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Minja M, Mbilinyi T, Mkinga B, Philipo EG, Owenya J, Kilonzi M. Prevalence, treatment, and factors associated with cryptococcal meningitis post introduction of integrase inhibitors antiretroviral based regimens among People Living with HIV in Tanzania. PLoS One 2024; 19:e0294940. [PMID: 38412200 PMCID: PMC10898767 DOI: 10.1371/journal.pone.0294940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/12/2024] [Indexed: 02/29/2024] Open
Abstract
OBJECTIVE This study aimed to assess the prevalence of Cryptococcal Meningitis (CM), treatment practice, and the associated factors post-introduction of Tenofovir Lamivudine and Dolutegravir (TLD) regimen among People Living with HIV (PLHIV) in Tanzania. METHODS This was an analytical cross-sectional study, and the data was collected retrospectively in three public regional referral hospitals (RRHs) in Dar es Salaam, Tanzania. A total of 405 files of the PLHIV admitted in the medical wards on the TLD regimen from January 2019 to December 2022 were reviewed. The collected information includes the patient's demographic characteristics, Cryptococcal status, CD4 level at the time of CM diagnosis, status of using ART, CM treatment approach, and outcome. Data was analyzed using SPSS software version 23. RESULTS Out of 405 patients, the majority 267(65.9%) were female, 224(55.3%) were aged between 36-55 years, and 293(72.3%) were married. ART defaulters were found to be 37(9.1%). The prevalence of CM was found to be 48(11.9%), out of which 42(87.5%) received fluconazole alone. ART defaulter and marital status significantly (p-value < 0.05) were associated with those who tested CM positive. CONCLUSION The study found the prevalence of CM among PLHIV to be significantly high and the majority were treated with fluconazole alone. ART defaulters and marital status were significantly associated with one being CM positive. Responsible authorities and stakeholders should enforce guideline adherence and PLHIV should be encouraged on medication adherence.
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Affiliation(s)
- Makyao Minja
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Tusaligwe Mbilinyi
- Department of Pharmaceutical Microbiology, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Bryceson Mkinga
- Department of Pharmacognosy, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Erick G Philipo
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Joyce Owenya
- Department of Pharmacy, Temeke Regional Referral Hospital, Dar es Salaam, Tanzania
| | - Manase Kilonzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Messina F, Santiso G, Arechavala A, Romero M, Depardo R, Marin E. Preemptive Therapy in Cryptococcosis Adjusted for Outcomes. J Fungi (Basel) 2023; 9:631. [PMID: 37367567 DOI: 10.3390/jof9060631] [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: 04/28/2023] [Revised: 05/27/2023] [Accepted: 05/29/2023] [Indexed: 06/28/2023] Open
Abstract
Cryptococcosis is one of the most serious opportunistic diseases in patients living with HIV. For this reason, early diagnosis and appropriate treatment are important. OBJECTIVES The aim of the study was to understand the development of patients diagnosed with cryptococcosis by detection of Cryptococcus antigen in serum by lateral flow assay (CrAg LFA) without nervous system involvement and with treatment in accordance with the results. MATERIALS AND METHODS A retrospective, longitudinal, analytical study was performed. Seventy patients with cryptococcosis initially diagnosed by serum CrAg LFA without meningeal involvement between January 2019 and April 2022 were analyzed for medical records. The treatment regimen was adapted to the results of blood culture, respiratory material, and pulmonary tomography imaging. RESULTS Seventy patients were included, 13 had probable pulmonary cryptococcosis, 4 had proven pulmonary cryptococcosis, 3 had fungemia, and 50 had preemptive therapy without microbiological or imaging findings compatible with cryptococcosis. Among the 50 patients with preemptive therapy, none had meningeal involvement or cryptococcosis recurrences to date. CONCLUSION Preemptive therapy avoided progression to meningitis in CrAg LFA-positive patients. Preemptive therapy with dose adjustment of fluconazole in patients with the mentioned characteristics was useful despite the use of lower doses than recommended.
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Affiliation(s)
- Fernando Messina
- Mycology Unit, Infectious Diseases Hospital F.J. Muñiz, Buenos Aires C1282AEN, Argentina
| | - Gabriela Santiso
- Mycology Unit, Infectious Diseases Hospital F.J. Muñiz, Buenos Aires C1282AEN, Argentina
| | - Alicia Arechavala
- Mycology Unit, Infectious Diseases Hospital F.J. Muñiz, Buenos Aires C1282AEN, Argentina
| | - Mercedes Romero
- Mycology Unit, Infectious Diseases Hospital F.J. Muñiz, Buenos Aires C1282AEN, Argentina
| | - Roxana Depardo
- Mycology Unit, Infectious Diseases Hospital F.J. Muñiz, Buenos Aires C1282AEN, Argentina
| | - Emmanuel Marin
- Mycology Unit, Infectious Diseases Hospital F.J. Muñiz, Buenos Aires C1282AEN, Argentina
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Challenges in Serologic Diagnostics of Neglected Human Systemic Mycoses: An Overview on Characterization of New Targets. Pathogens 2022; 11:pathogens11050569. [PMID: 35631090 PMCID: PMC9143782 DOI: 10.3390/pathogens11050569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 12/04/2022] Open
Abstract
Systemic mycoses have been viewed as neglected diseases and they are responsible for deaths and disabilities around the world. Rapid, low-cost, simple, highly-specific and sensitive diagnostic tests are critical components of patient care, disease control and active surveillance. However, the diagnosis of fungal infections represents a great challenge because of the decline in the expertise needed for identifying fungi, and a reduced number of instruments and assays specific to fungal identification. Unfortunately, time of diagnosis is one of the most important risk factors for mortality rates from many of the systemic mycoses. In addition, phenotypic and biochemical identification methods are often time-consuming, which has created an increasing demand for new methods of fungal identification. In this review, we discuss the current context of the diagnosis of the main systemic mycoses and propose alternative approaches for the identification of new targets for fungal pathogens, which can help in the development of new diagnostic tests.
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Srishyla D, Saemisch G, Turya F, Nalintya E, Jjunju S, Kagimu E, Rutakingirwa MK, Skipper CP, Boulware DR, Meya DB, Rajasingham R. Determinants of cryptococcal antigen (CrAg) screening uptake in Kampala, Uganda: An assessment of health center characteristics. Med Mycol 2022; 60:myac013. [PMID: 35353190 PMCID: PMC8973400 DOI: 10.1093/mmy/myac013] [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: 08/16/2021] [Revised: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Cryptococcal antigen (CrAg) screening and pre-emptive antifungal therapy for people with CD4 cell counts <100 cells/μl are recommended by the World Health Organization and several national HIV guidelines. We sought to evaluate CrAg screening program implementation across Uganda, in relation to health center level and distance from the capital. We conducted a cross-sectional study of 22 health centers across southern Uganda from April to June 2019. We reviewed laboratory records regarding number of CD4 cell count tests performed, proportion of outpatients with CD4 counts <200 cells/μl, and number of CrAg screening tests performed. We administered surveys to health center staff to understand barriers to advanced HIV care. We observed no significant difference in health center level and performance of CrAg screening; with each subsequent health center level, there was 1.17-fold (95% CI: 0.92-1.41) higher odds of CrAg screening performed per level. CrAg screening uptake was not associated with distance from the capital city (odds ratio = 0.96, 95% CI: 0.89-1.04). Qualitative data from surveys indicated that limitations to uptake of CrAg screening were secondary to dysfunctional CD4 machines, lack of provider awareness of CrAg screening guidelines, and inadequate/intermittent supply of CrAg tests. There were no significant associations between CrAg screening uptake and level of health center or distance of health center from the capital city. We identified systemic barriers to CrAg screening related to inadequate CD4 testing, insufficient knowledge regarding national screening guidelines, and irregular laboratory testing supplies. LAY SUMMARY The objective of this study was to evaluate cryptococcal antigen (CrAg) screening program implementation in Uganda, by type of healthcare center and by distance from the capital city. CrAg screening uptake was not associated with distance from the capital city, or the type of healthcare center.
