clinical features were extracted and used to train ten machine learning models, including Logistic Regression, KNN, DT, RF, Adaboost, Xgboost, LightGBM, Catboost, SVM, and NBM, to predict the outcome of HIV patients with cryptococcosis infection. The sensitivity, specificity, AUC, and F1 value were applied to assess model performance in both the testing and training sets. The optimal model was selected and interpreted. RESULTS A total of 396 patients were included in the study. The average in-hospital mortality of HIV/AIDS patients with cryptococcosis was 12.9% from 2012 to 2019. After feature screening, 20 clinical features were selected for model construction, accounting for 93.8%, including ART, Electrolyte disorder, Anemia, and 17 laboratory tests. The RF model (AUC 0.9787, Sensitivity 0.9535, Specificity 0.8889, F1 0.7455) and the SVM model (AUC 0.9286, Sensitivity 0.7907, Specificity 0.9786, F1 0.8293) had excellent performance. The SHAP analysis showed that the primary risk factors for prognosis prediction were identified as BUN/CREA, Electrolyte disorder, NEUT%, Urea, and IBIL. CONCLUSIONS RF and SVM machine learning models have shown promising predictive abilities for the prognosis of hospitalized HIV/AIDS patients with cryptococcosis, which can aid clinical assessment and treatment decisions for patient prognosis.
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Affiliation(s)
- Baili Zhan
- Guangxi-ASEAN Collaborative Innovation Center for Major Disease Prevention and Treatment, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, China
| | - Wudi Wei
- Guangxi-ASEAN Collaborative Innovation Center for Major Disease Prevention and Treatment, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, China
- Joint Laboratory for Emerging Infectious Diseases in China (Guangxi)-ASEAN, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Zhiman Xie
- The Fouth People's Hospital of Nanning, Nanning, Guangxi, 530021, China
| | - Sirun Meng
- The Fouth People's Hospital of Nanning, Nanning, Guangxi, 530021, China
| | - Xiuli Bao
- Guangxi Key Laboratory of AlDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Xiaotao He
- Guangxi Key Laboratory of AlDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Xiaoting Xie
- Guangxi Key Laboratory of AlDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Meng Zhang
- Guangxi-ASEAN Collaborative Innovation Center for Major Disease Prevention and Treatment, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, China
| | - Li Ye
- Guangxi Key Laboratory of AlDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China.
- Joint Laboratory for Emerging Infectious Diseases in China (Guangxi)-ASEAN, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China.
| | - Junjun Jiang
- Guangxi-ASEAN Collaborative Innovation Center for Major Disease Prevention and Treatment, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, China.
- Joint Laboratory for Emerging Infectious Diseases in China (Guangxi)-ASEAN, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China.
| | - Shixiong Yang
- The Fouth People's Hospital of Nanning, Nanning, Guangxi, 530021, China.
| | - Hao Liang
- Guangxi-ASEAN Collaborative Innovation Center for Major Disease Prevention and Treatment, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, China.
- Joint Laboratory for Emerging Infectious Diseases in China (Guangxi)-ASEAN, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China.
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Dao A, Kim HY, Garnham K, Kidd S, Sati H, Perfect J, Sorrell TC, Harrison T, Rickerts V, Gigante V, Alastruey-Izquierdo A, Alffenaar JW, Morrissey CO, Chen SCA, Beardsley J. Cryptococcosis-a systematic review to inform the World Health Organization Fungal Priority Pathogens List. Med Mycol 2024; 62:myae043. [PMID: 38935902 PMCID: PMC11210623 DOI: 10.1093/mmy/myae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/01/2023] [Accepted: 04/27/2024] [Indexed: 06/29/2024] Open
Abstract
Cryptococcosis causes a high burden of disease worldwide. This systematic review summarizes the literature on Cryptococcus neoformans and C. gattii infections to inform the World Health Organization's first Fungal Priority Pathogen List. PubMed and Web of Science were used to identify studies reporting on annual incidence, mortality, morbidity, antifungal resistance, preventability, and distribution/emergence in the past 10 years. Mortality rates due to C. neoformans were 41%-61%. Complications included acute renal impairment, raised intracranial pressure needing shunts, and blindness. There was moderate evidence of reduced susceptibility (MIC range 16-32 mg/l) of C. neoformans to fluconazole, itraconazole, ketoconazole, voriconazole, and amphotericin B. Cryptococcus gattii infections comprised 11%-33% of all cases of invasive cryptococcosis globally. The mortality rates were 10%-23% for central nervous system (CNS) and pulmonary infections, and ∼43% for bloodstream infections. Complications described included neurological sequelae (17%-27% in C. gattii infections) and immune reconstitution inflammatory syndrome. MICs were generally low for amphotericin B (MICs: 0.25-0.5 mg/l), 5-flucytosine (MIC range: 0.5-2 mg/l), itraconazole, posaconazole, and voriconazole (MIC range: 0.06-0.5 mg/l). There is a need for increased surveillance of disease phenotype and outcome, long-term disability, and drug susceptibility to inform robust estimates of disease burden.
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Affiliation(s)
- Aiken Dao
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, Australia
- Westmead Institute for Medical Research, Westmead, Sydney, Australia
- Westmead Clinical School, Westmead Hospital, Sydney, Australia
| | - Hannah Yejin Kim
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Department of Pharmacy, Westmead Hospital, Westmead, Australia
| | - Katherine Garnham
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, Australia
- Sunshine Coast University Hospital, Birtinya, Qld 4575, Australia
| | - Sarah Kidd
- National Mycology Reference Centre, Microbiology and Infectious Diseases, SA Pathology, Adelaide, Australia
| | - Hatim Sati
- AMR Division, World Health Organization, Geneva, Switzerland
| | | | - Tania C Sorrell
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, Australia
- Westmead Institute for Medical Research, Westmead, Sydney, Australia
- Westmead Clinical School, Westmead Hospital, Sydney, Australia
| | - Thomas Harrison
- Institute of Infection and Immunity, St George’s University London, London, UK
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK
| | | | - Valeria Gigante
- AMR Division, World Health Organization, Geneva, Switzerland
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, Australia
- Westmead Clinical School, Westmead Hospital, Sydney, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - C Orla Morrissey
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
- Monash University, Department of Infectious Diseases, Melbourne, Victoria, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Westmead, Sydney, Australia
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, Australia
- Westmead Institute for Medical Research, Westmead, Sydney, Australia
- Westmead Clinical School, Westmead Hospital, Sydney, Australia
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3
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Miwa T, Okamoto K, Ikeuchi K, Yamamoto S, Okugawa S, Ichida A, Akamatsu N, Hasegawa K, Tsutsumi T. The Role of Frequent Screening or Diagnostic Testing of Serum Cryptococcal Antigen in Liver Transplant Recipients: A Descriptive Epidemiology. Open Forum Infect Dis 2024; 11:ofae255. [PMID: 38774792 PMCID: PMC11108085 DOI: 10.1093/ofid/ofae255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Indexed: 05/24/2024] Open
Abstract
Background Cryptococcosis is a notable infectious complication of liver transplantation. Currently, there is no recommendation for screening serum cryptococcal antigen (CrAg) levels in solid organ transplant recipients. We aimed to explore the role of serum CrAg in liver transplant recipients at an institution where posttransplant serum CrAg has been widely tested. Methods This retrospective study was conducted at a tertiary care center in Japan. All liver transplant recipients with serum CrAg measured either for screening or for diagnostic testing at least once after transplantation between April 2005 and March 2022 were included. For participants with either a positive CrAg test result or positive culture for Cryptococcus, we manually reviewed clinical manifestations, management, and prognosis from the medical records. Results During the study period, 12 885 serum CrAg tests (median, 16 tests per patient) were performed in 468 liver transplant recipients. The 1-year posttransplant incidence of positive serum CrAg test results and culture-proven cryptococcosis was 1.9% (9/468) and 0.6% (3/468), respectively. No patient with persistently negative serum CrAg test results showed growth of Cryptococcus in culture. Four patients had clinical manifestations consistent with cryptococcosis, of whom 2 (50.0%) started antifungal therapy promptly based on a positive serum CrAg test result. In contrast, 5 patients had no clinical manifestations. Three of the 5 (60.0%) patients did not receive antifungal therapy and remained free of clinical manifestations. Conclusions Serum CrAg test was more sensitive than culture among liver transplant recipients and prompted early diagnosis and antifungal therapy in symptomatic patients. However, serial screening of serum CrAg in asymptomatic patients may be of little value, with the potential for false-positive results.
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Affiliation(s)
- Toshiki Miwa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infectious Diseases, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuhiko Ikeuchi
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Shinya Yamamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Akihiko Ichida
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeya Tsutsumi
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
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Chakravarty J, Reddy S, Gupta MK, Tilak R, Diwaker C, Sundar S. Screening for cryptococcal antigen in asymptomatic people with HIV: urgent need in Eastern India. AIDS 2023; 37:2359-2363. [PMID: 37650766 DOI: 10.1097/qad.0000000000003702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVE Cryptococcal meningitis (CM) is a leading cause of mortality in people with HIV (PWH). Despite recommendation by the National programme, cryptococcal antigen (CrAg) screening in PWH with CD4 + <200/μl has not been implemented in practice. Therefore, we conducted a prospective study in government funded Antiretroviral treatment centre to determine the prevalence of asymptomatic cryptococcal antigenemia in PWH with CD4 + cell count <200 cells/μl, subclinical cryptococcal meningitis in serum CrAg positive subjects and their outcome. METHOD Serum CrAg (BIOSYNEX CryptoPS) screening was conducted in newly diagnosed asymptomatic retro-positive adults with CD4 + <200/μl between January 2021 and March 2022. We also conducted cerebrospinal fluid (CSF) CrAg testing in all PWH who were serum CrAg positive and appropriate therapy was instituted. All the enrolled participants were followed up till February 2023. RESULT Among enrolled 142 PWH patients, 22 (15.49%) were positive for serum CrAg. Among these 22, seven (31.8%) patients had CD4 + cell count between 100 and 199 cells/μl. CSF CrAg was positive in 11 (50%) serum CrAg positive cases. Serum CrAg positivity was significantly associated with low CD4 + cell count, poor clinical stage and concomitant Pneumocystis pneumonia. However, mortality was not significantly different in Serum CrAg positive and negative PWH. None of the deaths in CrAg positive PWH was due to cryptococcal disease. CONCLUSION Higher prevalence of cryptococcal antigenemia and subclinical CM among PWH with CD4 + cell count <200 cells/μl with good treatment outcomes with therapy reiterates the need for CrAg screening among PWH in Eastern India.
