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Takoutsing BD, Ooi SZY, Egu C, Gillespie CS, Dalle DU, Erhabor J, Ciuculete AC, Kesici Ö, Awad AK, Dokponou YCH, Khan M, Ikwuegbuenyi CA, Dada OE, Bandyopadhyay S, Bankole NDA. Management and outcome of intracranial fungal infections in children and adults in Africa: a scoping review. BMC Infect Dis 2024; 24:789. [PMID: 39107727 PMCID: PMC11301832 DOI: 10.1186/s12879-024-09694-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 07/31/2024] [Indexed: 08/10/2024] Open
Abstract
INTRODUCTION Intracranial fungal infections' (IcFIs) varying clinical manifestations lead to difficulties in diagnosis and treatment. African populations are disproportionately affected by the high burden of the disease. There is a lack of clarity as to the diagnostic and treatment modalities employed across the continent. In this review, we aim to detail the management, and outcome of IcFIs across Africa. METHODS This scoping review was conducted using the Arksey and O'Malley framework. MEDLINE, EMBASE, Cochrane Library, African Index Medicus, and African Journals Online were searched for relevant articles from database inception to August 10th, 2021. The Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews guidelines were used to report the findings of the review. RESULTS Of the 5,779 records identified, 131 articles were included. The mean age was 35.6 years, and the majority (56.4%) were males. The majority (n = 8,433/8,693, 97.0%) of IcFIs presented as a meningitis, the most common communicable predisposing factor of IcFIs was HIV/AIDS (n = 7,815/8,693, 89.9%), and the most common non-communicable risk factor was diabetes mellitus (n = 32/8,693, 0.4%). Cryptococcus species was the most common (n = 8,428/8,693, 97.0%) causative organism. The most commonly used diagnostic modality was cerebrospinal (CSF) cultures (n = 4,390/6,830, 64.3%) for diffuse IcFIs, and MRI imaging (n = 12/30, 40%) for focal IcFIs. The most common treatment modality was medical management with antifungals only (n = 4,481/8,693, 51.6%). The most commonly used antifungal agent in paediatric, and adult patients was amphotericin B and fluconazole dual therapy (51.5% vs 44.9%). The overall mortality rate was high (n = 3,475/7,493, 46.3%), and similar for both adult and paediatric patients (47.8% vs 42.1%). CONCLUSION Most IcFIs occurred in immunosuppressed individuals, and despite the new diagnostic techniques, CSF culture was mostly used in Africa. Antifungals regimens used was similar between children and adults. The outcome of IcFIs in Africa was poor for both paediatric and adult patients.
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Affiliation(s)
| | | | - Chinedu Egu
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Conor S Gillespie
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - David Ulrich Dalle
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Joshua Erhabor
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | | | - Özgür Kesici
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Ahmed K Awad
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | | | - Mehdi Khan
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | | | | | - Soham Bandyopadhyay
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
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Musubire A, Kagimu E, Mugabi T, Meya DB, Boulware DR, Bahr NC. Complex Decisions in HIV-Related Cryptococcosis: Addressing Second Episodes of Cryptococcal Meningitis. Curr HIV/AIDS Rep 2024; 21:75-85. [PMID: 38400871 PMCID: PMC11016006 DOI: 10.1007/s11904-024-00691-3] [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] [Accepted: 02/08/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE OF REVIEW This review highlights the difficulties in diagnosing and treating persons with a prior history of cryptococcal meningitis who improve but suffer from a recurrence of symptoms. This scenario is well known to those who frequently care for patients with cryptococcal meningitis but is not well understood. We highlight major gaps in knowledge. RECENT FINDINGS We recently summarized our experience with 28 persons with paradoxical immune reconstitution inflammatory syndrome (IRIS) and 81 persons with microbiological relapse. CD4 count and cerebrospinal fluid white blood cell count were higher in IRIS than relapse but neither was reliable enough to routinely differentiate these conditions. Second-episode cryptococcal meningitis remains a difficult clinical scenario as cryptococcal antigen, while excellent for initial diagnosis has no value in differentiating relapse of infection from other causes of recurrent symptoms. Updated research definitions are proposed and rapid, accurate diagnostic tests are urgently needed.
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Affiliation(s)
- Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, 66160 KS, USA.