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Affiliation(s)
- Diksha Srishyla
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
| | - Gabriel Saemisch
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
| | - Fred Turya
- Infectious Diseases Institute, Kampala, Uganda
| | | | | | | | | | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
| | | | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
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5
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Gressler AE, Volke D, Firacative C, Schnabel CL, Müller U, Krizsan A, Schulze-Richter B, Brock M, Brombacher F, Escandón P, Hoffmann R, Alber G. Identification of Disease-Associated Cryptococcal Proteins Reactive With Serum IgG From Cryptococcal Meningitis Patients. Front Immunol 2021; 12:709695. [PMID: 34367172 PMCID: PMC8342929 DOI: 10.3389/fimmu.2021.709695] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/21/2021] [Indexed: 01/16/2023] Open
Abstract
Cryptococcus neoformans, an opportunistic fungal pathogen ubiquitously present in the environment, causes cryptococcal meningitis (CM) mainly in immunocompromised patients, such as AIDS patients. We aimed to identify disease-associated cryptococcal protein antigens targeted by the human humoral immune response. Therefore, we used sera from Colombian CM patients, with or without HIV infection, and from healthy individuals living in the same region. Serological analysis revealed increased titers of anti-cryptococcal IgG in HIV-negative CM patients, but not HIV-positive CM patients, compared to healthy controls. In contrast, titers of anti-cryptococcal IgM were not affected by CM. Furthermore, we detected pre-existing IgG and IgM antibodies even in sera from healthy individuals. The observed induction of anti-cryptococcal IgG but not IgM during CM was supported by analysis of sera from C. neoformans-infected mice. Stronger increase in IgG was found in wild type mice with high lung fungal burden compared to IL-4Rα-deficient mice showing low lung fungal burden. To identify the proteins targeted by human anti-cryptococcal IgG antibodies, we applied a quantitative 2D immunoproteome approach identifying cryptococcal protein spots preferentially recognized by sera from CM patients or healthy individuals followed by mass spectrometry analysis. Twenty-three cryptococcal proteins were recombinantly expressed and confirmed to be immunoreactive with human sera. Fourteen of them were newly described as immunoreactive proteins. Twelve proteins were classified as disease-associated antigens, based on significantly stronger immunoreactivity with sera from CM patients compared to healthy individuals. The proteins identified in our screen significantly expand the pool of cryptococcal proteins with potential for (i) development of novel anti-cryptococcal agents based on implications in cryptococcal virulence or survival, or (ii) development of an anti-cryptococcal vaccine, as several candidates lack homology to human proteins and are localized extracellularly. Furthermore, this study defines pre-existing anti-cryptococcal immunoreactivity in healthy individuals at a molecular level, identifying target antigens recognized by sera from healthy control persons.
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Affiliation(s)
- A Elisabeth Gressler
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Daniela Volke
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Carolina Firacative
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Christiane L Schnabel
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Uwe Müller
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Andor Krizsan
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Bianca Schulze-Richter
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Matthias Brock
- Fungal Genetics and Biology Group, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Frank Brombacher
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Cape Town, South Africa
| | | | - Ralf Hoffmann
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Gottfried Alber
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
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6
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Abstract
Cryptococcosis is an invasive fungal infection of global significance caused by yeasts of the genus Cryptococcus. The prevalence of HIV in certain areas of the world and the expanding population of immunocompromised patients contribute to the ongoing global disease burden. Point-of-care serologic testing has allowed for more rapid diagnosis and implementation of screening programs in resource-limited settings. Management involves therapy aimed at reduction in fungal burden, maintenance of intracranial pressure, and optimization of host immunity. Despite diagnostic and therapeutic advances, cryptococcosis continues to be a disease with unacceptably high incidence and mortality, particularly in resource-limited settings.
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Affiliation(s)
- Alexis C Gushiken
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - Kapil K Saharia
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - John W Baddley
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA.
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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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Cryptococcus neoformans meningitis in kidney transplant recipients: A diagnostic and therapeutic challenge. Med Mycol Case Rep 2021; 32:84-87. [PMID: 34026474 PMCID: PMC8120857 DOI: 10.1016/j.mmcr.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/17/2021] [Accepted: 04/24/2021] [Indexed: 11/23/2022] Open
Abstract
Cryptococcosis is the third most common invasive fungal infection in solid organ transplant recipients. We describe three cases of neuro-meningeal cryptococcosis occurring among kidney transplant (KT) patients, and discuss the diagnostic and therapeutic challenges in this context. Median time from KT to infection was 6 months [range: 3-9]. The most common clinical manifestations at diagnosis were fever (2/3), headache (2/3), and confusion (2/3); none had extra-neurological involvement. CrAg was positive in all cases at diagnosis both in serum and cerebrospinal fluid (CSF). For two patients, analysis of previous samples showed that CrAg was detected in plasma up to 4 weeks before diagnosis. All patients received induction treatment with liposomal amphotericin-B (L-AmB) and flucytosine for a median duration of 10 days [range: 7-14], followed by fluconazole maintenance therapy. Acute kidney injury secondary to L-AmB therapy was observed in only one case, but all patients had a tacrolimus overdose following initiation of maintenance therapy due to drug-drug interactions between fluconazole and tacrolimus. Among KTR, early detection of Cryptococcus meningitis using serum CrAg is possible. Close monitoring of renal function during treatment is essential due to the nephrotoxicity of L-AmB, but also drug-drug interactions between fluconazole and calcineurin inhibitors.
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Harrington KRV, Wang YF, Rebolledo PA, Liu Z, Yang Q, Kempker RR. Evaluation of a Cryptococcal Antigen Lateral Flow Assay and Cryptococcal Antigen Positivity at a Large Public Hospital in Atlanta, Georgia. Open Forum Infect Dis 2021; 8:ofab123. [PMID: 34189154 PMCID: PMC8233569 DOI: 10.1093/ofid/ofab123] [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: 12/23/2020] [Accepted: 03/09/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cryptococcus neoformans is a major cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected persons worldwide, and there are scarce recent data on cryptococcal antigen (CrAg) positivity in the United States We sought to determine the frequency of cryptococcal disease and compare the performance of a CrAg lateral flow assay (LFA) versus latex agglutination (LA) test. METHODS All patients from Grady Health System in Atlanta who had a serum or cerebrospinal fluid (CSF) sample sent for CrAg testing as part of clinical care from November 2017 to July 2018 were included. Percentage positivity and test agreement were calculated. RESULTS Among 467 patients, 557 diagnostic tests were performed; 413 on serum and 144 on CSF. The mean age was 44 years, and most were male (69%) and had HIV (79%). Twenty-four (6.4%, 95% confidence interval [CI] = 4.1-9.4) patients were serum CrAg positive, and 8 (5.8%, 95% CI = 2.6-11.2) individuals tested positive for CSF CrAg. Although overall agreement between the LA and LFA was substantial to high for CSF (κ = 0.71, 95% CI = 0.51-0.91) and serum (κ = 0.93, 95% CI = 0.86-1.00), respectively, there were important discrepancies. Five patients had false-positive CSF LA tests that affected clinical care, and 4 patients had discordant serum tests. CONCLUSIONS We found a moderately high proportion of cryptococcal disease and important discrepancies between the LA test and LFA. Clinical implications of these findings include accurate detection of serum CrAg and averting unnecessary treatment of meningitis with costly medications associated with high rates of adverse events.