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Affiliation(s)
| | | | | | - Ragini Tilak
- Department of Microbiology, IMS BHU, Varanasi, India
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Paccoud O, Shuping L, Mashau R, Greene G, Quan V, Meiring S, Govender NP. Impact of prior cryptococcal antigen screening on in-hospital mortality in cryptococcal meningitis or fungaemia among HIV-seropositive individuals in South Africa: a cross-sectional observational study. Clin Microbiol Infect 2023; 29:1063-1069. [PMID: 37086780 DOI: 10.1016/j.cmi.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVES We investigated whether patients with cryptococcal meningitis (CM) or fungaemia detected through South Africa's laboratory cryptococcal antigen (CrAg) screening programme had better outcomes than those presenting directly to the hospital. METHODS We compared 14-day in-hospital case-fatality ratios of HIV-seropositive individuals with CD4 counts below 100 cells/μL and laboratory-confirmed CM/fungaemia from 2017-2021, with or without evidence of a positive blood CrAg test within 14 days prior to diagnosis. We evaluated whether the impact of prior CrAg screening on mortality varied according to the study period (pre-COVID-19: before March 2020 vs. COVID-19: after March 2020). RESULTS Overall, 24.5% (830/3390) of patients had a prior positive CrAg test within 14 days of diagnosis. CrAg-screened patients were less likely to have an altered mental status at baseline than non-CrAg-screened patients (38.1% [296/776] vs. 42.6% [1010/2372], p = 0.03), and had a lower crude 14-day case-fatality ratio (24.7% [205/830] vs. 28.3% [724/2560]; OR, 0.83 [95% CI, 0.69-0.99]; p = 0.045). Previous CrAg screening was associated with a greater reduction in the crude 14-day mortality during the COVID-19 period (OR, 0.64 [0.47-0.87]; p = 0.005) compared with before (OR, 0.95 [0.76-1.19]; p = 0.68). After adjustment, previous CrAg screening within 14 days was associated with increased survival only during the COVID-19 period (adjusted OR, 0.70 [0.51-0.96]; p = 0.03). DISCUSSION Previous CrAg screening was associated with a survival benefit in patients hospitalized with CM/fungaemia during the COVID-19 period, with fewer patients having an altered mental status at baseline, suggesting that these patients may have been diagnosed with cryptococcosis earlier.
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Affiliation(s)
- Olivier Paccoud
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; Université Paris Cité, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Hospital Necker-Enfants Maladies, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Liliwe Shuping
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Rudzani Mashau
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Greg Greene
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Vanessa Quan
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Susan Meiring
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Institute of Infection and Immunity, St George's University of London, London, UK; Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Chen S, Yu G, Chen M, You Y, Gu L, Wang Q, Wang H, Lai G, Yu Z, Wen W. Comparison of different therapeutic approaches for pulmonary cryptococcosis in kidney transplant recipients: a 15-year retrospective analysis. Front Med (Lausanne) 2023; 10:1107330. [PMID: 37484845 PMCID: PMC10361058 DOI: 10.3389/fmed.2023.1107330] [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: 01/12/2023] [Accepted: 06/15/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Organ transplant recipients are at increased risk of developing pulmonary cryptococcosis (PC) due to weakened cell-mediated immunity caused by immunosuppressors. However, the nonspecific symptoms associated with PC can often lead to misdiagnosis and inappropriate treatment. Methods We conducted a retrospective analysis of data from 23 kidney transplant recipients with PC between April 2006 to January 2021. Results The median time from transplantation to the diagnosis of pathology-proven PC 4.09 years. Seventeen patients presented respiratory symptoms, including sputum-producing cough and dyspnea. Additionally, three patients also developed central nervous system (CNS) infections. Chest CT scans frequently revealed nodule-shaped lesions, which can mimic lung carcinoma. Serological tests did not demonstrate any specific changes. Nine patients received surgical resection as treatment. Fourteen patients were treated with antifungal medication only. No recurrence was observed in all 23 patients. Conclusion Our study suggests that fever and sputum-producing cough are common symptoms of PC, and cryptococcal meningitis should not be excluded if corresponding symptoms occur. Fluconazole is a common and effective antifungal agent. Surgical resection should be considered for patients who do not respond well to antifungal therapy. Clinicians should be aware of these findings when evaluating transplant recipients with respiratory symptoms.
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Affiliation(s)
- Shuyang Chen
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guoqing Yu
- Department of Nephrology, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Meiyan Chen
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Yanjing You
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Lei Gu
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qing Wang
- The Third Affiliated People’s Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Huijuan Wang
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Guoxiang Lai
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Zongyang Yu
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Wen Wen
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
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Acharya S, Allam RR, Karanjkar VK, Rathod D, Mahajan R, Deshpande P, Palkar A, Todmal S, Koli S, Dhande S, Dale J, Yeldandi VV, Harshana A, Agarwal R, Upadhyaya S, Nyendak M. Implementation of point-of-care testing and prevalence of cryptococcal antigenaemia among patients with advanced HIV disease in Mumbai, India. BMJ Open 2023; 13:e070500. [PMID: 37349096 PMCID: PMC10314426 DOI: 10.1136/bmjopen-2022-070500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/08/2023] [Indexed: 06/24/2023] Open
Abstract
OBJECTIVES To describe the implementation of screening for cryptococcal antigenaemia by point-of-care (POC) serum cryptococcal antigen (CrAg) lateral flow assay, measure the prevalence and factors associated with serum cryptococcal antigenaemia in the routine programmatic setting. DESIGN Cross-sectional study. SETTING Seventeen publicly funded antiretroviral therapy (ART) centres in Mumbai, India. PARTICIPANTS Serum CrAg screening was offered to all adolescents (>10 years of age) and adults with advanced HIV disease (AHD) (CD4 <200 cells/mm3 or with WHO clinical stage III/IV) regardless of symptoms of cryptococcal meningitis. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was to describe the implementation of serum CrAg screening and secondary outcome was to measure the prevalence of serum cryptococcal antigenaemia and its risk factors. RESULTS A total of 2715 patients with AHD were tested for serum CrAg by POC assay. Of these, 25 (0.9%) had a CrAg positive result. Among CrAg-positive patients, only one had symptoms. Serum CrAg positivity was 3.6% (6/169) and 1.6% (6/520) among those presenting with CD4 <100 cells/mm3 in the treatment naïve and treatment experienced group, respectively. On multivariable analysis, CD4 count <100 cells/mm3 (OR: 2.3, 95% CI 1.01 to 5.3; p=0.05) and people living with HIV who were treatment naïve (OR: 2.5, 95% CI 1.04 to 6.0; p=0.04) were significantly associated with a positive serum CrAg result. Lumbar puncture was obtained in 20/25 patients within 4 days (range: 1-4 days) of positive serum CrAg result and one person was confirmed to have meningitis. All serum CrAg-positive patients who had a negative cerebrospinal fluid CrAg were offered pre-emptive therapy. CONCLUSIONS Implementation of a POC CrAg assay was possible with existing ART centre staff. Initiation of pre-emptive therapy and management of cryptococcal antigenaemia are operationally feasible at ART centres. The Indian National AIDS Control Programme may consider reflexive CrAg screening of all AHD patients with CD4 <100 cells/mm3.
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Affiliation(s)
| | - Ramesh Reddy Allam
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Delhi, India
| | | | | | - Raman Mahajan
- International Training and Education HIV (I-TECH), Delhi, India
| | | | - Amol Palkar
- International Training and Education HIV (I-TECH), Delhi, India
| | | | - Sagar Koli
- International Training and Education HIV (I-TECH), Delhi, India
| | - Sachin Dhande
- International Training and Education HIV (I-TECH), Delhi, India
| | | | | | - Amit Harshana
- International Training and Education HIV (I-TECH), Delhi, India
| | - Reshu Agarwal
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Delhi, India
| | - Sunita Upadhyaya
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Delhi, India
| | - Melissa Nyendak
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Delhi, India
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8
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Wake RM, Molloy SF, Jarvis JN, Harrison TS, Govender NP. Cryptococcal Antigenemia in Advanced Human Immunodeficiency Virus Disease: Pathophysiology, Epidemiology, and Clinical Implications. Clin Infect Dis 2023; 76:764-770. [PMID: 35986670 PMCID: PMC9938740 DOI: 10.1093/cid/ciac675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/14/2022] Open
Abstract
Cryptococcal antigen (CrAg) is detectable in blood prior to the onset of symptomatic cryptococcal meningitis (CM), a leading cause of death among people with advanced human immunodeficiency virus (HIV) disease globally. Highly sensitive assays can detect CrAg in blood, and screening people with HIV with low CD4 counts, followed by preemptive antifungal treatment, is recommended and widely implemented as part of a global strategy to prevent CM and end cryptococcal-related deaths. Cryptococcal antigenemia encompasses a spectrum of conditions from preclinical asymptomatic infection (cerebrospinal fluid [CSF] CrAg-negative) through subclinical (CSF CrAg-positive without overt meningism) to clinical symptomatic cryptococcal disease, usually manifesting as CM. In this review, we summarize current understanding of the pathophysiology, risk factors for, and clinical implications of cryptococcal antigenemia within this spectrum. We also provide an update on global prevalence, recommended screening and treatment strategies, and future considerations for improving outcomes among patients with cryptococcal antigenemia.
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Affiliation(s)
- Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Síle F Molloy
- Institute for Infection and Immunity, St George's University of London, London, United Kingdom
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George's University of London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Nelesh P Govender
- Institute for Infection and Immunity, St George's University of London, London, United Kingdom
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
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Ahuja J, Soneja M, Wig N, Biswas A, Xess I, Singh G, Vibha D, Nischal N. Cryptococcal antigenemia in people living with HIV and AIDS. Int J STD AIDS 2023; 34:130-136. [PMID: 36426734 DOI: 10.1177/09564624221141157] [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: 11/27/2022]
Abstract
AIM To assess the prevalence of cryptococcal antigenemia among people living with HIV/AIDS (PLHA) with CD4 ≤100/mm3. DESIGN This observational study was performed on PLHA with laboratory-confirmed CD4 ≤100/mm3. All PLHA were recruited irrespective of their duration of HIV diagnosis, antiretroviral therapy (ART) naïve, or ART failure. METHODS The prevalence of cryptococcal antigen (CrAg) was assessed in 102 PLHA, with CD4 ≤100/mm3, using a latex agglutination test on serum samples. All the subjects were followed up for 3 months. RESULTS Amongst 102 PLHA, 62 (60.8%) and 40 (39.2%) patients were ART-naïve and ART failures, respectively, with 2.9% (n = 3) having clinical features of meningitis and 6.8% (n = 7) patients being asymptomatic CrAg-positive. At the 3 month follow-up, total mortality was 10.8%, of which 33.3% and 8.8% were among CrAg-positive and negative patients (p = 0.05). Mortality in asymptomatic and meningitis symptomatic CrAg-positive patients was 1.03% (n = 1) and 2.06% (n = 2), respectively. Of note, five patients were lost to follow-up. CONCLUSION Cryptococcal antigenemia is common among patients with CD4 ≤100/mm3 who were either ART naïve or had treatment failure. Asymptomatic patients who underwent pre-emptive therapy demonstrated good clinical outcomes.