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Zhao H, Lu Y, Li S, Qin J, Xu M, Ye H, Yang Z, Rao J, Chen G, Su F, Hu Z, Xu L. Voriconazole plus flucytosine is not superior to amphotericin B deoxycholate plus flucytosine as an induction regimen for cryptococcal meningitis treatment. Mycoses 2024; 67:e13674. [PMID: 37986630 DOI: 10.1111/myc.13674] [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: 08/17/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The efficacy and side effects of voriconazole plus 5-flucytosine (Vori + 5-FC) versus amphotericin B deoxycholate plus 5-flucytosine (AmBd + 5-FC) as an induction treatment for cryptococcal meningitis are unknown. METHODS Forty-seven patients treated with Vori + 5-FC and 92 patients treated with AmBd + 5-FC were included in the current study after propensity score matching (PSM) at a ratio of 1:2. Two-week laboratory test results and 90-day mortality were compared between the two groups. RESULTS After 2 weeks of induction treatment, the CSF Cryptococcus sterile culture rate was 57.1% in the Vori + 5-FC group and 76.5% in the AmBd + 5-FC group (p = .026). No difference was found in the normalization of CSF indicators (glucose, total protein, intracranial pressure and India ink sterile rate) between the two groups. Both the Vori + 5FC regimen and AmBd + 5-FC regimen obviously decreased haemoglobin concentrations, platelet counts and serum potassium levels (all p ≤ .010). Notably, the Vori + 5FC regimen did not influence serum creatinine levels (p = .263), while AmBd + 5FC increased serum creatinine levels (p = .019) after 2-week induction treatment. The Vori + 5-FC group and AmBd + 5-FC group had similar 90-day cumulative survival rates (89.9% vs. 87.8%, p = .926). CONCLUSION The Vori + 5-FC regimen was associated with low 2-week CSF sterile culture and was not superior to AmBd + 5-FC as induction therapy in terms of the 90-day cumulative survival rate of CM patients.
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Affiliation(s)
- Handan Zhao
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yanqiu Lu
- Chongqing Public Health Medical Center, Southwest University Public Health Hospital, Chongqing, China
| | - Shan Li
- Department of Infectious Diseases, The Ninth Hospital of Nanchang, Nanchang, China
| | - Jiangying Qin
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Miaomiao Xu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Hui Ye
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
| | - Zongxing Yang
- Xixi Hospital of Hangzhou, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianfeng Rao
- Department of Infectious Diseases, The Ninth Hospital of Nanchang, Nanchang, China
| | - Guochun Chen
- Department of Infectious Diseases, The Third Peoples' Hospital of Changzhou, Changzhou, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Lijun Xu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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McHale TC, Boulware DR, Kasibante J, Ssebambulidde K, Skipper CP, Abassi M. Diagnosis and management of cryptococcal meningitis in HIV-infected adults. Clin Microbiol Rev 2023; 36:e0015622. [PMID: 38014977 PMCID: PMC10870732 DOI: 10.1128/cmr.00156-22] [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] [Indexed: 11/29/2023] Open
Abstract
Cryptococcal meningitis is a leading cause of morbidity and mortality globally, especially in people with advanced HIV disease. Cryptococcal meningitis is responsible for nearly 20% of all deaths related to advanced HIV disease, with the burden of disease predominantly experienced by people in resource-limited countries. Major advancements in diagnostics have introduced low-cost, easy-to-use antigen tests with remarkably high sensitivity and specificity. These tests have led to improved diagnostic accuracy and are essential for screening campaigns to reduce the burden of cryptococcosis. In the last 5 years, several high-quality, multisite clinical trials have led to innovations in therapeutics that have allowed for simplified regimens, which are better tolerated and result in less intensive monitoring and management of medication adverse effects. One trial found that a shorter, 7-day course of deoxycholate amphotericin B is as effective as the longer 14-day course and that flucytosine is an essential partner drug for reducing mortality in the acute phase of disease. Single-dose liposomal amphotericin B has also been found to be as effective as a 7-day course of deoxycholate amphotericin B. These findings have allowed for simpler and safer treatment regimens that also reduce the burden on the healthcare system. This review provides a detailed discussion of the latest evidence guiding the clinical management and special circumstances that make cryptococcal meningitis uniquely difficult to treat.
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Affiliation(s)
- Thomas C. McHale
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Caleb P. Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Ssebambulidde K, Anjum SH, Hargarten JC, Chittiboina P, Shoham S, Seyedmousavi S, Marr KA, Hammoud DA, Billioux BJ, Williamson PR. Treatment recommendations for non-HIV associated cryptococcal meningoencephalitis including management of post-infectious inflammatory response syndrome. Front Neurol 2022; 13:994396. [PMID: 36530631 PMCID: PMC9751747 DOI: 10.3389/fneur.2022.994396] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/04/2022] [Indexed: 08/29/2023] Open
Abstract
Cryptococcal meningoencephalitis (CM) continues to cause major morbidity and mortality in a range of patients such as those immunosuppressed from HIV and with biologic immunosuppressants, including treatments of autoimmunity, malignancies, and conditioning regimens for transplantation. It is currently the most common cause of non-viral meningitis in the United States. Infections in previously healthy patients also develop with autoantibodies to granulocyte-macrophage colony stimulating factor or with monogenetic defects. In all populations, mortality and significant long-term morbidity occur in 30-50% despite therapy, and immune reconstitution and post-infectious inflammatory response syndromes complicate management. To help with these difficult cases, we present here a practical tutorial of the care of a range of patients with CM in the absence of HIV/AIDS.