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Affiliation(s)
- Kristin R V Harrington
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia, USA,Emory University Rollins School of Public Health, Department of Epidemiology, Atlanta, Georgia, USA,Correspondence: Kristin R. V. Harrington, BS, Department of Epidemiology, Rollins School of Public Health, Emory University, 3rd Floor, Claudia Nance Rollins Building, 1518 Clifton Road, Atlanta, Georgia, USA 30322 ()
| | - Yun F Wang
- Emory University School of Medicine, Department of Pathology & Laboratory Medicine, Atlanta, Georgia, USA,Grady Memorial Hospital, Department of Pathology & Clinical Laboratories, Atlanta, Georgia, USA
| | - Paulina A Rebolledo
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia, USA,Emory University Rollins School of Public Health, Department of Global Health, Atlanta, Georgia, USA
| | - Zhiyong Liu
- Grady Memorial Hospital, Department of Pathology & Clinical Laboratories, Atlanta, Georgia, USA
| | - Qianting Yang
- Grady Memorial Hospital, Department of Pathology & Clinical Laboratories, Atlanta, Georgia, USA
| | - Russell R Kempker
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia, USA
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10
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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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11
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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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12
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Williams SC, Sweeney J, Parameswaran L. Diagnostic and management considerations in the modern patient with AIDS: a case of concurrent disseminated Kaposi sarcoma and colesional Cryptococcus neoformans. BMJ Case Rep 2020; 13:e233860. [PMID: 32295799 PMCID: PMC7199148 DOI: 10.1136/bcr-2019-233860] [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: 04/01/2020] [Indexed: 11/04/2022] Open
Abstract
In the era of highly active antiretroviral therapy (HAART), disseminated Kaposi sarcoma (KS) has become much rarer in the USA. We report a case of a 34-year-old man with KS of the skin, oropharynx, lung and rectum. Within the same lung nodule, we discovered significant burden of colesional Cryptococcus neoformans, in the context of a positive asymptomatic cryptococcal antigenemia, which was a previously unreported occurrence. The gold standard of treatment for KS continues to be HAART. The role of chemotherapy is still controversial. In addition, a cryptococcal antigen screen-and-treat approach with fluconazole is still not routinely recommended in the USA to prevent serious meningeal disease despite recent studies showing efficacy and applicability. We discuss both issues here and the outcome of our patient. We also present the patient's own unique perspective in dealing with the ramifications of these diagnoses.
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Affiliation(s)
- Samuel Clay Williams
- Tri-Institutional MD PhD Program, Weill Cornell Medical College, New York, New York, USA
| | - Jacob Sweeney
- Weill Cornell Medicine Department of Pathology and Laboratory Medicine, New York, New York, USA
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13
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Hembach L, Bonin M, Gorzelanny C, Moerschbacher BM. Unique subsite specificity and potential natural function of a chitosan deacetylase from the human pathogen Cryptococcus neoformans. Proc Natl Acad Sci U S A 2020; 117:3551-3559. [PMID: 32015121 PMCID: PMC7035615 DOI: 10.1073/pnas.1915798117] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Cryptococcus neoformans is an opportunistic fungal pathogen that infects ∼280,000 people every year, causing >180,000 deaths. The human immune system recognizes chitin as one of the major cell-wall components of invading fungi, but C. neoformans can circumvent this immunosurveillance mechanism by instead exposing chitosan, the partly or fully deacetylated form of chitin. The natural production of chitosans involves the sequential action of chitin synthases (CHSs) and chitin deacetylases (CDAs). C. neoformans expresses four putative CDAs, three of which have been confirmed as functional enzymes that act on chitin in the cell wall. The fourth (CnCda4/Fpd1) is a secreted enzyme with exceptional specificity for d-glucosamine at its -1 subsite, thus preferring chitosan over chitin as a substrate. We used site-specific mutagenesis to reduce the subsite specificity of CnCda4 by converting an atypical isoleucine residue in a flexible loop region to the bulkier or charged residues tyrosine, histidine, and glutamic acid. We also investigated the effect of CnCda4 deacetylation products on human peripheral blood-derived macrophages, leading to a model explaining the function of CnCda4 during infection. We propose that CnCda4 is used for the further deacetylation of chitosans already exposed on the C. neoformans cell wall (originally produced by CnChs3 and CnCda1 to 3) or released from the cell wall as elicitors by human chitinases, thus making the fungus less susceptible to host immunosurveillance. The absence of CnCda4 during infection could therefore promote the faster recognition and elimination of this pathogen.
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Affiliation(s)
- Lea Hembach
- Institute for Biology and Biotechnology of Plants, University of Münster, 48143 Münster, Germany
| | - Martin Bonin
- Institute for Biology and Biotechnology of Plants, University of Münster, 48143 Münster, Germany
| | - Christian Gorzelanny
- Experimental Dermatology, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Bruno M Moerschbacher
- Institute for Biology and Biotechnology of Plants, University of Münster, 48143 Münster, Germany;
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14
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Ji XC, Zhou LF, Li CY, Shi YJ, Wu ML, Zhang Y, Fei XF, Zhao G. Reduction of Human DNA Contamination in Clinical Cerebrospinal Fluid Specimens Improves the Sensitivity of Metagenomic Next-Generation Sequencing. J Mol Neurosci 2020; 70:659-666. [PMID: 32002752 DOI: 10.1007/s12031-019-01472-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 12/26/2019] [Indexed: 12/25/2022]
Abstract
Metagenomics next-generation sequencing (mNGS) is increasingly available for the detection of obscure infectious diseases of the central nervous system. However, human DNA contamination from elevated white cells, one of the characteristic cerebrospinal fluid (CSF) features in meningitis patients, greatly reduces the sensitivity of mNGS in the pathogen detection. Currently, effective approaches to selectively reduce host DNA contamination from clinical CSF samples are still lacking. In this study, a total of 20 meningitis patients were enrolled, including 10 definitively diagnosed tuberculous meningitis (TBM) and 10 definite cryptococcal meningitis (CM) cases. To evaluate the effect of reduced human DNA in the sensitivity of mNGS detection, three specimen-processing protocols were performed: (i) To remove human DNA, saponin, a nonionic surfactant, was used to selectively lyse white cells in CSF followed by DNase treatment prior to the extraction of DNA; (ii) to reduce host DNA, CSF was centrifuged to remove human cells, and the supernatant was collected for DNA extraction; and (iii) DNA extraction from the unprocessed specimens was set as the control. We found that saponin processing significantly elevated the NGS unique reads for Cryptococcus (P < 0.01) compared with the control but had no effects for Mycobacterium tuberculosis (P > 0.05). However, detection of centrifuged supernatants improved the NGS unique reads for both TBM and CM compared with controls (P < 0.01). Our results demonstrate that the use of mNGS of centrifuged supernatants from clinical CSF samples in patients with TBM and CM is a simple and effective method to improve the sensitivity of pathogen detection.