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Affiliation(s)
- Jatin Ahuja
- Department of Medicine, 28730All India Institute of Medical Sciences, New Delhi, India.,75911Indraprastha Apollo Hospital, New Delhi, India
| | - Manish Soneja
- Department of Medicine, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Ashutosh Biswas
- Department of Medicine, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Immaculata Xess
- Department of Microbiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Gagandeep Singh
- Department of Microbiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Neeraj Nischal
- Department of Medicine, 28730All India Institute of Medical Sciences, New Delhi, India
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10
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Oladele RO, Jordan AM, Okaa JU, Osaigbovo II, Shettima SA, Shehu NY, Davies AA, Mohammed Y, Alex-Wele MA, Iliyasu G, Nwaokenye JC, Fayemiwo SA, Udoh UA, Gbajabiamila T, Denning DW, Chiller TM. A multicenter survey of asymptomatic cryptococcal antigenemia among patients with advanced HIV disease in Nigeria. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001313. [PMID: 36963010 PMCID: PMC10021610 DOI: 10.1371/journal.pgph.0001313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/23/2022] [Indexed: 02/04/2023]
Abstract
As of 2018, cryptococcal antigen (CrAg) screening in patients with advanced human immunodeficiency virus (HIV) disease (AHD) was not routinely implemented in Nigeria despite being recommended in the national HIV treatment guidelines. Our aim was to determine the prevalence and risk factors for asymptomatic cryptococcal antigenemia in adult people living with HIV (PLHIV) in Nigeria to advocate for the implementation of routine CrAg screening. A descriptive cross-sectional study and CrAg screening of consecutive adult PLHIV with CD4 counts ≤200 cells/μL was conducted from April 2018 to April 2019 at HIV clinics in eleven tertiary hospitals spread across Nigeria's six geopolitical regions. Prevalence of asymptomatic cryptococcal antigenemia was estimated by facility and geopolitical zone. Logistic regression was conducted to identify risk factors for cryptococcal antigenemia. In total, 1,114 patients with AHD were screened. The overall prevalence of asymptomatic cryptococcal antigenemia was 3.9% with wide variation across facilities (range: 0/75 [0%]- 15/122 [12.3%]) and geopolitical zones (range: 0/75 [0%]-19/279 [6.8%]). Prevalence of antigenemia was highest in the South-West (19/279 [6.8%]) and lowest in the North-East (0/75 [0%]). Prevalence was 5.2% (26/512) and 3.2% (18/561) in patients with CD4<100 and CD4 of 101-200, respectively. Of all patients with antigenemia, 50% were on antiretroviral therapy (ART) at the time of having a positive CrAg test. In adjusted analysis, cryptococcal antigenemia was significantly less in patients on ART and patients who had completed any formal education. The survey showed a high overall burden of cryptococcal antigenemia in Nigeria, with variable prevalence across geopolitical regions. We provided valuable evidence for implementing routine CrAg screening of AHD patients in Nigeria which has commenced in selected centres.
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Affiliation(s)
- Rita O Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine University of Lagos, Lagos, Nigeria
- Medical Mycology Society of Nigeria, Lagos, Nigeria
| | - Alexander M Jordan
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control, Atlanta, Georgia, United States of America
| | - Joy U Okaa
- Department of Pharmaceutical Microbiology and Biotechnology, Nnamdi Azikiwe University, Awka, Nigeria
| | - Iriagbonse I Osaigbovo
- Department of Medical Microbiology, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Shuwaram A Shettima
- Department of Medical Microbiology, Parasitology and immunology, Modibbo Adama University Teaching Hospital, Yola, Nigeria
| | - Nathan Y Shehu
- West African Centre for Emerging Infectious Disease, Jos University Teaching Hospital, Jos, Nigeria
| | - Adeyinka A Davies
- Department of Medical Microbiology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
| | - Yahaya Mohammed
- Department of Medical Microbiology and Parasitology, Faculty of Basic Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
| | - Mary A Alex-Wele
- Department of Medical Microbiology and Parasitology, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| | - Garba Iliyasu
- Infectious Disease Unit, Department of Medicine, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Jude C Nwaokenye
- Department of Medical Microbiology and Parasitology, University College Hospital, Ibadan, Nigeria
| | - Samuel A Fayemiwo
- Department of Medical Microbiology and Parasitology, University College Hospital, Ibadan, Nigeria
| | - Ubong A Udoh
- Department of Medical Microbiology and Parasitology, University of Calabar, Calabar, Nigeria
| | - Titilola Gbajabiamila
- Clinical Sciences Department, Nigerian Institute of Medical research, Lagos, Nigeria
| | - David W Denning
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Tom M Chiller
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control, Atlanta, Georgia, United States of America
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11
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Howard-Jones AR, Sparks R, Pham D, Halliday C, Beardsley J, Chen SCA. Pulmonary Cryptococcosis. J Fungi (Basel) 2022; 8:1156. [PMID: 36354923 PMCID: PMC9696922 DOI: 10.3390/jof8111156] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 07/25/2023] Open
Abstract
Pulmonary cryptococcosis describes an invasive lung mycosis caused by Cryptococcus neoformans or Cryptococcus gattii complex. It is often a high-consequence disease in both immunocompromised and immunocompetent populations, and may be misdiagnosed as pulmonary malignancy, leading to a delay in therapy. Epidemiology follows that of cryptococcal meningoencephalitis, with C. gattii infection more common in certain geographic regions. Diagnostic tools include histopathology, microscopy and culture, and the detection of cryptococcal polysaccharide antigen or Cryptococcus-derived nucleic acids. All patients with lung cryptococcosis should have a lumbar puncture and cerebral imaging to exclude central nervous system disease. Radiology is key, both as an adjunct to laboratory testing and as the initial means of detection in asymptomatic patients or those with non-specific symptoms. Pulmonary cryptococcomas (single or multiple) may also be associated with disseminated disease and/or cryptococcal meningitis, requiring prolonged treatment regimens. Optimal management for severe disease requires extended induction (amphotericin B and flucytosine) and consolidation therapy (fluconazole) with close clinical monitoring. Susceptibility testing is of value for epidemiology and in regions where relatively high minimum inhibitory concentrations to azoles (particularly fluconazole) have been noted. Novel diagnostic tools and therapeutic agents promise to improve the detection and treatment of cryptococcosis, particularly in low-income settings where the disease burden is high.
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Affiliation(s)
- Annaleise R. Howard-Jones
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
| | - Rebecca Sparks
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - David Pham
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Catriona Halliday
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Justin Beardsley
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Sharon C.-A. Chen
- Centre for Infectious Diseases & Microbiology Laboratory Services, New South Wales Health Pathology—Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2145, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2006, Australia
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12
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Affiliation(s)
- Mahomed-Yunus S Moosa
- From the Department of Infectious Diseases (M.-Y.S.M.), and the KwaZulu-Natal Research Innovation and Sequencing Platform (R.J.L.), University of KwaZulu-Natal, Durban, South Africa
| | - Richard J Lessells
- From the Department of Infectious Diseases (M.-Y.S.M.), and the KwaZulu-Natal Research Innovation and Sequencing Platform (R.J.L.), University of KwaZulu-Natal, Durban, South Africa
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13
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Tenforde MW, Muthoga C, Ponatshego P, Ngidi J, Mine M, Greene G, Jordan A, Chiller T, Larson BA, Jarvis JN. Cost-effectiveness of cryptococcal antigen screening at CD4 counts of 101-200 cells/µL in Botswana. Wellcome Open Res 2021; 6:55. [PMID: 35087954 PMCID: PMC8767426 DOI: 10.12688/wellcomeopenres.16624.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Cryptococcal antigen (CrAg) screening in individuals with advanced HIV reduces cryptococcal meningitis (CM) cases and deaths. The World Health Organization recently recommended increasing screening thresholds from CD4 ≤100 cells/µL to ≤200 cells/µL. CrAg screening at CD4 ≤100 cells/µL is cost-effective; however, the cost-effectiveness of screening patients with CD4 101-200 cells/µL requires evaluation. Methods: Using a decision analytic model with Botswana-specific cost and clinical estimates, we evaluated CrAg screening and treatment among individuals with CD4 counts of 101-200 cells/µL. We estimated the number of CM cases and deaths nationally and treatment costs without screening. For screening we modeled the number of CrAg tests performed, number of CrAg-positive patients identified, proportion started on pre-emptive fluconazole, CM cases and deaths. Screening and treatment costs were estimated and cost per death averted or disability-adjusted life year (DALY) saved compared with no screening. Results: Without screening, we estimated 142 CM cases and 85 deaths annually among individuals with CD4 101-200 cells/µL, with treatment costs of $368,982. With CrAg screening, an estimated 33,036 CrAg tests are performed, and 48 deaths avoided (1,017 DALYs saved). While CrAg screening costs an additional $155,601, overall treatment costs fall by $39,600 (preemptive and hospital-based CM treatment), yielding a net increase of $116,001. Compared to no screening, high coverage of CrAg screening and pre-emptive treatment for CrAg-positive individuals in this population avoids one death for $2440 and $114 per DALY saved. In sensitivity analyses assuming a higher proportion of antiretroviral therapy (ART)-naïve patients (75% versus 15%), cost per death averted was $1472; $69 per DALY saved. Conclusions: CrAg screening for individuals with CD4 101-200 cells/µL was estimated to have a modest impact, involve additional costs, and be less cost-effective than screening populations with CD4 counts ≤100 cells/µL. Additional CrAg screening costs must be considered against other health system priorities.
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Affiliation(s)
- Mark W. Tenforde
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98195, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, 98195, USA
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Julia Ngidi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- National Health Laboratory, Gaborone, Botswana
| | - Madisa Mine
- National Health Laboratory, Gaborone, Botswana
| | - Greg Greene
- Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - Alexander Jordan
- Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - Tom Chiller
- Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - Bruce A. Larson
- Department of Global Health, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Joseph N. Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- London School of Hygiene & Tropical Medicine, London, UK
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14
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Wang C, Li R, Ma C, Du J, Gu L. Early diagnosis of disseminated cryptococcosis by cryptococcal antigen lateral-flow assay. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 55:177-179. [PMID: 34535392 DOI: 10.1016/j.jmii.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/16/2021] [Accepted: 08/06/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Chaoyu Wang
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
| | - Ran Li
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Chen Ma
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Junyang Du
- Dynamiker Sub-Center of Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Disease, Tianjin, China
| | - Li Gu
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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15
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Hurt WJ, Tenforde MW, Molefi M, Mitchell HK, Milton T, Azama MS, Goercke I, Mulenga F, Tlhako N, Tsholo K, Srivastava T, Leeme TB, Simoonga G, Muthoga C, Lechiile K, Mine M, Jarvis JN. Prevalence and Sequelae of Cryptococcal Antigenemia in Antiretroviral Therapy-Experienced Populations: An Evaluation of Reflex Cryptococcal Antigen Screening in Botswana. Clin Infect Dis 2021; 72:1745-1754. [PMID: 32236414 DOI: 10.1093/cid/ciaa356] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/30/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Evidence to inform cryptococcal antigen (CrAg)-screening guidelines among ART-experienced populations is lacking. We performed a study evaluating the utility of reflex CrAg screening in Gaborone, Botswana. METHODS CD4 count data were collected from the HIV reference laboratory from 2014-2016. CrAg screening was performed on samples with CD4 ≤100 cells/µL beginning January 2015. The proportion of CD4 counts ≤100 cells/µL was determined and the frequency of repeat CrAg testing described. Analyses ascertained the impact of ART status on CrAg prevalence and outcomes, and whether CrAg titers could be used for risk stratification. RESULTS Overall, 5.6% (3335/59 300) of individuals tested had CD4 ≤100 cells/μL; 2108 samples with CD4 ≤100 cells/μL from 1645 unique patients were CrAg tested. Over half of samples were from ART-experienced individuals: 40.9% (863) on ART and 12.1% (255) defaulters; 22% (463) of CrAg tests were on repeat samples. CrAg prevalence was 4.8% (72/1494; 95% CI, 3.8-6.0%) among outpatients and 21.9% (32/151; 95% CI, 15.3-28.5%) among inpatients. CrAg prevalence rates did not differ by ART status, but 6-month mortality was significantly lower in CrAg-positive individuals on ART at screening. Ten CrAg positives were identified through repeat testing. A CrAg titer cutoff ≥1:80 provided the best discrimination for 6-month survival. CONCLUSIONS CrAg-positivity rates in an ART-experienced population were comparable to those seen in ART-naive populations. Repeat screening identified individuals who seroconverted to CrAg positivity and were at risk of cryptococcal disease. CrAg titers ≥1:80 can help identify the individuals at highest risk of death for more intensive management.