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Affiliation(s)
- Kenneth Ssebambulidde
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Seher H. Anjum
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Jessica C. Hargarten
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Shmuel Shoham
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Kieren A. Marr
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Bridgette Jeanne Billioux
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Peter R. Williamson
- Translational Mycology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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Zhao H, Cheng J, Zhou L, Luo Y, Zhu R, Jiang Y, Wang X, Zhu L. Induction therapy with high dose fluconazole plus flucytosine for human immunodeficiency virus‐uninfected cryptococcal meningitis patients: Feasible or not? Mycoses 2022; 66:59-68. [PMID: 36111370 PMCID: PMC10087831 DOI: 10.1111/myc.13528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/05/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cryptococcal meningitis (CM) is increasingly recognised in human immunodeficiency virus (HIV)-uninfected patients with high mortality. The efficacy and safety profiles of induction therapy with high-dose fluconazole plus flucytosine remain unclear. METHODS HIV-uninfected CM patients who received high-dose fluconazole (800 mg/d) for initial therapy in Huashan Hospital were included in this retrospective study from January 2013 to December 2018. Efficacy and safety of initial therapy, clinical outcomes and risk factors were evaluated. RESULTS Twenty-seven (71.1%) patients who received high-dose fluconazole with flucytosine combination therapy and 11 (28.9%) having fluconazole alone for induction therapy were included. With a median duration of 42 days (IQR, 28-86), the successful response rate of initial therapy was 76.3% (29/38), while adverse drug reactions occurred in 14 patients (36.8%). The rate of persistently positive cerebrospinal fluid (CSF) culture results was 30.6% at 2 weeks, which was significantly associated with CSF CrAg titre >1:1280 (OR 9.56; 95% CI 1.40-103.65; p = .010) and CSF culture of Cryptococcus >3.9 log10 CFU/ml (OR 19.20; 95% CI 1.60-920.54; p = .011), and decreased to 8.6% at 4 weeks. One-year mortality was 15.8% (6/38), and low serum albumin (35 g/L) was found as an independent risk factor for 1-year mortality (HR 6.31; 95% CI 1.150-34.632; p = .034). CONCLUSIONS Induction therapy with high-dose fluconazole (800 mg/d), combined with flucytosine, effectively treated HIV-uninfected CM and was well tolerated. Long-term fluconazole treatment with continued monitoring is beneficial for patients with persistent infection.
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Affiliation(s)
- Hua‐Zhen Zhao
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Jia‐Hui Cheng
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Ling‐Hong Zhou
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Yu Luo
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Rong‐Sheng Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Ying‐Kui Jiang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Xuan Wang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Li‐Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
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Yetmar ZA, Ranganath N, Mendoza MA, Razonable RR. Clinical and Microbiologic Outcomes of Central Nervous System Cryptococcosis: Re-examining the Need for a 2-Week Cerebrospinal Fluid Analysis. Mycoses 2022; 65:733-740. [PMID: 35535694 DOI: 10.1111/myc.13467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cryptococcus spp. infection involving the central nervous system (CNS) is associated with poor outcomes. Current guidelines recommend repeating a cerebrospinal fluid (CSF) fungal culture after 2 weeks of treatment to evaluate for clearance. However, this practice has not clearly been associated with outcomes. OBJECTIVES We sought to assess the relationship between CSF fungal clearance at 2 weeks and 12-month mortality in patients with CNS cryptococcosis. METHODS This is a retrospective cohort study from 2011-2020 of patients with CNS cryptococcosis. Factors associated with 12-month mortality were assessed with Fisher's exact test for categorical variables and Mann-Whitney test for continuous variables. RESULTS Among 51 patients with CNS cryptococcosis, 42 (82.4%) were initially CSF culture positive. Among 27 patients with follow-up CSF culture at 2 weeks, 6 (22.2%) had a positive result. Factors associated with a positive CSF culture at 2 weeks were an initial CSF cryptococcal antigen titer ≥1:2560, fungemia, and an elevated intracranial pressure requiring therapeutic lumbar punctures. The 12-month mortality rate was 33.3% and this was significantly associated with baseline fungemia, extra-CNS cryptococcal involvement and requirement of intensive care unit level of care. Lack of CSF culture clearance by 2 weeks was not associated with 12-month mortality. CONCLUSIONS CNS cryptococcosis has a high mortality rate. A markedly elevated CSF cryptococcal antigen and opening CSF pressure was associated with lack of CSF culture clearance at 2 weeks of treatment. Severe disseminated disease and cryptococcemia were associated with 12-month mortality.