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MESH Headings
- Adult
- Aged
- Cerebrospinal Fluid/microbiology
- Cryptococcus/genetics
- Cryptococcus/pathogenicity
- Female
- Genome, Bacterial
- Genome, Human
- High-Throughput Nucleotide Sequencing/methods
- High-Throughput Nucleotide Sequencing/standards
- Humans
- Male
- Meningitis, Cryptococcal/cerebrospinal fluid
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/microbiology
- Metagenomics/methods
- Metagenomics/standards
- Middle Aged
- Molecular Diagnostic Techniques/methods
- Molecular Diagnostic Techniques/standards
- Mycobacterium tuberculosis/genetics
- Mycobacterium tuberculosis/pathogenicity
- Sensitivity and Specificity
- Sequence Analysis, DNA/methods
- Sequence Analysis, DNA/standards
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/microbiology
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Affiliation(s)
- Xin-Chao Ji
- Department of Neurology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Lin-Fu Zhou
- Department of Neurology, The 987 Hospital of PLA, Baoji, China
| | - Chao-Yang Li
- Department of Neurology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Ya-Jun Shi
- Department of Neurology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Meng-Li Wu
- Department of Neurology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Yun Zhang
- Department of Neurology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Xiao-Fei Fei
- Department of Neurology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, Air Force Military Medical University, Xi'an, China.
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15
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Klumph M, Hoeynck B, Baumgardner DJ. Cryptococcal Antigen Testing in an Integrated Medical System: Eastern Wisconsin. J Patient Cent Res Rev 2020; 7:57-62. [PMID: 32002448 PMCID: PMC6988710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
Cryptococcosis is a serious environmentally acquired endemic fungal infection commonly associated with immunocompromised hosts. Little is known regarding frequency or distribution in Wisconsin. We explored the geodemographic and clinical features of patients tested with cryptococcal antigen tests (CrAg) - previously shown to be >90% sensitive and >90% specific - within a large health care system located in eastern Wisconsin. To examine this, we retrospectively analyzed 1465 CrAg tests on 1211 unique patients (female: 50.2%; white race: 73.9%; mean age: 53.7 ± 16.5 years). At least one CrAg result was positive in 23 of 1211 patients (1.9%). From these, 21 of 23 were immunocompromised. Positive patients were disproportionately male (82.6%) and nonwhite (3.8% of those tested vs 1.2% of whites tested); P<0.01 for both. These associations remained in multivariable models. Positive patients were not significantly older (59.1 vs 53.6 years; P=0.07). Overall, 17 separate zip codes had at least one positive case. Positive patients were more prevalent in the zip codes that included the city of Milwaukee (11 of 377 [2.9% of those tested] vs 12 of 834 [1.4% of all those tested in the remaining area of the state]), but this difference was not statistically significant. No other case clustering or close proximity to waterways was observed (41% were <162 m from green space, similar to historical controls). Overall, male sex, nonwhite race/ethnicity, and immunocompromised status, not zip code, were statistically associated with positive CrAg.
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Affiliation(s)
- Marianne Klumph
- Department of Family Medicine, Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
- Center for Urban Population Health, Milwaukee, WI
| | - Brian Hoeynck
- Aurora Research Institute, Aurora Health Care, Milwaukee, WI
| | - Dennis J. Baumgardner
- Department of Family Medicine, Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
- Center for Urban Population Health, Milwaukee, WI
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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16
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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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17
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Blankley S, Gashu T, Ahmad B, Belaye AK, Ringtho L, Mesic A, Zizhou S, Casas EC. Lessons learned: Retrospective assessment of outcomes and management of patients with advanced HIV disease in a semi-urban polyclinic in Epworth, Zimbabwe. PLoS One 2019; 14:e0214739. [PMID: 30969987 PMCID: PMC6457534 DOI: 10.1371/journal.pone.0214739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 03/19/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION HIV continues to be one of the leading causes of infectious death worldwide and presentation with advanced HIV disease is associated with increased morbidity and mortality. Recommendations for the management of advanced HIV disease include prompt screening and treatment of opportunistic infections, rapid initiation of ART and intensified adherence support. We present treatment outcomes of a cohort of patients presenting with advanced HIV disease in a semi-urban Zimbabwean polyclinic. METHODS Retrospective cohort analysis of adult patients enrolled for care at Epworth polyclinic, Zimbabwe between 2007 and end June 2016. Treatment outcomes at 6 and 12 months were recorded. Multivariate logistical regression analysis was undertaken to identify risk factors for presentation with advanced HIV Disease (CD4 count less than 200 cells/mm3 or WHO stage 3 or 4) and risks for attrition at 12 months. RESULTS 16,007 anti-retroviral therapy naive adult patients were included in the final analysis, 47.4% of whom presented with advanced HIV disease. Patients presenting with advanced HIV disease had a higher mortality rate at 12 months following enrollment compared to early stage patients (5.11% vs 0.45%). Introduction of a package of differentiated care for patients with a CD4 count of less than 100 cells/mm3 resulted in diagnosis of cryptococcal antigenaemia in 7% of patients and a significant increase in the diagnosis of TB, although there was no significant difference in attrition at 6 or 12 months for these patients compared to those enrolled prior to the introduction of the differentiated care. CONCLUSIONS The burden of advanced HIV disease remained high over the study period in this semi-urban polyclinic in Zimbabwe. Introduction of a package of differentiated care for those with advanced HIV disease increased the diagnosis of opportunistic infections and represents a model of care which can be replicated in other polyclinics in the resource constrained Zimbabwean context.
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Affiliation(s)
- Simon Blankley
- Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe
- * E-mail:
| | - Tadele Gashu
- Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe
| | - Bilal Ahmad
- Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe
| | - Abi kebra Belaye
- Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe
| | - Lucia Ringtho
- Médecins Sans Frontières/Doctors Without Borders, Berlin, Germany
| | - Anita Mesic
- Médecins Sans Frontières/Doctors Without Borders, Amsterdam, Netherlands
| | - Simukai Zizhou
- Provincial Medical Directorate, Ministry of Health and Child Care, Marondera, Zimbabwe
| | - Esther C. Casas
- Médecins Sans Frontières/Doctors Without Borders, Amsterdam, Netherlands
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18
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Benzekri NA, Sambou JF, Ndong S, Tamba IT, Faye D, Diallo MB, Diatta JP, Faye K, Sall I, Sall F, Manga NM, Malomar JJ, Ndour CT, Hawes SE, Seydi M, Gottlieb GS. Prevalence, predictors, and management of advanced HIV disease among individuals initiating ART in Senegal, West Africa. BMC Infect Dis 2019; 19:261. [PMID: 30876400 PMCID: PMC6420737 DOI: 10.1186/s12879-019-3826-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/15/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The WHO guidelines for the management of advanced HIV disease recommend a package of care consisting of rapid initiation of antiretroviral therapy (ART), enhanced screening and diagnosis of tuberculosis (TB) and cryptococcal meningitis, co-trimoxazole prophylaxis, isoniazid preventive therapy (IPT), fluconazole pre-emptive therapy, and adherence support. The goals of this study were to determine the prevalence of advanced HIV disease among individuals initiating ART in Senegal, to identify predictors of advanced disease, and to evaluate adherence to the WHO guidelines. METHODS This study was conducted among HIV-positive individuals initiating ART in Dakar and Ziguinchor, Senegal. Clinical evaluations, laboratory analyses, questionnaires and chart review were conducted. Logistic regression was used to identify predictors of advanced disease. RESULTS A total of 198 subjects were enrolled; 70% were female. The majority of subjects (71%) had advanced HIV disease, defined by the WHO as a CD4 count < 200 cells/mm3 or clinical stage 3 or 4. The median CD4 count was 185 cells/mm3. The strongest predictors of advanced disease were age ≥ 35 (OR 5.80, 95%CI 2.35-14.30) and having sought care from a traditional healer (OR 3.86, 95%CI 1.17-12.78). Approximately one third of subjects initiated ART within 7 days of diagnosis. Co-trimoxazole prophylaxis was provided to 65% of subjects with CD4 counts ≤350 cells/mm3 or stage 3 or 4 disease. TB symptom screening was available for 166 subjects; 54% reported TB symptoms. Among those with TB symptoms, 39% underwent diagnostic evaluation. Among those eligible for IPT, one subject received isoniazid. No subjects underwent CrAg screening or received fluconazole to prevent cryptococcal meningitis. CONCLUSIONS This is the first study to report an association between seeking care from a traditional healer and presentation with WHO defined advanced disease in sub-Saharan Africa. Given the widespread use of traditional healers in sub-Saharan Africa, future studies to further explore this finding are indicated. Although the majority of individuals in this study presented with advanced disease and warranted management according to WHO guidelines, there were numerous missed opportunities to prevent HIV-associated morbidity and mortality. Programmatic evaluation is needed to identify barriers to implementation of the WHO guidelines and enhanced funding for operational research is indicated.