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Affiliation(s)
- William J Hurt
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
| | - Mark W Tenforde
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | | | - Hannah K Mitchell
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Thandi Milton
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
| | | | | | | | - Nametso Tlhako
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
| | - Katlego Tsholo
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
| | - Tuhina Srivastava
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tshepo B Leeme
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Charles Muthoga
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kwana Lechiile
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Madisa Mine
- Botswana National Health Laboratory, Gaborone, Botswana
| | - Joseph N Jarvis
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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16
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Huang SH, Lee CY, Tsai CS, Tsai MS, Liu CE, Hsu WT, Chen HA, Liu WD, Yang CJ, Sun HY, Ko WC, Lu PL, Lee YT, Hung CC. Screening for Cryptococcal Antigenemia and Burden of Cryptococcosis at the Time of HIV Diagnosis: A Retrospective Multicenter Study. Infect Dis Ther 2021; 10:1363-1377. [PMID: 34057690 PMCID: PMC8322196 DOI: 10.1007/s40121-021-00451-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/22/2021] [Indexed: 11/06/2022] Open
Abstract
Introduction Screening for cryptococcal antigen (CrAg) is recommended for people living with HIV (PLWH) who present with low CD4 lymphocyte counts. Real-world experience is important to identify gaps between the guidelines and clinical practice. We investigated the trends of CrAg testing and prevalence of cryptococcal antigenemia among PLWH at the time of HIV diagnosis and the related mortality in Taiwan from 2009 to 2018. Methods Medical records of newly diagnosed PLWH seeking care at six medical centers around Taiwan between 2009 and 2018 were reviewed. The annual trends of PLWH who had CrAg testing and cryptococcal antigenemia were examined by Cochran-Armitage test. Among PLWH with CD4 < 200 cells/µl, timing of CrAg testing was analyzed for association with 12-month all-cause mortality in Kaplan-Meier plots and in a Cox proportional hazards model after adjustments. Results Among 5372 included PLWH, 1150 (21.4%) presented with baseline CD4 < 100 cells/µl, and this proportion had decreased during the study period [from 108 (29.3%) in 2009 to 93 (22.3%) in 2018 (P = 0.039)]. The overall prevalence of cryptococcal antigenemia was 7.8% among PLWH with CD4 < 100 cells/µl, which remained stable during the 10-year study period (P = 0.356) and was 2.6% among PLWH with CD4 100–199 cells/µl. The uptake of CrAg testing had increased from 65.7% in 2009 to 78.0% in 2018 (P = 0.002) among PLWH with CD4 < 100 cells/µl. Late CrAg testing, defined by 14 days or later after HIV diagnosis, was associated with increased risk of 12-month mortality compared to early CrAg testing (adjusted hazard ratio 2.028, 95% CI 1.109–3.708). Conclusions Burden of cryptococcosis remained high among PLWH with low CD4 lymphocyte counts in Taiwan. Uptake of CrAg screening among late HIV presenters was still suboptimal and delayed. Late CrAg testing was associated with a higher mortality. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00451-5.
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Affiliation(s)
- Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chun-Yuan Lee
- Department of Internal Medicine, Kaohsiung Medical University Hospital and College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chin-Shiang Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mao-Song Tsai
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chun-Eng Liu
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Ting Hsu
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Douliu, Yun-Lin County, Taiwan
| | - Hong-An Chen
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Wang-Da Liu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan.,Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Chia-Jui Yang
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Liang Lu
- Department of Internal Medicine, Kaohsiung Medical University Hospital and College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yuan-Ti Lee
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chien-Ching Hung
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan. .,Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan. .,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan. .,China Medical University, Taichung, Taiwan.
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17
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Tenforde MW, Milton T, Rulaganyang I, Muthoga C, Tawe L, Chiller T, Greene G, Jordan A, Williams CG, Owen L, Leeme TB, Boose A, Ngidi J, Mine M, Jarvis JN. Outcomes of Reflex Cryptococcal Antigen (CrAg) Screening in Human Immunodeficiency Virus (HIV)-Positive Patients With CD4 Counts of 100-200 Cells/µL in Botswana. Clin Infect Dis 2021; 72:1635-1638. [PMID: 32604411 DOI: 10.1093/cid/ciaa899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/24/2020] [Indexed: 01/20/2023] Open
Abstract
Increasing the CD4-count threshold for cryptococcal antigen (CrAg) screening from ≤100 to ≤200 cells/µL resulted in a 3-fold increase in numbers screened. CrAg-prevalence was 3.5% at CD4 101-200 and 6.2% ≤100 cells/µL. Six-month mortality was 21.4% (9/42) in CrAg-positive CD4 ≤100 cells/µL and 3.2% (1/31) in CrAg-positive CD4 101-200 cells/µL.
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Affiliation(s)
- Mark W Tenforde
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA.,Botswana-UPenn Partnership, Gaborone, Botswana
| | | | | | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Tom Chiller
- Mycotics Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Gregory Greene
- Mycotics Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alexander Jordan
- Mycotics Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Leah Owen
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Tshepo B Leeme
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Amber Boose
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Julia Ngidi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Madisa Mine
- Botswana National Health Laboratory, Gaborone, Botswana
| | - Joseph N Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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18
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Temfack E, Rim JJB, Spijker R, Loyse A, Chiller T, Pappas PG, Perfect J, Sorell TC, Harrison TS, Cohen JF, Lortholary O. Cryptococcal Antigen in Serum and Cerebrospinal Fluid for Detecting Cryptococcal Meningitis in Adults Living With Human Immunodeficiency Virus: Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies. Clin Infect Dis 2021; 72:1268-1278. [PMID: 32829406 PMCID: PMC8522332 DOI: 10.1093/cid/ciaa1243] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Indexed: 02/01/2023] Open
Abstract
Cryptococcal antigen (CrAg) detection could direct the timely initiation of antifungal therapy. We searched MEDLINE and Embase for studies where CrAg detection in serum/cerebrospinal fluid (CSF) and CSF fungal culture were done on adults living with human immunodeficiency virus (HIV) who had suspected cryptococcal meningitis (CM). With Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2), we evaluated the risk of bias in 11 included studies with 3600 participants, and used a random-effects meta-analysis to obtain summary sensitivity and specificity of serum and CSF CrAg, as well as agreement between CSF CrAg and CSF culture. Summary sensitivity and specificity of serum CrAg were 99.7% (97.4-100) and 94.1% (88.3-98.1), respectively, and summary sensitivity and specificity of CSF CrAg were 98.8% (96.2-99.6) and 99.3% (96.7-99.9), respectively. Agreement between CSF CrAg and CSF culture was 98% (97-99). In adults living with HIV who have CM symptoms, serum CrAg negativity may rule out CM, while positivity should prompt induction antifungal therapy if lumbar puncture is not feasible. In a first episode of CM, CSF CrAg positivity is diagnostic.
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Affiliation(s)
- Elvis Temfack
- Institut Pasteur, Centre National de la Recherche Scientifique,
Molecular Mycology Unit Unite Mixte de Recherche 2000,
Paris, France
- Internal Medicine Unit, Douala General Hospital,
Douala, Cameroon
| | | | - Rene Spijker
- Cochrane Netherlands, Julius Centre for Health Sciences and Primary
Care, University Medical Centre Utrecht,
Utrecht, The
Netherlands
| | - Angela Loyse
- Institute of Infection and Immunity, St. George’s University of
London, London, United Kingdom
- Department of Infection, St George’s University Hospitals
National Health Service Trust, London,
United Kingdom
- Institute of Infectious Disease and Molecular Medicine, University of
Cape Town, Cape Town, South Africa
| | - Tom Chiller
- Tulane School of Public Health and Tropical Medicine,
Atlanta, Georgia, USA
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at
Birmingham, Birmingham, Alabama, USA
| | - John Perfect
- Division of Infectious Diseases, Department of Medicine, Duke
University Medical Centre, Durham, North
Carolina, USA
| | - Tania C Sorell
- University of Sydney Faculty of Medicine and Health, Westmead Clinical
School and Centre for Infectious Diseases and Microbiology, The Westmead
Institute of Medical Research, Westmead,
Australia
| | - Thomas S Harrison
- Institute of Infection and Immunity, St. George’s University of
London, London, United Kingdom
- Department of Infection, St George’s University Hospitals
National Health Service Trust, London,
United Kingdom
- Institute of Infectious Disease and Molecular Medicine, University of
Cape Town, Cape Town, South Africa
| | - Jérémie F Cohen
- Institut National de la Sante et de la Recherche Medicale UMR 1153
Hospital, Assistance Publique-Hopitaux de Paris, Paris Descartes
University, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases,
Necker Hospital, Assistance Publique-Hopitaux de Paris. Paris Descartes
University, Paris, France
| | - Olivier Lortholary
- Institut Pasteur, Centre National de la Recherche Scientifique,
Molecular Mycology Unit Unite Mixte de Recherche 2000,
Paris, France
- University Paris Descartes, Necker Pasteur Center for Infectious
Diseases and Tropical Medicine, Hôpital Necker - Enfants malades,
Assistance Publique-Hopitaux de Paris, Institut Hospitalo-Universitaire
Imagine, Paris, France
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Johnson MD, Lewis RE, Dodds Ashley ES, Ostrosky-Zeichner L, Zaoutis T, Thompson GR, Andes DR, Walsh TJ, Pappas PG, Cornely OA, Perfect JR, Kontoyiannis DP. Core Recommendations for Antifungal Stewardship: A Statement of the Mycoses Study Group Education and Research Consortium. J Infect Dis 2021; 222:S175-S198. [PMID: 32756879 DOI: 10.1093/infdis/jiaa394] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In recent years, the global public health community has increasingly recognized the importance of antimicrobial stewardship (AMS) in the fight to improve outcomes, decrease costs, and curb increases in antimicrobial resistance around the world. However, the subject of antifungal stewardship (AFS) has received less attention. While the principles of AMS guidelines likely apply to stewarding of antifungal agents, there are additional considerations unique to AFS and the complex field of fungal infections that require specific recommendations. In this article, we review the literature on AMS best practices and discuss AFS through the lens of the global core elements of AMS. We offer recommendations for best practices in AFS based on a synthesis of this evidence by an interdisciplinary expert panel of members of the Mycoses Study Group Education and Research Consortium. We also discuss research directions in this rapidly evolving field. AFS is an emerging and important component of AMS, yet requires special considerations in certain areas such as expertise, education, interventions to optimize utilization, therapeutic drug monitoring, and data analysis and reporting.