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Affiliation(s)
- Zachary A Yetmar
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Nischal Ranganath
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria A Mendoza
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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Stead GA, Cresswell FV, Jjunju S, Oanh PK, Thwaites GE, Donovan J. The role of optic nerve sheath diameter ultrasound in brain infection. eNeurologicalSci 2021; 23:100330. [PMID: 33728383 PMCID: PMC7935708 DOI: 10.1016/j.ensci.2021.100330] [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: 12/21/2020] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
Abstract
Brain infections cause significant morbidity and mortality worldwide, especially in resource-limited settings with high HIV co-infection rates. Raised intracranial pressure [ICP] may complicate brain infection and worsen neurological injury, yet invasive ICP monitoring is often unavailable. Optic nerve sheath diameter [ONSD] ultrasound may allow detection of raised ICP at the bedside; however, pathology in brain infection is different to traumatic brain injury, in which most studies have been performed. The use of ONSD ultrasound has been described in tuberculous meningitis, cryptococcal meningitis and cerebral malaria; however correlation with invasive ICP measurement has not been performed. Normal optic nerve sheath values are not yet established for most populations, and thresholds for clinical intervention cannot be assumed to match those used in non-infective brain pathology. ONSD ultrasound may be suitable for use in resource-limited settings by clinicians with limited ultrasound training. Standardisation of scanning technique, consensus on normal ONSD values, and action on abnormal results, are areas for future research. This scoping review examines the role of ONSD ultrasound in brain infection. We discuss pathophysiology, and describe the rationale, practicalities, and challenges of utilising ONSD ultrasound for brain infection monitoring and management. We discuss the existing evidence base for this technique, and identify knowledge gaps and future research priorities.
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Key Words
- AIDS, Acquired immunodeficiency syndrome
- Brain infection
- CSF, Cerebrospinal fluid
- HIV, Human immunodeficiency virus
- ICP, Intracranial pressure
- IQR, Interquartile range
- IRIS, Immune reconstitution inflammatory syndrome
- LP, Lumbar puncture
- MAP, Mean arterial pressure
- Meningitis
- ONSD, Optic nerve sheath diameter
- Optic nerve sheath diameter
- ROC, Receiver-operator characteristic
- Raised intracranial pressure
- SD, Standard deviation
- TB meningitis, Tuberculous meningitis
- TBI, Traumatic brain injury
- Ultrasound
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Affiliation(s)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, Kampala, Uganda
- Clinical Research Department London School of Hygiene and Tropical Medicine, London, United Kingdom
- Medical Research Council – Uganda Virus Research Institute - London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Pham K.N. Oanh
- Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Guy E. Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
| | - Joseph Donovan
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
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Kitonsa J, Kiwanuka J, Anywaine Z, Kansiime S, Katumba K, Aeron N, Beardsley J, Kibengo F, Gray A, Kaleebu P, Day J. Quality of life and associated factors among HIV positive patients after completion of treatment for Cryptococcal meningitis. PLoS Negl Trop Dis 2021; 15:e0008983. [PMID: 33657099 PMCID: PMC7959361 DOI: 10.1371/journal.pntd.0008983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 03/15/2021] [Accepted: 11/13/2020] [Indexed: 11/30/2022] Open
Abstract
Background Cryptococcal meningitis (CCM) remains one of the leading causes of mortality among HIV infected patients. Due to factors such as the severity of CCM pathology, the quality of life (QOL) of patients post-treatment is likely to be poor. Few studies have reported on QOL of CCM patients post treatment completion. We used data collected among patients in the CryptoDex trial (ISRCTN59144167) to determine QOL and associated factors at week 10 and six months from treatment initiation. Methodology CryptoDex was a double-blind placebo-controlled trial of adjunctive dexamethasone in HIV infected adults with CCM, conducted between 2013 and 2015 in six countries in Asia and Africa. QOL was determined using the descriptive and Visual Analog Scales (VAS) of the EuroQol Five-Dimension-Three-Level (EQ-5D-3L) tool. We derived index scores, and described these and the VAS scores at 10 weeks and 6 months; and used linear regression to determine the relationship between various characteristics and VAS scores at both time points. VAS scores were interpreted as very good (81–100), good (51–80), normal (31–50) and bad/very bad (0–30). Results Of 451 patients enrolled in the trial, 238 had QOL evaluations at week 10. At baseline, their mean age (SD) was 35.2(8.5) years. The mean index scores (SD) were 0.785(0.2) and 0.619(0.4) among African and Asian patients respectively at week 10, and 0.879(0.2) and 0.731(0.4) among African and Asian patients respectively at month six. The overall mean VAS score (SD) at 10 weeks was 57.2 (29.7), increasing significantly to 72(27.4) at month six (p<0.001). At week 10, higher VAS score was associated with greater weight (p = 0.007) and being African (p<0.001), while lower VAS score was associated with positive yeast culture at day 14 (p = 0.026). At month six, higher VAS score remained associated with African origin (p = 0.006) while lower VAS score was associated with positive yeast culture (p = 0.006). Lower VAS scores were associated with higher number of inpatient days at 10 weeks and 6 months (p = 0.003 and 0.002 respectively). Conclusion QOL was good among patients that had completed therapy for CCM, but below perfect. Strategies to improve QOL among CCM survivors are required. In spite of the remarkable reduction in Cryptococcal meningitis (CCM) related morbidity and mortality with increased use of antiretroviral therapy, incidence remains unacceptably high especially in sub-Saharan Africa and Asia where more than 90% of the cases and deaths occur. Due to factors such as the severity of CCM pathology, the quality of life (QOL) of patients post-treatment is also likely to be poor. Few studies have reported on QOL of CCM patients post treatment completion. We used data collected among patients in the CryptoDex trial (ISRCTN59144167) to determine self-perceived QOL and associated factors among 238 survivors at week 10 and 203 survivors at six months from treatment initiation. We determined QOL using the descriptive and Visual Analog Scales (VAS) of the EuroQol Five-Dimension-Three-Level (EQ-5D-3L) tool. We found that while self-perceived QOL was only relatively good among this cohort of patients who had survived through treatment for CCM, it continued to improve over the 6 months following diagnosis. Low weight at diagnosis, prolonged hospital admission, positive yeast culture at day 14/treatment completion, and being Asian were associated with lower QOL. QOL is an important outcome that should be considered among HIV infected patients treated for serious infections such as CCM.