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Affiliation(s)
- Noelle A Benzekri
- Department of Medicine, University of Washington, Box 358061, 750 Republican St, Seattle, WA, 98109-4725, USA.
| | | | - Sanou Ndong
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | | | - Mouhamadou Baïla Diallo
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | - Khadim Faye
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | - Fatima Sall
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | | | - Cheikh T Ndour
- Division de Lutte contre le Sida et les IST, Ministère de la Santé et de l'Action Sociale, Dakar, Sénégal
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Moussa Seydi
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | - Geoffrey S Gottlieb
- Department of Medicine, University of Washington, Box 358061, 750 Republican St, Seattle, WA, 98109-4725, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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Hailu K, Niguse S, Hagos K, Abdulkader M. Cryptococcal antigenemia and associated risk factors among ART-naïve and ART-experienced HIV-infected peoples at selected health institutions of Mekelle, Northern Ethiopia. Microbiologyopen 2018; 8:e00746. [PMID: 30277315 PMCID: PMC6562113 DOI: 10.1002/mbo3.746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 08/31/2018] [Accepted: 09/10/2018] [Indexed: 01/14/2023] Open
Abstract
Cryptococcal infection is a major cause of opportunistic infection in HIV/AID‐infected peoples. We determined cryptococcal antigenemia and cryptococcal meningitis among antiretroviral therapy (ART) initiated and ART‐naive HIV‐infected peoples. A cross‐sectional study was conducted at selected health facilities in Mekelle, Ethiopia. Blood was collected to determine CD4 and plasma cryptococcal antigen (CrAg). CSF CrAg and CSF culture and urease tests were also done. Socio‐demographic and clinical data were collected using a structured questionnaire and clinical chart review. From the enrolled study participants, 267 study participants had complete data, of which, 137 (51%) were females. From the study participants, 140 (52%) and 127 (48%) were ART experienced and ART naïve, respectively. The prevalence of cryptococcal antigenemia was 9 (3.4%). All the study participants, except one (CD4 = 120 cells/mm3), had CD4 count less than 100 cells/mm3. From CrAg‐positive peoples, 6 (4.7%) were ART naïve. Five CrAg‐positive peoples had cryptococcal meningitis. Being male, rural residence, and being hospitalized were associated with cryptococcal antigenemia. Cryptococcal infection poses a substantial risk of HIV‐positive peoples. This study provides relevant data for CrAg screening interventions in patients with low CD4 cell counts.
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Affiliation(s)
- Kibra Hailu
- Laboratory Department, Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia
| | - Selam Niguse
- Medical Microbiology and Immunology Unit, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Kiflom Hagos
- Medical Microbiology and Immunology Unit, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Mahmud Abdulkader
- Medical Microbiology and Immunology Unit, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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20
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Rhein J, Hullsiek KH, Evans EE, Tugume L, Nuwagira E, Ssebambulidde K, Kiggundu R, Mpoza E, Musubire AK, Bangdiwala AS, Bahr NC, Williams DA, Abassi M, Muzoora C, Meya DB, Boulware DR. Detrimental Outcomes of Unmasking Cryptococcal Meningitis With Recent ART Initiation. Open Forum Infect Dis 2018; 5:ofy122. [PMID: 30094292 PMCID: PMC6080052 DOI: 10.1093/ofid/ofy122] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 05/21/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Increased antiretroviral therapy (ART) availability has been associated with more patients developing cryptococcosis after ART initiation. Despite this changing epidemiology, data regarding cryptococcal meningitis in those already receiving ART are limited. We compared clinical presentations and outcomes among ART-naïve and ART-experienced Ugandans. METHODS We prospectively enrolled 605 HIV-infected persons with first-episode cryptococcal meningitis from August 2013 to May 2017 who received amphotericin-based combination therapy. We classified participants by ART status and ART duration and compared groups for 2-week survival. RESULTS Overall, 46% (281/605) of participants were receiving ART at presentation. Compared with those not receiving ART, those receiving ART had higher CD4 counts (P < .001) and lower cerebrospinal fluid fungal burdens (P < .001). Of those receiving ART, 56% (156/281) initiated ART within 6 months, and 18% (51/281) initiated ART within 14 days. Two-week mortality did not differ by ART status (27% in both ART-naïve and ART-experienced%; P > .99). However, 47% (24/51) of those receiving ART for ≤14 days died within 2 weeks, compared with 19% (20/105) of those receiving ART for 15-182 days and 26% (32/125) of those receiving ART for >6 months (P < .001). Among persons receiving ART for >6 months, 87% had HIV viral loads >1000 copies/mL. CONCLUSIONS Cryptococcosis after ART initiation is common in Africa. Patients initiating ART who unmask cryptococcal meningitis are at a high risk of death. Immune recovery in the setting of central nervous system infection is detrimental, and management of this population requires further study. Implementing pre-ART cryptococcal antigen screening is urgently needed to prevent cryptococcal meningitis after ART initiation.
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Affiliation(s)
- Joshua Rhein
- University of Minnesota, Minneapolis, Minneapolis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Emily E Evans
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Nathan C Bahr
- University of Minnesota, Minneapolis, Minneapolis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- University of Minnesota, Minneapolis, Minneapolis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mahsa Abassi
- University of Minnesota, Minneapolis, Minneapolis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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21
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Abstract
Cryptococcal meningitis is the most common central nervous system infection in the world today. It occurs primarily, but not exclusively, in immunocompromised individuals and despite substantial improvement in management of clinical events like AIDS, the numbers of cases of cryptococcosis remain very high. Unfortunately, despite several antifungal agents available for treatment, morbidity and mortality rates remain high with this fungal infection. In this Review, we will describe the treatments and strategies for success, identify the failures, and provide insights into the future developments / improvements for management. This sugar-coated yeast can play havoc within the human brain. Our goals must be to either prevent or diagnose disease early and treat aggressively with all our clinical tools when disease is detected.