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Affiliation(s)
- Melissa D Johnson
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Russell E Lewis
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, Laboratory of Mycology Research, McGovern Medical School, Houston, Texas, USA
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis, Sacramento, California, USA
| | - David R Andes
- Department of Medicine and Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases, Weill Cornell Medicine of Cornell University, New York, New York, USA
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Oliver A Cornely
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Centre for Infection Research, partner site Bonn-Cologne, Cologne, Germany.,CECAD Cluster of Excellence, University of Cologne, Cologne, Germany.,Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, MD Anderson Cancer Center, Houston, Texas, USA
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20
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Tenforde MW, Muthoga C, Ponatshego P, Ngidi J, Mine M, Greene G, Jordan A, Chiller T, Larson BA, Jarvis JN. Cost-effectiveness of cryptococcal antigen screening at CD4 counts of 101-200 cells/µL in Botswana. Wellcome Open Res 2021; 6:55. [PMID: 35087954 PMCID: PMC8767426 DOI: 10.12688/wellcomeopenres.16624.1] [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] [Accepted: 02/19/2021] [Indexed: 04/06/2024] Open
Abstract
Background: Cryptococcal antigen (CrAg) screening in individuals with advanced HIV reduces cryptococcal meningitis (CM) cases and deaths. The World Health Organization recently recommended increasing screening thresholds from CD4 ≤100 cells/µL to ≤200 cells/µL. CrAg screening at CD4 ≤100 cells/µL is cost-effective; however, the cost-effectiveness of screening patients with CD4 101-200 cells/µL requires evaluation. Methods: Using a decision analytic model with Botswana-specific cost and clinical estimates, we evaluated CrAg screening and treatment among individuals with CD4 counts of 101-200 cells/µL. We estimated the number of CM cases and deaths nationally and treatment costs without screening. For screening we modeled the number of CrAg tests performed, number of CrAg-positive patients identified, proportion started on pre-emptive fluconazole, CM cases and deaths. Screening and treatment costs were estimated and cost per death averted or disability-adjusted life year (DALY) saved compared with no screening. Results: Without screening, we estimated 142 CM cases and 85 deaths annually among individuals with CD4 101-200 cells/µL, with treatment costs of $368,982. With CrAg screening, an estimated 33,036 CrAg tests are performed, and 48 deaths avoided (1,017 DALYs saved). While CrAg screening costs an additional $155,601, overall treatment costs fall by $39,600 (preemptive and hospital-based CM treatment), yielding a net increase of $116,001. Compared to no screening, high coverage of CrAg screening and pre-emptive treatment for CrAg-positive individuals in this population avoids one death for $2440 and $114 per DALY saved. In sensitivity analyses assuming a higher proportion of antiretroviral therapy (ART)-naïve patients (75% versus 15%), cost per death averted was $1472; $69 per DALY saved. Conclusions: CrAg screening for individuals with CD4 101-200 cells/µL was estimated to have a modest impact, involve additional costs, and be less cost-effective than screening populations with CD4 counts ≤100 cells/µL. Additional CrAg screening costs must be considered against other health system priorities.
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Affiliation(s)
- Mark W. Tenforde
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98195, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, 98195, USA
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Julia Ngidi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- National Health Laboratory, Gaborone, Botswana
| | - Madisa Mine
- National Health Laboratory, Gaborone, Botswana
| | - Greg Greene
- Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - Alexander Jordan
- Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - Tom Chiller
- Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - Bruce A. Larson
- Department of Global Health, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Joseph N. Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- London School of Hygiene & Tropical Medicine, London, UK
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21
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Xu XL, Zhao T, Harypursat V, Lu YQ, Li Y, Chen YK. Asymptomatic cryptococcal antigenemia in HIV-infected patients: a review of recent studies. Chin Med J (Engl) 2020; 133:2859-2866. [PMID: 33273336 PMCID: PMC10631590 DOI: 10.1097/cm9.0000000000001134] [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: 06/24/2020] [Indexed: 11/26/2022] Open
Abstract
The prevalence of asymptomatic cryptococcal antigenemia (ACA) in human immunodeficiency virus (HIV) infected individuals has been observed to be elevated. The prevalence of ACA ranges from 1.3% to 13%, with different rates of prevalence in various regions of the world. We reviewed studies conducted internationally, and also referred to two established expert consensus guideline documents published in China, and we have concluded that Chinese HIV-infected patients should undergo cryptococcal antigen screening when CD4 T-cell counts fall below 200 cells/μL and that the recommended treatment regimen for these patients follow current World Health Organization guidelines, although it is likely that this recommendation may change in the future. Early screening and optimized preemptive treatment for ACA is likely to help decrease the incidence of cryptococcosis, and is lifesaving. Further studies are warranted to explore issues related to the optimal management of ACA.
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Affiliation(s)
- Xiao-Lei Xu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing 400036, China
| | - Ting Zhao
- Division of Science and Education, Chongqing Public Health Medical Center, Chongqing 400036, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing 400036, China
| | - Yan-Qiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing 400036, China
| | - Yan Li
- Public Health College, Zunyi Medical University, Zunyi, Guizhou 563000, China
| | - Yao-Kai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing 400036, China
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22
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HIV-associated Cryptococcal Meningitis: a Review of Novel Short-Course and Oral Therapies. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of review
HIV-associated cryptococcal meningitis remains a significant public health problem in parts of Africa and Asia and a major cause of AIDS-related mortality, accounting for 15% of all AIDS-related deaths worldwide. Cryptococcal meningitis is uniformly fatal if untreated, and access to antifungal therapy in regions with the highest burden is often limited. Outcomes with fluconazole monotherapy are poor, and induction treatment with amphotericin B and high-dose fluconazole for 2 weeks is associated with significant drug-related toxicities and prolonged hospital admissions. This review focuses on the potential of novel short-course and oral combination therapies for cryptococcal meningitis.
Recent findings
Recent clinical trials have shown that shorter courses of amphotericin, if paired with oral flucytosine, rather than fluconazole, can achieve non-inferior mortality outcomes. In addition, an oral combination of fluconazole and flucytosine is a potential alternative. Liposomal amphotericin B may further simplify treatment; it is associated with fewer drug-related toxicities, and a recent phase II randomised controlled trial demonstrated that a single, high dose of liposomal amphotericin is non-inferior to 14 standard daily doses at clearing Cryptococcus from cerebrospinal fluid. This has been taken forward to an ongoing phase III, clinical endpoint study.
Summary
The incidence and mortality associated with cryptococcal meningitis is still unacceptably high. There is evidence supporting the use of short-course amphotericin B and oral combination antifungal treatment regimens for cryptococcal meningitis (CM). Ongoing research into short-course, high-dose treatment with liposomal amphotericin may also help reduce the impact of this devastating disease.
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Tepungipame AT, Tonen-Wolyec S, Kalla GC, Longembe EB, Atike RO, Likwela JL, Mbopi-Kéou FX, Bélec L, Batina-Agasa S. Predictors of AIDS-related death among adult HIV-infected inpatients in Kisangani, the Democratic Republic of Congo. Pan Afr Med J 2020; 37:144. [PMID: 33425177 PMCID: PMC7757268 DOI: 10.11604/pamj.2020.37.144.25802] [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: 08/28/2020] [Accepted: 09/07/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Human Immunodeficiency Virus (HIV) infection continues to be a major public health concern in sub-Saharan Africa. We aimed to evaluate potential factors associated with AIDS-related death among adult HIV-infected inpatients in Kisangani, the Democratic Republic of the Congo (DRC). Methods this is a hospital-based retrospective, observational analysis carried out between 1st January 2019 and 31st March 2020 among inpatients HIV, at 12 facilities integrating the HIV prevention and care packages in Kisangani. Factors associated with AIDS-related death were analyzed using the logistic regression models. Results a total of 347 HIV-infected inpatients were included. Among those, the rate of AIDS-related death was 25.1% (95% CI: 20.8-29.9). The rates of AIDS-related death were lower among patients with a university education (aOR: 0.03 [95% CI: 0.00-1.0]) and higher among patients in WHO clinical stage 4 (aOR: 15.4 [6.8-27.8]), patients with poor highly active antiretroviral therapy (HAART) observance (aOR: 14.5 [2.3-40.4), and patients suffering from opportunistic infections (aOR: 9.3 [95% CI: 3.4-25.1]), including cryptococcal meningitis (aOR: 27 [95% CI: 6.0-125.7]) and viral infections associated with zona and Kaposi sarcoma (aOR: 4.8 [95% CI: 2.2-10.4]). Conclusion in our retrospective study on a large sample of inpatients hospitalized in Kisangani, classic causes of death were found. The association with the low level of education suggests that the economic level of the patients who die is a determining factor, difficult to correct. The identification of a limited number of other factors will allow a better medical management.
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Affiliation(s)
- Alliance Tagoto Tepungipame
- Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo.,National AIDS and STIs Control Programme, Kisangani, Democratic Republic of the Congo
| | - Serge Tonen-Wolyec
- Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo.,Ecole Doctorale Régionale d´Afrique Centrale en Infectiologie Tropicale, Franceville, Gabon
| | - Ginette Claude Kalla
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Eugeune Basandja Longembe
- Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | - Rachel Olonga Atike
- Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | - Joris Losimba Likwela
- Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | - Francois-Xavier Mbopi-Kéou
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,The Institute for the Development of Africa (The-IDA), Yaoundé, Cameroon
| | - Laurent Bélec
- Laboratory of Virology, Hôpital Européen Georges Pompidou, and University of Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Salomon Batina-Agasa
- Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo
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24
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Greene G, Lawrence DS, Jordan A, Chiller T, Jarvis JN. Cryptococcal meningitis: a review of cryptococcal antigen screening programs in Africa. Expert Rev Anti Infect Ther 2020; 19:233-244. [PMID: 32567406 DOI: 10.1080/14787210.2020.1785871] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Cryptococcal meningitis remains a significant contributor to AIDS-related mortality despite widened access to antiretroviral therapy. Cryptococcal antigen (CrAg) can be detected in the blood prior to development of meningitis. Development of highly sensitive and specific rapid diagnostic CrAg tests has helped facilitate the adoption of CrAg screening programs in 19 African countries. AREAS COVERED The biological rationale for CrAg screening and the programmatic strategies for its implementation are reviewed. We describe the approach to the investigation of patients with cryptococcal antigenemia and the importance of lumbar puncture to identify individuals who may have cryptococcal meningitis in the absence of symptoms. The limitations of current treatment recommendations and the potential role of newly defined combination antifungal therapies are discussed. A literature review was conducted using a broad database search for cryptococcal antigen screening and related terms in published journal articles dating up to December 2019. Conference abstracts, publicly available guidelines, and project descriptions were also incorporated. EXPERT OPINION As we learn more about the risks of cryptococcal antigenemia, it has become clear that the current management paradigm is inadequate. More intensive investigation and management are required to prevent the development of cryptococcal meningitis and reduce mortality associated with cryptococcal antigenemia.
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Affiliation(s)
- Greg Greene
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, a Division of the NHLS , Johannesburg, South Africa.,Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK.,Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana
| | - Alex Jordan
- Mycotic Diseases Branch, Centers for Disease Control and Prevention , Atlanta, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention , Atlanta, USA
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK.,Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana
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25
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Li Y, Huang X, Chen H, Qin Y, Hou J, Li A, Wu H, Yan X, Chen Y. The prevalence of cryptococcal antigen (CrAg) and benefits of pre-emptive antifungal treatment among HIV-infected persons with CD4+ T-cell counts < 200 cells/μL: evidence based on a meta-analysis. BMC Infect Dis 2020; 20:410. [PMID: 32532212 PMCID: PMC7291520 DOI: 10.1186/s12879-020-05126-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 05/28/2020] [Indexed: 01/08/2023] Open
Abstract
Background Current WHO guidelines (2018) recommend screening for cryptococcal antigen (CrAg) in HIV-infected persons with CD4+ T cell counts< 100 cells/μL, followed by pre-emptive antifungal therapy among CrAg positive (CrAg+) persons, to prevent cryptococcal meningitis related deaths. This strategy may also be considered for those persons with a CD4+ T cell count of < 200 cells/uL according the WHO guidelines. However, there is sparse evidence in the literature supporting CrAg screening and pre-emptive antifungal therapy in those HIV-infected persons with this CD4+ T cell counts< 200 cells/μL. Method We conducted a meta-analysis using data extracted from randomized controlled studies (RCTs) and cohort studies found in a search of Pubmed, Web of Science, the Cochrane Library and the EMBASE/MEDLINE database. Results The pooled prevalence of CrAg positivity in HIV-infected persons with CD4+ T cell counts< 200 cells/μL was 5% (95%CI: 2–7). The incidence of CM in CrAg+ persons was 3% (95%CI: 1–6). Among those CrAg+ persons who did not receive pre-emptive treatment, or those who received placebo, the incidence of CM was 5% (95%CI: 2–9), whereas the incidence of CM among those who received pre-emptive antifungal therapy was 3% (95%CI: 1–6), which is a statistically significant reduction in incidence of 40% (RR: 7.64, 95%CI: 2.96–19.73, p < 0.00001). As for persons with CD4+ T cell counts between 101 ~ 200 cells/μL, the risk ratio for the incidence of CM among those receiving placebo or no intervention was 1.15, compared to those receiving antifungal treatment (95%CI: 0.16–8.13). Conclusions In our meta-analysis the incidence of CM was significantly reduced by pre-emptive antifungal therapy in CrAg+ HIV-infected persons with CD4 < 200 cells/μL. However, more specific observational data in persons with CD4+ T cell counts between 101 ~ 200 cells/μL are required in order to emphasize specific benefit of CrAg screening and pre-emptive antifungal treating in CrAg+ persons with CD4+ T cell counts < 200 cells/μL.