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Affiliation(s)
- Jonathan Kitonsa
- Medical Research Council / Uganda Virus Research institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- * E-mail: ,
| | - Julius Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University Kampala, Uganda
| | - Zacchaeus Anywaine
- Medical Research Council / Uganda Virus Research institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Sheila Kansiime
- Medical Research Council / Uganda Virus Research institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Kenneth Katumba
- Medical Research Council / Uganda Virus Research institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Namirembe Aeron
- Medical Research Council / Uganda Virus Research institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Justin Beardsley
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Vietnam, Ho Chi Minh City, Vietnam
- Marie Bashir Institute, Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Freddie Kibengo
- Medical Research Council / Uganda Virus Research institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Pontiano Kaleebu
- Medical Research Council / Uganda Virus Research institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jeremy Day
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Vietnam, Ho Chi Minh City, Vietnam
- Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Headington, Oxford,United Kingdom
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HIV-Associated Cryptococcal Meningitis Patients Treated with Amphotericin B Deoxycholate Plus Flucytosine under Routine Care Conditions in a Referral Center in São Paulo, Brazil. Mycopathologia 2020; 186:93-102. [PMID: 33258083 DOI: 10.1007/s11046-020-00512-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/19/2020] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cryptococcal meningitis remains a common cause of mortality in low- and middle-income countries, where amphotericin B deoxycholate (amphotericin) plus fluconazole is the most common treatment. Flucytosine is almost uniformly absent as is outcome data on flucytosine use in routine care. The main goal of this study was identified the cumulative mortality at 2, 4, and 10 weeks after hospital admission. METHODS We conducted a retrospective, observational cohort study among HIV-infected adults with cryptococcal meningitis receiving amphotericin plus flucytosine as induction therapy in Brazil. We assessed cumulative mortality at 2, 4, and 10 weeks and the cumulative proportion discontinuating amphotericin or flucytosine due to toxicity at 2 weeks. We performed multiple logistic regression to identify variables associated with in-hospital mortality. RESULTS In total, 77 individuals (n = 66 men) were included with median baseline CD4 of 29 (IQR, 9-68) cells/mcL. Twenty (26%) had at least one concurrent neurological disease diagnosed. Sixty (78%) patients received at least 14 days of amphotericin plus flucytosine. Cumulative mortality was 5% (4/77) at 2 weeks, 8% (6/77) at 4 weeks, and 19% (15/77) at 10 weeks. Cumulative proportion of patients that discontinuated amphotericin or flucytosine due to toxicity was 20% (16/77) at 2 weeks. In addition, in-hospital mortality was associated with receiving ≤ 10 days of induction therapy (odds ratio = 4.5, 95% CI 1.2-17.1, P = 0.028) or positive cerebrospinal fluid fungal culture after 2 weeks (odds ratio = 3.8, 95% CI 1.1-13.5, P = 0.035). CONCLUSION In this "real-world" study, amphotericin plus flucytosine shows low early mortality of patients with HIV-associated cryptococcal meningitis. Early discontinuation due to adverse events was moderate. More effective and safe antifungals are needed in order to improve the outcome of cryptococcal meningitis.