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Affiliation(s)
- Ahmad Mourad
- Department of Medicine, Medical Center, Duke University, Durham, NC, USA
| | - John R Perfect
- Department of Medicine, Medical Center, Duke University, Durham, NC, USA
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22
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Thomsen D, Hviid CJ, Hønge BL, Medina C, Té DDS, Correira FG, Østergaard L, Erikstrup C, Wejse C, Laursen AL, Jespersen S. Increased mortality among HIV infected patients with cryptococcal antigenemia in Guinea-Bissau. Pan Afr Med J 2018; 29:18. [PMID: 29662603 PMCID: PMC5899773 DOI: 10.11604/pamj.2018.29.18.14099] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 11/09/2017] [Indexed: 11/11/2022] Open
Abstract
Cryptococcal antigenemia may precede development of cryptococcal meningitis and death among patients with advanced HIV infection. Among 200 retrospectively and randomly selected ART-naïve patients with CD4 counts < 100 cells/μl from Guinea-Bissau, 20 (10%) had a positive cryptococcal antigen test. Self-reported headache and fever were predictors of a positive test, while cryptococcal antigenemia was a strong predictor of death within the first year of follow-up, MRR 2.22 (95% CI: 1.15-4.30). Screening for cryptococcal antigenemia should be implemented for patients with advanced HIV in Guinea-Bissau. Pre-emptive anti-fungal therapy should be initiated prior to ART-initiation if the screening is positive.
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Affiliation(s)
- Ditte Thomsen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Cecilie Juul Hviid
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Bo Langhoff Hønge
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Candida Medina
- National HIV Programme, Ministry of Health, Bissau, Guinea-Bissau
| | | | | | - Lars Østergaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Wejse
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark.,GloHAU, Center for Global Health, School of Public Health, Aarhus University, Aarhus, Denmark
| | - Alex Lund Laursen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Sanne Jespersen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
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23
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Abstract
Cryptococcal meningitis remains a significant cause of morbidity and mortality amongst patients living with human immunodeficiency virus (HIV). The prevalence in the developed world has decreased as HIV is being diagnosed earlier, but is still significant, and the prevalence in resource-limited settings is exceedingly high. The presenting symptoms usually include a headache, fever, and, less often, cranial nerve abnormalities. Space-occupying lesions do occur, but are rare. Once diagnosed, patients should be treated with a combination of amphotericin and flucytosine, with step-down therapy to fluconazole for a minimum of a year, or until the CD4 count is above 100 cells/μL, whichever is longer. In the acute phase of treatment increased opening pressure is common, which should be managed aggressively with frequent lumbar punctures, or through neurosurgical interventions (lumbar drains, ventriculoperitoneal shunts) if those fail. Antiretrovirals should be delayed at least 2 weeks, but maybe as many as 10 weeks, after initiation of antifungal therapy in order to prevent clinical or subclinical immune reconstitution inflammatory syndrome (IRIS), which may lead to increased mortality. However, if IRIS does develop, there is no role for antiretroviral interruption, and the condition should be managed supportively by use of anti-inflammatories and aggressive management of elevated opening pressure, if present. Steroids should be administered for specific indications only (IRIS or cryptococcoma with cerebral edema and risk of herniation) as routine use of steroids increases mortality in cryptococcal meningitis.
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Affiliation(s)
- Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - William G Powderly
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States.
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24
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Cáceres DH, Zuluaga A, Tabares ÁM, Chiller T, González Á, Gómez BL. Evaluation of a Cryptococcal antigen Lateral Flow Assay in serum and cerebrospinal fluid for rapid diagnosis of cryptococcosis in Colombia. Rev Inst Med Trop Sao Paulo 2017; 59:e76. [PMID: 29267584 PMCID: PMC5738761 DOI: 10.1590/s1678-9946201759076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/10/2017] [Indexed: 11/26/2022] Open
Abstract
A Lateral Flow Assay to detect cryptococcal antigen (CrAg® LFA) in serum and cerebrospinal fluid for the rapid diagnosis of cryptococcosis was evaluated. A retrospective validation was performed. Sensitivity and specificity of the CrAg® LFA was 100%. High concordance (kappa index=1.0) between Cryptococcal Antigen Latex Agglutination System (CALAS®) and CrAg® LFA was observed. CrAg® LFA showed higher analytical sensitivity for detecting low concentrations of cryptococcal antigen.
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Affiliation(s)
- Diego H Cáceres
- Corporación para Investigaciones Biológicas (CIB), Medical and Experimental Mycology Group, Medellín, Colombia
| | - Alejandra Zuluaga
- Corporación para Investigaciones Biológicas (CIB), Medical and Experimental Mycology Group, Medellín, Colombia
| | - Ángela M Tabares
- Corporación para Investigaciones Biológicas (CIB), Medical and Experimental Mycology Group, Medellín, Colombia
| | - Tom Chiller
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, United States
| | - Ángel González
- Universidad de Antioquia, Escuela de Microbiología, Grupo de Investigación en Microbiología Básica y Aplicada, Medellín, Colombia
| | - Beatriz L Gómez
- Corporación para Investigaciones Biológicas (CIB), Medical and Experimental Mycology Group, Medellín, Colombia.,Universidad del Rosario, Escuela de Medicina y Ciencias de la Salud, Bogotá, Colombia
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25
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Rick F, Niyibizi AA, Shroufi A, Onami K, Steele SJ, Kuleile M, Muleya I, Chiller T, Walker T, Van Cutsem G. Cryptococcal antigen screening by lay cadres using a rapid test at the point of care: A feasibility study in rural Lesotho. PLoS One 2017; 12:e0183656. [PMID: 28877182 PMCID: PMC5587318 DOI: 10.1371/journal.pone.0183656] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 08/08/2017] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Cryptococcal meningitis is one of the leading causes of death among people with HIV in Africa, primarily due to delayed presentation, poor availability and high cost of treatment. Routine cryptococcal antigen (CrAg) screening of patients with a CD4 count less than 100 cells/mm3, followed by pre-emptive therapy if positive, might reduce mortality in high prevalence settings. Using the cryptococcal antigen (CrAg) lateral flow assay (LFA), screening is possible at the point of care (POC). However, critical shortages of health staff may limit adoption. This study investigates the feasibility of lay counsellors conducting CrAg LFA screening in rural primary care clinics in Lesotho. METHODS From May 2014 to June 2015, individuals who tested positive for HIV were tested for CD4 count and those with CD4 <100 cells/mm3 were screened with CrAg LFA. All tests were performed by lay counsellors. CrAg-positive asymptomatic patients received fluconazole, while symptomatic patients were referred to hospital. Lay counsellors were trained and supervised by a laboratory technician and counsellor activity supervisor. Additionally, nurses and doctors were trained on CrAg screening and appropriate treatment. RESULTS During the study period, 1,388 people were newly diagnosed with HIV, of whom 129 (9%) presented with a CD4 count <100 cells/mm3. Of these, 128 (99%) were screened with CrAg LFA and 14/128 (11%) tested positive. Twelve of the 14 (86%) were asymptomatic, and received outpatient fluconazole. All commenced ART with a median time to initiation of 15.5 days [IQR: 14-22]. Of the asymptomatic patients, nine (75%) remained asymptomatic after a median time of 5 months [IQR; 3-6] of follow up. One (8%) became co-infected with tuberculosis and died and two were transferred out. The two patients with symptomatic cryptococcal meningitis (CM) were referred to hospital, where they later died. CONCLUSIONS CrAg LFA screening by lay counsellors followed by pre-emptive fluconazole treatment for asymptomatic cases, or referral to hospital for symptomatic cases, proved feasible. However, regular follow-up to ensure proper management of cryptococcal disease was needed. These early results support the wider use of CrAg LFA screening in remote primary care settings where upper cadres of healthcare staff may be in short supply.