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Affiliation(s)
- Yao Li
- Division of infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China.,Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Yuanyuan Qin
- Division of infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China.,Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Jianhua Hou
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Aixin Li
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiaofeng Yan
- Section of Medical Affairs Administration, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- Division of infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China.
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26
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Xu M, Peng Z, Xu C, Chen Y, Cheng J, Chi Y, Wei H, Chen W, Hu Z. Underlying Cryptococcal Diseases and the Correlation With Serum Cryptococcal Antigen Titers in Hospitalized HIV-Infected Patients Screened Positive for Cryptococcal Antigenemia. Front Cell Infect Microbiol 2020; 10:170. [PMID: 32391288 PMCID: PMC7192964 DOI: 10.3389/fcimb.2020.00170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/31/2020] [Indexed: 12/13/2022] Open
Abstract
Background: The prevalence of different underlying cryptococcal diseases in human immunodeficiency virus (HIV)-infected patients screened positive for cryptococcal antigenemia and the association between cryptococcal diseases and serum cryptococcal antigen (CrAg) titers were understudied. Methods: HIV-infected patients with CD4 < 200 cells/ul, admitted to the second hospital of Nanjing, Nanjing, China, from January 2016 to September 2019, were retrospectively analyzed. Integrated into routine HIV care, all these patients were screened for cryptococcal antigenemia with CrAg lateral flow assay. Positive patients received extensive laboratory and radiological studies to evaluate underlying cryptococcal diseases. Results: A total of 872 HIV inpatients were screened for serum CrAg. The prevalence of cryptococcal antigenemia in the study population was 10.3% (95% CI, 8.3–12.3%), 87.6% of which with cryptococcal antigenemia had clinically cryptococcal diseases. The prevalence of cryptococcal meningitis (CM), cryptococcemia and pulmonary cryptococcosis (PC) in patients with cryptococcal antigenemia were 58.4% (95% CI, 48.0–68.9%), 50.7% (95% CI, 39.1–62.2%), and 68.5% (95% CI, 58.7–78.4%), respectively. The median (range) serum CrAg titers in severe cryptococcal diseases (CM or cryptococcemia), localized PC (without co-existing CM or cryptococcemia) and isolated cryptococcal antigenemia were 1:2560 (1:10–1:2560), 1:20 (1:2–1:320), and 1:5 (1:2–1:320), respectively. Serum CrAg titers ≥1:320 were independently associated with CM (adjusted OR 26.88; 95%CI, 8.36–86.42). Severe cryptococcal diseases were found in all patients with serum CrAg titers ≥1:640. None of the patients with serum CrAg titers ≤ 1:5 had CM. Conclusion: The prevalence of cryptococcal antigenemia was high in HIV inpatients, supporting routine CrAg screening. Clinical cryptococcal diseases, most commonly the PC, existed in the majority of the patients with cryptococcal antigenemia. Since serum CrAg titer is correlated with cryptococcal disease severity, it may possibly guide anti-fungal treatment.
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Affiliation(s)
- Miaomiao Xu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhihang Peng
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Chuanjun Xu
- Department of Radiology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yaling Chen
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jian Cheng
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yun Chi
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Hongxia Wei
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wei Chen
- Department of Clinical Research Center, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
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Multicenter Cryptococcal Antigen Screening of HIV-Infected Patients in Iran. Curr Microbiol 2020; 77:1667-1672. [PMID: 32296917 DOI: 10.1007/s00284-020-01970-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 03/25/2020] [Indexed: 10/24/2022]
Abstract
Early diagnosis and targeted preemptive antifungal treatment are crucial in reducing cryptococcal meningitis (CM)-related mortality in individuals living with human immunodeficiency virus (HIV). The present study was performed to determine cryptococcal antigenemia and outcomes among HIV-infected patients in Iran. This multicenter prospective study was conducted between October 2016 and December 2018. For the purpose of the study, blood samples were randomly collected from 177 profoundly immunosuppressed (CD4+ counts < 200 cells/µL) HIV-positive individuals in six major cities of Iran. The patients were antiretroviral therapy-naive or had received inadequate medication. The stored sera were screened for cryptococcal antigen (CrAg), using point-of-care lateral flow assay (IMMY® diagnostics, Norman, OK, US). Overall, out of the 174 asymptomatic patients, 3 (1.72%) cases were CrAg-positive using the LFA in serum. Accordingly, the prevalence of cryptococcal antigenemia was 7.14%, 0%, and 1.2% in the patients with the CD4+ counts of < 50, 50-100, and 100-200 cells/μL, respectively. The median age of the patients with antigenemia was 36 years (age range 8-55 years). The median CD4+ count of the cohort was 98 cells/μL (range 14-200 cells/μL). Routine screening of Iranian HIV-infected patients with CD4+ count of < 50 cells/µL before initiating antiretroviral therapy is justified. It is suggested to conduct more inclusive research throughout the whole country on more patients to recommend screening cryptococcal antigen strongly.
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Evaluation of Serum Cryptococcal Antigen Testing Using Two Novel Semiquantitative Lateral Flow Assays in Persons with Cryptococcal Antigenemia. J Clin Microbiol 2020; 58:JCM.02046-19. [PMID: 32024729 DOI: 10.1128/jcm.02046-19] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/03/2020] [Indexed: 02/04/2023] Open
Abstract
Early cryptococcal disease can be detected via circulating antigen in blood before fulminant meningitis develops, when early antifungal therapy improves survival. Two semiquantitative cryptococcal antigen (CrAg) lateral flow assays (LFAs) have been developed, but their diagnostic performance has not been defined. Cryopreserved serum samples from HIV-infected Ugandans obtained as part of a prospective CrAg-screening cohort were tested in duplicate for CrAg by the CrAgSQ (IMMY) and CryptoPS (Biosynex) lateral flow assays. Case-controlled diagnostic performance was measured using the FDA-approved CrAg LFA (IMMY) as a reference standard via McNemar's test. Of 99 serum samples tested, 57 were CrAg positive (CrAg+) by the CrAg LFA reference standard. By CrAgSQ, 57 were read as positive, with 98% sensitivity (56/57; 95% confidence interval [CI], 0.91 to 0.99) and 98% specificity (41/42; 95% CI, 0.88 to 0.99) (McNemar's, P = 0.99). The sample with a false-negative result by CrAgSQ (n = 1) had a titer of <1:5, while the sample with a false-positive result (n = 1) yielded a 1+ result. By CryptoPS, 52 samples were read as positive, with 88% sensitivity (50/57; 95% CI, 0.76 to 0.95) and 95% specificity (40/42; 95% CI, 0.84 to 0.99) (McNemar's, P = 0.18). The CryptoPS false-negative results included samples with titers of <1:5 (n = 1), 1:5 (n = 5), and 1:20 (n = 1), while samples with false-positive results by CryptoPS (n = 2) yielded Positive results. The CryptoPS assay missed 35% (7/20) of samples with CrAg LFA titers of ≤1:20. The new semiquantitative CrAg LFAs allow rapid estimation of titer levels in easy-to-perform platforms. The CrAgSQ demonstrated better qualitative sensitivity and specificity than the CryptoPS compared to the reference standard. The exact grading of the CrAgSQ results has some subjectivity, with interreader variability; however, qualitative reads were generally concordant for both assays.
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Tenforde MW, Muthoga C, Callaghan A, Ponatshego P, Ngidi J, Mine M, Jordan A, Chiller T, Larson BA, Jarvis JN. Cost-effectiveness of reflex laboratory-based cryptococcal antigen screening for the prevention and treatment of cryptococcal meningitis in Botswana. Wellcome Open Res 2020; 4:144. [PMID: 31803848 PMCID: PMC6871359 DOI: 10.12688/wellcomeopenres.15464.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 01/26/2023] Open
Abstract
Background: Cryptococcal antigen (CrAg) screening for antiretroviral therapy (ART)-naïve adults with advanced HIV/AIDS can reduce the incidence of cryptococcal meningitis (CM) and all-cause mortality. We modeled the cost-effectiveness of laboratory-based "reflex" CrAg screening for ART-naïve CrAg-positive patients with CD4<100 cells/µL (those currently targeted in guidelines) and ART-experienced CrAg-positive patients with CD4<100 cells/µL (who make up an increasingly large proportion of individuals with advanced HIV/AIDS). Methods: A decision analytic model was developed to evaluate CrAg screening and treatment based on local CD4 count and CrAg prevalence data, and realistic assumptions regarding programmatic implementation of the CrAg screening intervention. We modeled the number of CrAg tests performed, the number of CrAg positives stratified by prior ART experience, the proportion of patients started on pre-emptive antifungal treatment, and the number of incident CM cases and CM-related deaths. Screening and treatment costs were evaluated, and cost per death or disability-adjusted life year (DALY) averted estimated. Results: We estimated that of 650,000 samples undergoing CD4 testing annually in Botswana, 16,364 would have a CD4<100 cells/µL and receive a CrAg test, with 70% of patients ART-experienced at the time of screening. Under base model assumptions, CrAg screening and pre-emptive treatment restricted to ART-naïve patients with a CD4<100 cells/µL prevented 20% (39/196) of CM-related deaths in patients undergoing CD4 testing at a cost of US$2 per DALY averted. Expansion of preemptive treatment to include ART-experienced patients with a CD4<100 cells/µL resulted in 55 additional deaths averted (a total of 48% [94/196]) and was cost-saving compared to no screening. Findings were robust across a range of model assumptions. Conclusions: Reflex laboratory-based CrAg screening for patients with CD4<100 cells/µL is a cost-effective strategy in Botswana, even in the context of a relatively low proportion of advanced HIV/AIDS in the overall HIV-infected population, the majority of whom are ART-experienced.