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12
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Skipper C, Schleiss MR, Bangdiwala AS, Hernandez-Alvarado N, Taseera K, Nabeta HW, Musubire AK, Lofgren SM, Wiesner DL, Rhein J, Rajasingham R, Schutz C, Meintjes G, Muzoora C, Meya DB, Boulware DR. Cytomegalovirus Viremia Associated With Increased Mortality in Cryptococcal Meningitis in Sub-Saharan Africa. Clin Infect Dis 2020; 71:525-531. [PMID: 31504335 PMCID: PMC7384323 DOI: 10.1093/cid/ciz864] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/30/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis and tuberculosis are both important causes of death in persons with advanced human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). Cytomegalovirus (CMV) viremia may be associated with increased mortality in persons living with HIV who have tuberculosis. It is unknown whether concurrent CMV viremia is associated with mortality in other AIDS-related opportunistic infections. METHODS We prospectively enrolled Ugandans living with HIV who had cryptococcal meningitis from 2010-2012. Subsequently, we analyzed stored baseline plasma samples from 111 subjects for CMV DNA. We compared 10-week survival rates among those with and without CMV viremia. RESULTS Of 111 participants, 52% (58/111) had detectable CMV DNA (median plasma viral load 498 IU/mL, interquartile range [IQR] 259-2390). All samples tested were positive on immunoglobin G serology. The median CD4+ T cell count was 19 cells/µL (IQR 9-70) and did not differ by the presence of CMV viremia (P = .47). The 10-week mortality rates were 40% (23/58) in those with CMV viremia and 21% (11/53) in those without CMV viremia (hazard ratio 2.19, 95% confidence interval [CI] 1.07-4.49; P = .03), which remained significant after a multivariate adjustment for known risk factors of mortality (adjusted hazard ratio 3.25, 95% CI 1.49-7.10; P = .003). Serum and cerebrospinal fluid cytokine levels were generally similar and cryptococcal antigen-specific immune stimulation responses did not differ between groups. CONCLUSIONS Half of persons with advanced AIDS and cryptococcal meningitis had detectable CMV viremia. CMV viremia was associated with an over 2-fold higher mortality rate. It remains unclear whether CMV viremia in severely immunocompromised persons with cryptococcal meningitis contributes directly to this mortality or may reflect an underlying immune dysfunction (ie, cause vs effect). CLINICAL TRIALS REGISTRATION NCT01075152.
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Affiliation(s)
- Caleb Skipper
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Mark R Schleiss
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | | | - Kabanda Taseera
- Department of Medicine, Mbarara University of Science and Technology, Uganda
| | - Henry W Nabeta
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Sarah M Lofgren
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Darin L Wiesner
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Joshua Rhein
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, South Africa
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Uganda
| | - David B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
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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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14
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Chesdachai S, Rajasingham R, Nicol MR, Meya DB, Bongomin F, Abassi M, Skipper C, Kwizera R, Rhein J, Boulware DR. Minimum Inhibitory Concentration Distribution of Fluconazole against Cryptococcus Species and the Fluconazole Exposure Prediction Model. Open Forum Infect Dis 2019; 6:5550889. [PMID: 31420668 PMCID: PMC6767974 DOI: 10.1093/ofid/ofz369] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Fluconazole is lifesaving for treatment and prevention of cryptococcosis; however, optimal dosing is unknown. Initial fluconazole doses of 100mg to 2000mg/day have been used. Prevalence of fluconazole non-susceptible Cryptococcus is increasing over time, risking the efficacy of long-established standard dosing. Based on current minimum inhibitory concentration (MIC) distribution, we modeled fluconazole concentration and area under the curve (AUC) relative to MIC to propose a rational fluconazole dosing strategy. METHODS First, we conducted a systematic review using MEDLINE database for reports of fluconazole MIC distribution against clinical Cryptococcus isolates. Second, we utilized fluconazole concentrations from 92 Ugandans who received fluconazole 800mg/day coupled with fluconazole's known pharmacokinetics to predict plasma fluconazole concentrations for doses ranging from 100mg to 2000mg via linear regression. Third, the fluconazole AUC above MIC ratio were calculated using Monte Carlo simulation and using the MIC distribution elucidated during the systemic review. RESULTS We summarized 21 studies with 11,049 clinical Cryptococcus isolates. MICs were normally distributed with geometric mean of 3.4 μg/mL, median (MIC50) of 4 μg/mL, and 90th percentile (MIC90) of 16 μg/mL. The median MIC50 trended upwards from 4 μg/mL in 2000-2012 to 8 μg/mL in 2014-2018. Predicted sub-therapeutic fluconazole concentrations (below MIC) would occur in 40% with 100mg, 21% with 200mg, and 9% with 400mg. AUC/MIC ratio >100 would occur in 53% for 400mg, 74% for 800mg, 83% for 1200mg, and 88% for 1600mg. CONCLUSIONS Currently recommended fluconazole doses may be inadequate for cryptococcosis. Further clinical studies are needed for rational fluconazole dose selection.
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Affiliation(s)
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Melanie R Nicol
- College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Caleb Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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15
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Skipper C, Abassi M, Boulware DR. Diagnosis and Management of Central Nervous System Cryptococcal Infections in HIV-Infected Adults. J Fungi (Basel) 2019; 5:jof5030065. [PMID: 31330959 PMCID: PMC6787675 DOI: 10.3390/jof5030065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/24/2022] Open
Abstract
Cryptococcal meningitis persists as a significant source of morbidity and mortality in persons with HIV/AIDS, particularly in sub-Saharan Africa. Despite increasing access to antiretrovirals, persons presenting with advanced HIV disease remains common, and Cryptococcus remains the most frequent etiology of adult meningitis. We performed a literature review and herein present the most up-to-date information on the diagnosis and management of cryptococcosis. Recent advances have dramatically improved the accessibility of timely and affordable diagnostics. The optimal initial antifungal management has been newly updated after the completion of a landmark clinical trial. Beyond antifungals, the control of intracranial pressure and mitigation of toxicities remain hallmarks of effective treatment. Cryptococcal meningitis continues to present challenging complications and continued research is needed.