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Affiliation(s)
| | | | - Amir Shroufi
- Médecins Sans Frontières, Cape Town, South Africa
- * E-mail:
| | | | | | | | | | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Tiffany Walker
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States of America
| | - Gilles Van Cutsem
- Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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26
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Lofgren S, Abassi M, Rhein J, Boulware DR. Recent advances in AIDS-related cryptococcal meningitis treatment with an emphasis on resource limited settings. Expert Rev Anti Infect Ther 2017; 15:331-340. [PMID: 28111998 PMCID: PMC5602588 DOI: 10.1080/14787210.2017.1285697] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Recent advances in the treatment and prevention of cryptococcal meningitis have the potential to decrease AIDS-related deaths. Areas covered: Targeted screening for asymptomatic cryptococcal antigenemia in persons with AIDS is a cost effective method for reducing early mortality in patients on antiretroviral therapy. For persons with symptomatic cryptococcal meningitis, optimal initial management with amphotericin and flucytosine improves survival compared to alternative therapies; however, amphotsericin is difficult to administer and flucytosine has not been available in middle or low income countries, where cryptococcal meningitis is most prevalent. Expert commentary: Improved care for cryptococcal meningitis patients in resource-limited settings is possible, and new treatment possibilities are emerging.
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Affiliation(s)
- Sarah Lofgren
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - Mahsa Abassi
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - Joshua Rhein
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - David R Boulware
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
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27
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Gassiep I, McDougall D, Douglas J, Francis R, Playford EG. Cryptococcal infections in solid organ transplant recipients over a 15-year period at a state transplant center. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12639] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/28/2016] [Accepted: 08/21/2016] [Indexed: 02/03/2023]
Affiliation(s)
- Ian Gassiep
- Department of Infectious Diseases; Princess Alexandra Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - David McDougall
- Department of Infectious Diseases; Princess Alexandra Hospital; Brisbane QLD Australia
| | - Joel Douglas
- Department of Infectious Diseases; Princess Alexandra Hospital; Brisbane QLD Australia
| | - Ross Francis
- School of Medicine; University of Queensland; Brisbane QLD Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane QLD Australia
| | - Elliott G. Playford
- Department of Infectious Diseases; Princess Alexandra Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
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28
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Abstract
Cryptococcosis is an invasive mycosis caused by pathogenic encapsulated yeasts in the genus Cryptococcus. Cryptococcus gained prominence as a pathogen capable of widespread disease outbreaks in vulnerable populations. We have gained insight into the pathobiology of Cryptococcus, including the yeast' s capacity to adapt to environmental pressures, exploit new geographic environments, and cause disease in both immunocompromised and apparently immunocompetent hosts. Inexpensive, point-of-care testing makes diagnosis more feasible than ever. The associated worldwide burden and mortality remains unacceptably high. Novel screening strategies and preemptive therapy offer promise at making a sustained and much needed impact on this sugar-coated opportunistic mycosis.
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Affiliation(s)
- Eileen K Maziarz
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, DUMC Box 102359, 315 Trent Drive, Durham, NC 27710, USA.
| | - John R Perfect
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, DUMC Box 102359, 315 Trent Drive, Durham, NC 27710, USA
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29
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Vidal JE, Toniolo C, Paulino A, Colombo A, Dos Anjos Martins M, da Silva Meira C, Pereira-Chioccola VL, Figueiredo-Mello C, Barros T, Duarte J, Fonseca F, Alves Cunha M, Mendes C, Ribero T, Dos Santos Lazera M, Rajasingham R, Boulware DR. Asymptomatic cryptococcal antigen prevalence detected by lateral flow assay in hospitalised HIV-infected patients in São Paulo, Brazil. Trop Med Int Health 2016; 21:1539-1544. [PMID: 27699970 DOI: 10.1111/tmi.12790] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the prevalence of asymptomatic cryptococcal antigen (CRAG) using lateral flow assay (LFA) in hospitalised HIV-infected patients with CD4 counts <200 cells/μl. METHODS Hospitalised HIV-infected patients were prospectively recruited at Instituto de Infectologia Emilio Ribas, a tertiary referral hospital to HIV-infected patients serving the São Paulo State, Brazil. All patients were >18 years old without prior cryptococcal meningitis, without clinical suspicion of cryptococcal meningitis, regardless of antiretroviral (ART) status, and with CD4 counts <200 cells/μl. Serum CRAG was tested by LFA in all patients, and whole blood CRAG was tested by LFA in positive cases. RESULTS We enrolled 163 participants of whom 61% were men. The duration of HIV diagnosis was a median of 8 (range, 1-29) years. 26% were antiretroviral (ART)-naïve, and 74% were ART-experienced. The median CD4 cell count was 25 (range, 1-192) cells/μl. Five patients (3.1%; 95%CI, 1.0-7.0%) were asymptomatic CRAG-positive. Positive results cases were cross-verified by performing LFA in whole blood. CONCLUSIONS 3.1% of HIV-infected inpatients with CD4 <200 cells/μl without symptomatic meningitis had cryptococcal antigenemia in São Paulo, suggesting that routine CRAG screening may be beneficial in similar settings in South America. Our study reveals another targeted population for CRAG screening: hospitalised HIV-infected patients with CD4 <200 cells/μl, regardless of ART status. Whole blood CRAG LFA screening seems to be a simple strategy to prevention of symptomatic meningitis.
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Affiliation(s)
- José E Vidal
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil.,Faculdade de Medicina, Hospital das Clínicas, da Universidade de São Paulo, São Paulo, Brazil.,Instituto de Medicina Tropical da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | - Claudia Figueiredo-Mello
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Tiago Barros
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
| | | | | | | | - Clara Mendes
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
| | - Taiana Ribero
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
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30
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Abstract
Central nervous system (CNS) infections are potentially life threatening if not diagnosed and treated early. The initial clinical presentations of many CNS infections are non-specific, making a definitive etiologic diagnosis challenging. Nucleic acid in vitro amplification-based molecular methods are increasingly being applied for routine microbial detection. These methods are a vast improvement over conventional techniques with the advantage of rapid turnaround and higher sensitivity and specificity. Additionally, molecular methods performed on cerebrospinal fluid samples are considered the new gold standard for diagnosis of CNS infection caused by pathogens, which are otherwise difficult to detect. Commercial diagnostic platforms offer various monoplex and multiplex PCR assays for convenient testing of targets that cause similar clinical illness. Pan-omic molecular platforms possess potential for use in this area. Although molecular methods are predicted to be widely used in diagnosing and monitoring CNS infections, results generated by these methods need to be carefully interpreted in combination with clinical findings. This review summarizes the currently available armamentarium of molecular assays for diagnosis of central nervous system infections, their application, and future approaches.
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Screening HIV-Infected Patients with Low CD4 Counts for Cryptococcal Antigenemia prior to Initiation of Antiretroviral Therapy: Cost Effectiveness of Alternative Screening Strategies in South Africa. PLoS One 2016; 11:e0158986. [PMID: 27390864 PMCID: PMC4938608 DOI: 10.1371/journal.pone.0158986] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 06/26/2016] [Indexed: 11/19/2022] Open
Abstract
Background In 2015 South Africa established a national cryptococcal antigenemia (CrAg) screening policy targeted at HIV-infected patients with CD4+ T-lymphocyte (CD4) counts <100 cells/ μl who are not yet on antiretroviral treatment (ART). Two screening strategies are included in national guidelines: reflex screening, where a CrAg test is performed on remnant blood samples from CD4 testing; and provider-initiated screening, where providers order a CrAg test after a patient returns for CD4 test results. The objective of this study was to compare costs and effectiveness of these two screening strategies. Methods We developed a decision analytic model to compare reflex and provider-initiated screening in terms of programmatic and health outcomes (number screened, number identified for preemptive treatment, lives saved, and discounted years of life saved) and screening and treatment costs (2015 USD). We estimated a base case with prevalence and other parameters based on data collected during CrAg screening pilot projects integrated into routine HIV care in Gauteng, Free State, and Western Cape Provinces. We conducted sensitivity analyses to explore how results change with underlying parameter assumptions. Results In the base case, for each 100,000 CD4 tests, the reflex strategy compared to the provider-initiated strategy has higher screening costs ($37,536 higher) but lower treatment costs ($55,165 lower), so overall costs of screening and treatment are $17,629 less with the reflex strategy. The reflex strategy saves more lives (30 lives, 647 additional years of life saved). Sensitivity analyses suggest that reflex screening dominates provider-initiated screening (lower total costs and more lives saved) or saves additional lives for small additional costs (< $125 per life year) across a wide range of conditions (CrAg prevalence, patient and provider behavior, patient survival without treatment, and effectiveness of preemptive fluconazole treatment). Conclusions In countries with substantial numbers of people with untreated, advanced HIV disease such as South Africa, CrAg screening before initiation of ART has the potential to reduce cryptococcal meningitis and save lives. Reflex screening compared to provider-initiated screening saves more lives and is likely to be cost saving or have low additional costs per additional year of life saved.