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Affiliation(s)
- Mark W. Tenforde
- University of Washington School of Medicine, Seattle, Washington, 98195, USA
- University of Washington School of Public Health, Seattle, WA, 98195, USA
| | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Julia Ngidi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- National Health Laboratory, Gaborone, Botswana
| | - Madisa Mine
- National Health Laboratory, Gaborone, Botswana
| | - Alexander Jordan
- Centers for Disease Controls and Prevention, Atlanta, Georgia, 30329-4018, USA
| | - Tom Chiller
- Centers for Disease Controls and Prevention, Atlanta, Georgia, 30329-4018, USA
| | - Bruce A. Larson
- Boston University School of Public Health, Boston, MA, 02118, USA
| | - Joseph N. Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- London School of Hygiene & Tropical Medicine, London, UK
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Clinical Significance of Low Serum Cryptococcal Antigen Titers by Lateral Flow Assay in Immunocompromised Patients: a Retrospective Case-Control Study. J Clin Microbiol 2020; 58:JCM.01648-19. [PMID: 31723013 DOI: 10.1128/jcm.01648-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/08/2019] [Indexed: 12/11/2022] Open
Abstract
Cryptococcus species are associated with invasive fungal infections in immunosuppressed individuals. The clinical significance of low-titer cryptococcal antigen (CrAg) by lateral flow assay is frequently uncertain. We investigated the correlation of low CrAg titers with disease in an immunocompromised patient population. Patients with first-time positive CrAg results with low serum titers (≤1:10) at two medical centers (Los Angeles, CA) from April 2014 to July 2018 were included. Age-matched controls with high (≥1:20) and negative titers were selected. We extracted medical records for pertinent clinical, radiologic, and laboratory data for cryptococcal disease. From 2,196 serum samples submitted for CrAg testing, 96 cases were included (32 each in low-titer, high-titer, and negative-titer groups). One or more immunocompromising condition was identified in 95% of patients, including HIV infection (45%), solid organ transplant (26%), and cirrhosis (22%). Pulmonary cryptococcosis was diagnosed in 9 (28%) low-titer and 8 (25%) high-titer patients (P = 1.00). Disseminated cryptococcosis occurred in 7 (22%) low-titer and 15 (47%) high-titers cases (P = 0.064). Titers ≤1:10 more frequently represented isolated antigenemia in HIV-positive than non-HIV, immunocompromised patients (P < 0.001). Follow-up testing in patients with ≤1:5 titers (n = 21) showed persistently low titers in 6 of 12 instances and increased titers in 2 cases. Twenty-seven patients with low CrAg titers were treated with antifungal therapy and 22 (81%) responded well clinically. Low-serum CrAg titers (≤1:10) correlated with cryptococcal disease in a substantial proportion of non-HIV immunocompromised patients and should prompt careful clinical workup for cryptococcal infection.
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Wykowski J, Galagan SR, Govere S, Wallis CL, Moosa MY, Celum C, Drain PK. Cryptococcal antigenemia is associated with meningitis or death in HIV-infected adults with CD4 100-200 cells/mm 3. BMC Infect Dis 2020; 20:61. [PMID: 31959112 PMCID: PMC6971851 DOI: 10.1186/s12879-020-4798-1] [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: 10/25/2019] [Accepted: 01/15/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cryptococcal antigen (CrAg) screening with fluconazole prophylaxis has been shown to prevent cryptococcal meningitis and mortality for people living with HIV (PLWH) with CD4 < 100 cells/mm3. While cryptococcal meningitis occurs in individuals with CD4 100-200 cells/mm3, there is limited evidence that CrAg screening predicts cryptococcal meningitis or mortality among this group with moderate immunosuppression. Current IDSA and WHO clinical guidelines recommend restricting CrAg screening to PLWH with CD4 < 100 cells/mm3. METHODS We conducted a prospective cohort study of PLWH 18+ years who had not initiated ART in South Africa. We followed participants for 14 months to determine onset of cryptococcal meningitis or all-cause mortality. At study completion, we retrospectively tested stored serum samples for CrAg using an enzyme immunoassay (EIA). We calculated CD4-stratified incidence rates of outcomes and used Cox proportional hazards to measure associations between CrAg positivity and outcomes. RESULTS We enrolled 2383 PLWH, and 1309 participants had serum samples tested by CrAg EIA. The median CD4 was 317 cells/mm3 (interquartile range: 173-491 cells/mm3). By CD4 count at baseline, there were 209 individuals with a CD4 count of 100-200 cells/mm3 and available CrAg test results. Of these, four (1.9%) tested positive. Two of four (IR: 58.8 per 100 person-years) CrAg+ participants and 11 of 205 (IR: 5.6 per 100 person-years) CrAg- participants developed cryptococcal meningitis or died for an overall rate of death or cryptococcal meningitis that was 10.0-times higher for those who were CrAg+ (95% confidence interval: 2.2-45.3). Among those with CD4 < 100 cell/mm3 and CrAg EIA test results (N = 179), ten (5.6%) participants tested CrAg+. Among this group, seven of ten (IR: 137.6 per 100 person-years) CrAg+ participants and 26 of 169 (IR: 17.8 per 100 person-years) CrAg- participants developed cryptococcal meningitis or died, for a rate of death or cryptococcal meningitis that was 6.3-times higher for those who were CrAg+ (95% confidence interval: 2.7-14.6). CONCLUSIONS Although few PLWH with moderate immunosuppression screened CrAg positive, a positive CrAg test was predictive of increased risk of cryptococcal meningitis or death. Similar to those with a CD4 < 100 cell/mm3, systematic CrAg screening may reduce morbidity and mortality in PLWH with CD4 100-200 cells/mm3.
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Affiliation(s)
- James Wykowski
- Department of Medicine, University of Washington, Seattle, USA.
| | | | | | | | - Mahomed-Yunus Moosa
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Connie Celum
- Department of Medicine, University of Washington, Seattle, USA.,Global Health, University of Washington, Seattle, USA
| | - Paul K Drain
- Department of Medicine, University of Washington, Seattle, USA.,Global Health, University of Washington, Seattle, USA.,Epidemiology, University of Washington, Seattle, USA
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Borges MASB, Araújo Filho JAD, Soares RDBA, Vidal JE, Turchi MD. False-negative result of serum cryptococcal antigen lateral flow assay in an HIV-infected patient with culture-proven cryptococcaemia. Med Mycol Case Rep 2019; 26:64-66. [PMID: 31737475 PMCID: PMC6849355 DOI: 10.1016/j.mmcr.2019.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/16/2019] [Accepted: 10/27/2019] [Indexed: 12/19/2022] Open
Abstract
The detection of cryptococcal capsular antigen (CrAg) is very sensitive and specific, however false-negative results have been reported, mostly in cerebrospinal fluid. We report the case of an HIV-infected patient with CD4 = 42 cells/mL, asthenic, negative serum CrAg lateral flow assay (LFA) and culture-proven cryptococcaemia. Despite the high accuracy of LFA, false-negative result is possible. Careful clinical evaluation and close follow-up are relevant.
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Affiliation(s)
- Moara Alves Santa Bárbara Borges
- Instituto de Patologia Tropical e Saúde Pública da Universidade Federal de Goiás – R. 235, S/n - Setor Leste Universitário, CEP 74605-450, Goiânia, Goiás, Brazil
| | - João Alves de Araújo Filho
- Instituto de Patologia Tropical e Saúde Pública da Universidade Federal de Goiás – R. 235, S/n - Setor Leste Universitário, CEP 74605-450, Goiânia, Goiás, Brazil
- Pontifícia Universidade Católica de Goiás – R. 235, 15 - Setor Leste Universitário, CEP 74605-050, Goiânia, Goiás, Brazil
- Hospital Estadual de Doenças Tropicais Dr. AnuarAuad, Alameda do Contorno, 3556 - Jardim Bela Vista, CEP 74850-400, Goiânia, Goiás, Brazil
| | - Renata de Bastos Ascenço Soares
- Pontifícia Universidade Católica de Goiás – R. 235, 15 - Setor Leste Universitário, CEP 74605-050, Goiânia, Goiás, Brazil
- Hospital Estadual de Doenças Tropicais Dr. AnuarAuad, Alameda do Contorno, 3556 - Jardim Bela Vista, CEP 74850-400, Goiânia, Goiás, Brazil
| | - José Ernesto Vidal
- Instituto de Infectologia Emilio Ribas, Av. Doutor Arnaldo, 165, Pacaembu, CEP 01246-900, São Paulo, São Paulo, Brazil
- Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, Cerqueira César, CEP 05403-000, São Paulo, Brazil
| | - Marília Dalva Turchi
- Instituto de Patologia Tropical e Saúde Pública da Universidade Federal de Goiás – R. 235, S/n - Setor Leste Universitário, CEP 74605-450, Goiânia, Goiás, Brazil
- Hospital Estadual de Doenças Tropicais Dr. AnuarAuad, Alameda do Contorno, 3556 - Jardim Bela Vista, CEP 74850-400, Goiânia, Goiás, Brazil
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Abstract
PURPOSE OF REVIEW Defective cell-mediated immunity is a major risk factor for cryptococcosis, a fatal disease if untreated. Cryptococcal meningitis (CM), the main presentation of disseminated disease, occurs through hematogenous spread to the brain from primary pulmonary foci, facilitated by yeast virulence factors. We revisit remarkable recent improvements in the prevention, diagnosis and management of CM. RECENT FINDINGS Cryptococcal antigen (CrAg), main capsular polysaccharide of Cryptococcus spp. is detectable in blood and cerebrospinal fluid of infected patients with point of care lateral flow assays. Recent World Health Organization guidelines recommend 7-day amphotericin B plus flucytosine, then 7-day high dose (1200 mg/day) fluconazole for induction treatment of HIV-associated CM. Management of raised intracranial pressure, a consequence of CM, should rely mainly on daily therapeutic lumbar punctures until normalisation. In HIV-associated CM, following introduction of antifungal therapy, (re)initiation of antiretroviral therapy should be delayed by 4-6 weeks to prevent immune reconstitution inflammatory syndrome, common in CM. CM is a fatal disease whose diagnosis has recently been simplified. Treatment should always include antifungal combination therapy and management of raised intracranial pressure. Screening for immune deficiency should be mandatory in all patients with cryptococcosis.
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Tenforde MW, Muthoga C, Callaghan A, Ponatshego P, Ngidi J, Mine M, Jordan A, Chiller T, Larson BA, Jarvis JN. Cost-effectiveness of reflex laboratory-based cryptococcal antigen screening for the prevention and treatment of cryptococcal meningitis in Botswana. Wellcome Open Res 2019; 4:144. [PMID: 31803848 PMCID: PMC6871359 DOI: 10.12688/wellcomeopenres.15464.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 01/06/2023] Open
Abstract
Background: Cryptococcal antigen (CrAg) screening for antiretroviral therapy (ART)-naïve adults with advanced HIV/AIDS can reduce the incidence of cryptococcal meningitis (CM) and all-cause mortality. We modeled the cost-effectiveness of laboratory-based "reflex" CrAg screening for ART-naïve CrAg-positive patients with CD4<100 cells/µL (those currently targeted in guidelines) and ART-experienced CrAg-positive patients with CD4<100 cells/µL (who make up an increasingly large proportion of individuals with advanced HIV/AIDS). Methods: A decision analytic model was developed to evaluate CrAg screening and treatment based on local CD4 count and CrAg prevalence data, and realistic assumptions regarding programmatic implementation of the CrAg screening intervention. We modeled the number of CrAg tests performed, the number of CrAg positives stratified by prior ART experience, the proportion of patients started on pre-emptive antifungal treatment, and the number of incident CM cases and CM-related deaths. Screening and treatment costs were evaluated, and cost per death or disability-adjusted life year (DALY) averted estimated. Results: We estimated that of 650,000 samples undergoing CD4 testing annually in Botswana, 16,364 would have a CD4<100 cells/µL and receive a CrAg test, with 70% of patients ART-experienced at the time of screening. Under base model assumptions, CrAg screening and pre-emptive treatment restricted to ART-naïve patients with a CD4<100 cells/µL prevented 20% (39/196) of CM-related deaths in patients undergoing CD4 testing at a cost of US$2 per DALY averted. Expansion of preemptive treatment to include ART-experienced patients with a CD4<100 cells/µL resulted in 55 additional deaths averted (a total of 48% [94/196]) and was cost-saving compared to no screening. Findings were robust across a range of model assumptions. Conclusions: Reflex laboratory-based CrAg screening for patients with CD4<100 cells/µL is a cost-effective strategy in Botswana, even in the context of a relatively low proportion of advanced HIV/AIDS in the overall HIV-infected population, the majority of whom are ART-experienced.