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Affiliation(s)
- Caleb Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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16
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Zhao HZ, Wang RY, Wang X, Jiang YK, Zhou LH, Cheng JH, Huang LP, Harrison TS, Zhu LP. High dose fluconazole in salvage therapy for HIV-uninfected cryptococcal meningitis. BMC Infect Dis 2018; 18:643. [PMID: 30541454 PMCID: PMC6291952 DOI: 10.1186/s12879-018-3460-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 10/31/2018] [Indexed: 12/16/2022] Open
Abstract
Background The 2010 Infectious Diseases Society of America (IDSA) guidelines for management of cryptococcal diseases recommend high dose fluconazole (≥ 800 mg/day), either alone or with other antifungal drugs, as alternative anticryptococcal choices. But evidence for its use in the treatment of HIV-uninfected cryptococcal meningitis (CM) remains sparse. Methods A retrospective analysis of HIV-uninfected CM patients who received fluconazole 800 mg/day for salvage therapy from January 2011 to December 2016 at Huashan Hospital, Shanghai, China was performed. Efficacy and safety were assessed, and mortality and prognostic factors evaluated. Results A total of 44 patients were studied including 19 refractory to amphotericin B induction therapy, 8 refractory to fluconazole consolidation therapy (400 mg/d), and 17 intolerant of antifungal drugs. For salvage, 11 patients received triple therapy of high dose fluconazole, amphotericin B and flucytosine, 20 received dual therapy of high dose fluconazole and flucytosine, 13 received monotherapy of high dose fluconazole. Median duration of high dose fluconazole in salvage regimens was 136.5 days (range, 1–667 days). Clinical response rates were 72.1% (31/43) and 83.7% (36/43) when assessed at 2 weeks and the end of salvage therapy, respectively. Adverse events possibly related to high dose fluconazole occurred in 54.5% (24/44) of the patients, and all were mild or moderate. From the initiation of salvage therapy, 1-year all-cause mortality was 13.6% (6 of 44 patients) among the study population with no significant difference in refractory or intolerant patients. Conclusions Adherence to guideline recommendations of high dose fluconazole, alone or in combination with other antifungals, was safe and often effective for salvage therapy of HIV-uninfected CM patients.
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Affiliation(s)
- Hua-Zhen Zhao
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Central Urumqi Road, Shanghai, China
| | - Rui-Ying Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Central Urumqi Road, Shanghai, China
| | - Xuan Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Central Urumqi Road, Shanghai, China
| | - Ying-Kui Jiang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Central Urumqi Road, Shanghai, China
| | - Ling-Hong Zhou
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Central Urumqi Road, Shanghai, China
| | - Jia-Hui Cheng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Central Urumqi Road, Shanghai, China
| | - Li-Ping Huang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Central Urumqi Road, Shanghai, China
| | - Thomas Stephen Harrison
- Institute of Infection and Immunity, St George's, University of London, London, SW17, 0RE, UK.
| | - Li-Ping Zhu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Central Urumqi Road, Shanghai, China.
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Murphy RA, Hatlen TJ, Moosa MYS. High-Dose Fluconazole Consolidation Therapy for Cryptococcal Meningitis in Sub-Saharan Africa: Much to Gain, Little to Lose. AIDS Res Hum Retroviruses 2018; 34:399-403. [PMID: 29353491 DOI: 10.1089/aid.2017.0240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cryptococcal meningitis accounts for an estimated 25% of AIDS-associated mortality in sub-Saharan Africa. Accumulating animal and human evidence suggest that a higher, more fungicidal, dose of fluconazole during consolidation therapy could be more effective in controlling residual infection and may help significantly reduce posthospitalization mortality. Although the potential for toxicity is low, the use of fluconazole at a dose of 800 mg/day during consolidation therapy requires examination in a randomized clinical trial. In the interim, within countries where postdischarge mortality from cryptococcal meningitis is high and amphotericin-flucytosine combination therapy remains unavailable, the use of high-dose fluconazole consolidation therapy deserves serious consideration as a strategy with limited risk and the potential for considerable public health benefit.