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Affiliation(s)
- Mark W. Tenforde
- University of Washington School of Medicine, Seattle, Washington, 98195, USA
- University of Washington School of Public Health, Seattle, WA, 98195, USA
| | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Julia Ngidi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- National Health Laboratory, Gaborone, Botswana
| | - Madisa Mine
- National Health Laboratory, Gaborone, Botswana
| | - Alexander Jordan
- Centers for Disease Controls and Prevention, Atlanta, Georgia, 30329-4018, USA
| | - Tom Chiller
- Centers for Disease Controls and Prevention, Atlanta, Georgia, 30329-4018, USA
| | - Bruce A. Larson
- Boston University School of Public Health, Boston, MA, 02118, USA
| | - Joseph N. Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- London School of Hygiene & Tropical Medicine, London, UK
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Wu X, Shen Y. Management of human immunodeficiency virus-associated cryptococcal meningitis: Current status and future directions. Mycoses 2019; 62:874-882. [PMID: 31365770 DOI: 10.1111/myc.12977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 12/30/2022]
Abstract
Cryptococcal meningitis (CM) is one of the most common opportunistic infections of acquired immunodeficiency syndrome (AIDS), as well as an important cause of hospitalisation and death. In recent years, the mortality of CM has remained high in HIV/AIDS population, with up to 30%, including within developed countries. The treatment usually encompasses controls of Cryptococcus, HIV, and increased intracranial pressure. Recent progress on the management of HIV-associated CM mainly centres in optimising induction regimens, looking for appropriate timing of initiating antiretroviral therapy and prevention of symptomatic onset and adverse consequences. This review compared several international guidelines combined with the results from some clinical researches to illustrate the similarities, differences and potential in CM treatment. The present practice is still far from satisfactory, and there remains much to explore due to our limited understanding of the pathogenesis of HIV-associated CM. Thus, screening and monitoring should be strengthened, and better therapies in line with the actual situation of each country should be discovered.
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Affiliation(s)
- Xueyun Wu
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
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Prospective cohort of AIDS patients screened for cryptococcal antigenaemia, pre-emptively treated and followed in Brazil. PLoS One 2019; 14:e0219928. [PMID: 31344140 PMCID: PMC6658077 DOI: 10.1371/journal.pone.0219928] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/03/2019] [Indexed: 01/21/2023] Open
Abstract
Background Cryptococcal meningitis has a high morbidity and mortality among AIDS population. Cryptococcal antigen (CrAg) detection is considered an independent predictor for meningitis and death. Since 2011, the World Health Organization recommends CrAg screening for people living with HIV/AIDS (PLHAs) with CD4 counts <100–200 cells/μl. Its implementation is still limited in low-middle-income countries. We aimed to estimate the prevalence and predictors of CrAg positivity in PLHAs. We also evaluated outcomes among those who were CrAg-positive. Methods Prospective cohort conducted at an infectious diseases hospital, in Brazil. Adults with CD4 <200 cells/μl, without previous cryptococcal disease and regardless of symptoms, were enrolled from 2015 to 2018. CrAg tests were performed by LFA. Lumbar puncture was done in CrAg+ individuals and pre-emptive therapy was offered for those without meningitis. Results Of 214 individuals recruited, 88% were antiretroviral experienced, of which only 11.6% with viral suppression. Overall, CrAg prevalence was 7.9% (95% CI, 4.7–12.4). In CD4 ≤100 cells/μl group it was 7.5% (95% CI, 4.1–12.6) and 9.1% (95% CI, 3.4–19.0) in the group with CD4 101 to 199 cells/μl (p = 0.17). Prevalence in asymptomatic subjects was 5.3% (95% CI, 1.4–13.1). One among 17 CrAg+ participants had documented meningoencephalitis and no subclinical meningitis was detected. Adherence to pre-emptive treatment was 68.7% (11/16). There were no statistically significant differences in sociodemographic, clinical or laboratory characteristics to predict CrAg positivity. No case of cryptococcal disease was diagnosed among CrAg + subjects, followed by a median of 12 months. Conclusions CrAg screening for severely immunosuppressed PLHAs in Brazil yielded a prevalence of 7.9%. No difference was found in the prevalence of CrAg stratified by CD4 values (CD4 <100 versus CD4 101–199 cells/μl). No clinical nor laboratory factors predicted CrAg positivity, corroborating the need for the implementation of universal CrAg screening for PLHAs with CD4 <200 cells/μl in similar settings.
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Essouma M, Tangie LN, Temgoua MN, Kenfack UG, Ndam AN, Danwang C. Severe clinical immunodeficiency in a patient with human immunodeficiency virus infection and relatively high CD4 counts: a case report. J Med Case Rep 2019; 13:86. [PMID: 30867046 PMCID: PMC6417181 DOI: 10.1186/s13256-019-1982-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/15/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The coexistence of neuromeningeal cryptococcosis and Kaposi's sarcoma is not surprising in a patient with human immunodeficiency virus infection and a low CD4 count, although it is rarely described. However, we describe such an association in a patient with human immunodeficiency virus infection and a relatively high CD4 count. CASE PRESENTATION A 41-year old Cameroonian woman presented to our hospital with subacute occipital headaches associated with photophobia, blurred vision, phonophobia, projectile vomiting, and tonic seizures. In her past history, there was an human immunodeficiency virus infection known for 12 years, for which she had been taking (with good compliance) tenofovir-lamivudine-efavirenz-based antiretroviral therapy for the same period of time. One month before the consultation, gastric Kaposi's sarcoma had been diagnosed, justifying the treatment with doxorubicin she had received. A clinical examination was unremarkable. A computed tomography scan of her brain was normal, and cerebrospinal fluid analysis revealed Cryptococcus neoformans. Her CD4 count was 353/mm3. Orally administered antifungal treatment with fluconazole (1200 mg/day) and flucytosine (1500 mg × 4/day) was started immediately, but she died on the sixth day of this treatment. CONCLUSION This clinical case shows that the coexistence of neuromeningeal cryptococcosis and gastric Kaposi's sarcoma is possible in all patients with human immunodeficiency virus infection, regardless of CD4 count.
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Affiliation(s)
- Mickael Essouma
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Larry N. Tangie
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Mazou N. Temgoua
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Ulrich Gabin Kenfack
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Antonin N. Ndam
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
- Hepatogastroenterology Unit, Yaounde General Hospital, Yaounde, Cameroon
| | - Celestin Danwang
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
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Vechi HT, Theodoro RC, de Oliveira AL, Gomes RMODS, Soares RDDA, Freire MG, Bay MB. Invasive fungal infection by Cryptococcus neoformans var. grubii with bone marrow and meningeal involvement in a HIV-infected patient: a case report. BMC Infect Dis 2019; 19:220. [PMID: 30832607 PMCID: PMC6399886 DOI: 10.1186/s12879-019-3831-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 02/19/2019] [Indexed: 01/30/2023] Open
Abstract
Background Cryptococcosis is a common opportunistic infection in patients infected by Human Immunodeficiency Virus (HIV) and is the second leading cause of mortality in Acquired Immunodeficiency Syndrome (AIDS) patients worldwide. The most frequent presentation of cryptococcal infection is subacute meningitis, especially in patients with a CD4+ T Lymphocytes count below 100 cells/μL. However, in severely immunosuppressed individuals Cryptococcus neoformans can infect virtually any human organ, including the bone marrow, which is a rare presentation of cryptococcosis. Case presentation A 45-year-old HIV-infected male patient with a CD4+ T lymphocyte count of 26 cells/μL who presented to the emergency department with fever and pancytopenia. Throughout the diagnostic evaluation, the bone marrow aspirate culture yielded encapsulated yeasts in budding, identified as Cryptococcus sp. The bone marrow biopsy revealed a hypocellularity for age and absence of fibrosis. It was observed presence of loosely formed granuloma composed of multinucleated giant cells encompassing rounded yeast like organisms stained with mucicarmine, compatible with Cryptococcus sp. Then, the patient underwent a lumbar puncture to investigate meningitis, although he had no neurological symptoms and neurological examination was normal. The cerebrospinal fluid culture yielded Cryptococcus sp. The species and genotype identification step showed the infection was caused by Cryptococcus neoformans var. grubii (genotype VNI). The patient was initially treated with amphotericin B deoxycholate plus fluconazole for disseminated cryptococcosis, according to guideline recommendations. However, the patient developed acute kidney injury and the treatment was switched for fluconazole monotherapy. The symptoms disappeared completely with recovery of white blood cells and platelets counts. Cerebrospinal fluid cultures for fungi at one and two-weeks of treatment were negative. Conclusions Bone marrow infection caused by Cryptococcus neoformans is a rare presentation of cryptococcosis. The cryptococcal infection should be included for differential diagnosis in HIV-infected patients with fever and cytopenias, especially when CD4+ T lymphocytes count is below 100 cells/μL.
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Affiliation(s)
- Hareton Teixeira Vechi
- Department of Infectious Diseases, Hospital Giselda Trigueiro, Universidade Federal do Rio Grande do Norte, 110 Cônego Monte Street, Natal, Rio Grande do Norte, RN 59037-170, Brazil.
| | - Raquel Cordeiro Theodoro
- Department of Celular Biology and Genetics/Institute of Tropical Medicine, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, RN 59078-970, Brazil
| | - Andrea Lima de Oliveira
- Department of Celular Biology and Genetics/Institute of Tropical Medicine, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, RN 59078-970, Brazil
| | - Ronald Muryellison Oliveira da Silva Gomes
- Department of Celular Biology and Genetics/Institute of Tropical Medicine, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, RN 59078-970, Brazil
| | - Rodolfo Daniel de Almeida Soares
- Department of Hematology, Universidade Federal do Rio Grande do Norte, 619ª Nilo Peçanha Avenue, Natal, Rio Grande do Norte, RN 59012-300, Brazil
| | - Munya Gandour Freire
- Department of Pathology, Hospital Universitário Onofre Lopes, 600 Nilo Peçanha Avenue, Natal, Rio Grande do Norte, RN 59012-300, Brazil
| | - Mônica Baumgardt Bay
- Department of Infectious Diseases, Hospital Giselda Trigueiro, Universidade Federal do Rio Grande do Norte, 110 Cônego Monte Street, Natal, Rio Grande do Norte, RN 59037-170, Brazil
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Tenforde MW, Walker AS, Gibb DM, Manabe YC. Rapid antiretroviral therapy initiation in low- and middle-income countries: A resource-based approach. PLoS Med 2019; 16:e1002723. [PMID: 30645592 PMCID: PMC6333330 DOI: 10.1371/journal.pmed.1002723] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In an Essay, Mark Tenforde and colleagues advocate continued provision of baseline CD4 cell count testing in HIV care in low- and middle-income countries.
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Affiliation(s)
- Mark W. Tenforde
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, United States of America
- Botswana-UPenn Partnership, Gaborone, Botswana
- * E-mail:
| | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Yukari C. Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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