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Affiliation(s)
- Richard A. Murphy
- Department of Medicine, Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Timothy J. Hatlen
- Department of Medicine, Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Mahomed-Yunus S. Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Mora DJ, Ferreira-Paim K, Andrade-Silva LE, Bragine T, Rocha IH, Ribeiro BDM, Machado GH, Rodrigues Junior V, Silva-Teixeira DN, Meyer W, Silva-Vergara ML. Cytokine patterns in a prospective cohort of HIV-infected patients with cryptococcal meningitis following initiation of antifungal and antiretroviral therapy. PLoS One 2017; 12:e0176304. [PMID: 28486489 PMCID: PMC5423598 DOI: 10.1371/journal.pone.0176304] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/07/2017] [Indexed: 12/23/2022] Open
Abstract
Cryptococcal meningitis (CM) is a life-threatening infection in HIV-infected patients, especially in resource-limited settings. Cytokine patterns in the cerebrospinal fluid (CSF) and sera may be related to clinical outcomes. This study aimed to evaluate cytokine patterns in the CSF and sera of HIV-infected patients with CM as well as the cytokines produced by peripheral blood mononuclear cells (PBMCs) when stimulated with LPS and cryptococcal GXM. CSF and serum levels of IL-2, IL-4, IL-8, IL-10, IL-12p40, IL-17A, INF-γ, TNF-α and CXCL-10 were measured in HIV-infected patients with CM (CM+ HIV+) at various time points. Cytokine levels were evaluated in the PBMC culture supernatants and the baseline values were compared to those of HIV-infected patients without CM (CM- HIV+) and healthy controls (CM- HIV-). CSF cytokine levels at admission (n = 33) were higher than levels among the 23 survivors at week 2, but statistically significant differences were observed for IL-8 and IFN-γ (p<0.05). CSF and serum levels of IL-4 and IL-17A at week 10 (n = 16) were lower than the baseline values, whereas IL-2 levels increased compared to week 2 (p<0.05). At week 16 (n = 15), CSF and serum levels of IL-4, IL-10 and CXCL-10 were decreased compared to the baseline values (p<0.05). PBMCs from CM- HIV- individuals produced significantly higher levels of proinflammatory cytokines in response to LPS, with the exception of TNF-α, which showed higher levels among CM+ HIV+ patients. The PBMCs of CM patients produced higher levels of IL-4 than those of CM- HIV- patients in response to GXM stimulation, and levels progressively decreased during treatment (p<0.05). Then, a progressive shift in cytokine expression favoring a Th1 pattern was observed, which is crucial in controlling cryptococcal infection. A better understanding of the protective immune response against Cryptococcus neoformans will help to develop novel strategies to improve the outcomes of patients with cryptococcosis.
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Affiliation(s)
- Delio José Mora
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
- * E-mail:
| | - Kennio Ferreira-Paim
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | | | - Thatiane Bragine
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | - Ivonete Helena Rocha
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | - Barbara de Melo Ribeiro
- Infectious Diseases Unit, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | | | | | - David Nascimento Silva-Teixeira
- Institute of Health Sciences, Department of Clinical Medicine, Triângulo Mineiro Federal University, Uberaba, Minas Gerais, Brazil
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School-Westmead Hospital, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
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Repeated therapeutic lumbar punctures in cryptococcal meningitis – necessity and/or opportunity? Curr Opin Infect Dis 2016; 29:539-545. [DOI: 10.1097/qco.0000000000000315] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Srichatrapimuk S, Sungkanuparph S. Integrated therapy for HIV and cryptococcosis. AIDS Res Ther 2016; 13:42. [PMID: 27906037 PMCID: PMC5127046 DOI: 10.1186/s12981-016-0126-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/16/2016] [Indexed: 12/27/2022] Open
Abstract
Cryptococcosis has been one of the most common opportunistic infections and causes of mortality among HIV-infected patients, especially in resource-limited countries. Cryptococcal meningitis is the most common form of cryptococcosis. Laboratory diagnosis of cryptococcosis includes direct microscopic examination, isolation of Cryptococcus from a clinical specimen, and detection of cryptococcal antigen. Without appropriate treatment, cryptococcosis is fatal. Early diagnosis and treatment is the key to treatment success. Treatment of cryptococcosis consists of three main aspects: antifungal therapy, intracranial pressure management for cryptococcal meningitis, and restoration of immune function with antiretroviral therapy (ART). Optimal integration of these three aspects is crucial to achieving successful treatment and reducing the mortality. Antifungal therapy consists of three phases: induction, consolidation, and maintenance. A combination of two drugs, i.e. amphotericin B plus flucytosine or fluconazole, is preferred in the induction phase. Fluconazole monotherapy is recommended during consolidation and maintenance phases. In cryptococcal meningitis, intracranial pressure rises along with CSF fungal burden and is associated with morbidity and mortality. Aggressive control of intracranial pressure should be done. Management options include therapeutic lumbar puncture, lumbar drain insertion, ventriculostomy, or ventriculoperitoneal shunt. Medical treatment such as corticosteroids, mannitol, and acetazolamide are ineffective and should not be used. ART has proven to have a great impact on survival rates among HIV-infected patients with cryptococcosis. The time to start ART in HIV-infected patients with cryptococcosis has to be deferred until 5 weeks after the start of antifungal therapy. In general, any effective ART regimen is acceptable. Potential drug interactions between antiretroviral agents and amphotericin B, flucytosine, and fluconazole are minimal. Of most potential clinical relevance is the concomitant use of fluconazole and nevirapine. Concomitant use of these two drugs should be cautious, and patients should be monitored closely for nevirapine-associated adverse events, including hepatotoxicity. Overlapping toxicities of antifungal and antiretroviral drugs and immune reconstitution inflammatory syndrome are not uncommon. Early recognition and appropriate management of these consequences can reinforce the successful integrated therapy in HIV-infected patients with cryptococcosis.
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