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Koguchi-Yoshioka H, Hashimoto-Azuma N, Takamure M, Soga F, Hideshima E, Komuro R, Matsumoto C. Asymptomatic meningeal and pulmonary cryptococcosis during the course of low-dose prednisolone therapy for bullous pemphigoid. DERMATOL SIN 2016. [DOI: 10.1016/j.dsi.2015.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Coetzee LM, Moodley K, Glencross DK. Performance Evaluation of the Becton Dickinson FACSPresto™ Near-Patient CD4 Instrument in a Laboratory and Typical Field Clinic Setting in South Africa. PLoS One 2016; 11:e0156266. [PMID: 27224025 PMCID: PMC4880207 DOI: 10.1371/journal.pone.0156266] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 05/11/2016] [Indexed: 12/27/2022] Open
Abstract
Background The BD-FACSPresto™ CD4 is a new, point-of-care (POC) instrument utilising finger-stick capillary blood sampling. This study evaluated its performance against predicate CD4 testing in South Africa. Methods Phase-I testing: HIV+ patient samples (n = 214) were analysed on the Presto™ under ideal laboratory conditions using venous blood. During Phase-II, 135 patients were capillary-bled for CD4 testing on FACSPresto™, performed according to manufacturer instruction. Comparative statistical analyses against predicate PLG/CD4 method and industry standards were done using GraphPad Prism 6. It included Bland-Altman with 95% limits of agreement (LOA) and percentage similarity with coefficient of variation (%CV) analyses for absolute CD4 count (cells/μl) and CD4 percentage of lymphocytes (CD4%). Results In Phase-I, 179/217 samples yielded reportable results with Presto™ using venous blood filled cartridges. Compared to predicate, a mean bias of 40.4±45.8 (LOA of -49.2 to 130.2) and %similarity (%CV) of 106.1%±7.75 (7.3%) was noted for CD4 absolute counts. In Phase-2 field study, 118/135 capillary-bled Presto™ samples resulted CD4 parameters. Compared to predicate, a mean bias of 50.2±92.8 (LOA of -131.7 to 232) with %similarity (%CV) 105%±10.8 (10.3%), and 2.87±2.7 (LOA of -8.2 to 2.5) with similarity of 94.7±6.5% (6.83%) noted for absolute CD4 and CD4% respectively. No significant clinical differences were indicated for either parameter using two sampling methods. Conclusion The Presto™ produced remarkable precision to predicate methods, irrespective of venous or capillary blood sampling. A consistent, clinically insignificant over-estimation (5–7%) of counts against PLG/CD4 and equivalency to FACSCount™ was noted. Further field studies are awaited to confirm longer-term use.
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Affiliation(s)
- Lindi-Marie Coetzee
- National Health Laboratory Service of South Africa (NHLS), Charlotte Maxeke Hospital, CD4 Laboratory, Parktown, Johannesburg, South Africa.,Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2198, Johannesburg, South Africa
| | - Keshendree Moodley
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2198, Johannesburg, South Africa
| | - Deborah Kim Glencross
- National Health Laboratory Service of South Africa (NHLS), Charlotte Maxeke Hospital, CD4 Laboratory, Parktown, Johannesburg, South Africa.,Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2198, Johannesburg, South Africa
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Vidal JE. Preemptive Therapy for Cryptococcal Meningitis: A Valid Strategy for Latin America? J Fungi (Basel) 2016; 2:jof2020014. [PMID: 29376931 PMCID: PMC5753076 DOI: 10.3390/jof2020014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/11/2016] [Accepted: 05/16/2016] [Indexed: 11/16/2022] Open
Abstract
AIDS-related cryptococcal meningitis continues to cause a substantial burden of death in low and middle income countries. Better diagnostics allow detection of cryptococcosis in the asymptomatic phase and using these technologies to screen at-risk persons would likely reduce mortality. The World Health Organization recommends cryptococcal antigen screening among populations with a prevalence of cryptococcal antigenaemia (CRAG) > 3%. There is scarce data about CRAG prevalence in Latin America. Four studies (only one published as a full text) showed asymptomatic CRAG prevalence between 2.7% and 6.2% in several sub-sets of HIV-infected patients. The CRAG lateral flow assay (LFA) has several advantages over other techniques for actual implementation of a screening program. Although more studies are necessary to confirm available data, implementation of the CRAG screening strategy seems to be opportune in Latin America.
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Affiliation(s)
- José E Vidal
- Department of Neurology; Emilio Ribas Institute of Infectious Diseases; Av Doutor Arnaldo 165, Cerqueira César, São Paulo, CEP 05411-000, Brazil.
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35
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Schmalzle SA, Buchwald UK, Gilliam BL, Riedel DJ. Cryptococcus neoformans infection in malignancy. Mycoses 2016; 59:542-52. [PMID: 26932366 DOI: 10.1111/myc.12496] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/10/2016] [Accepted: 02/04/2016] [Indexed: 12/25/2022]
Abstract
Cryptococcosis is an opportunistic invasive fungal infection that is well described and easily recognised when it occurs as meningitis in HIV-infected persons. Malignancy and its treatment may also confer a higher risk of infection with Cryptococcus neoformans, but this association has not been as well described. A case of cryptococcosis in a cancer patient is presented, and all cases of coincident C. neoformans infection and malignancy in adults published in the literature in English between 1970 and 2014 are reviewed. Data from these cases were aggregated in order to describe the demographics, type of malignancy, site of infection, clinical manifestations, treatment and outcomes of cryptococcosis in patients with cancer. Haematologic malignancies accounted for 82% of cases, with lymphomas over-represented compared to US population data (66% vs. 53% respectively). Cryptococcosis was reported rarely in patients with solid tumours. Haematologic malignancy patients were more likely to have central nervous system (P < 0.001) or disseminated disease (P < 0.001), receive Amphotericin B as part of initial therapy (P = 0.023), and had higher reported mortality rates than those with solid tumours (P = 0.222). Providers should have heightened awareness of the possibility of cryptococcosis in patients with haematologic malignancy presenting with infection.
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Affiliation(s)
- Sarah A Schmalzle
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - Ulrike K Buchwald
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - Bruce L Gilliam
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - David J Riedel
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
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Application of Culture-Independent Rapid Diagnostic Tests in the Management of Invasive Candidiasis and Cryptococcosis. J Fungi (Basel) 2015; 1:217-251. [PMID: 29376910 PMCID: PMC5753112 DOI: 10.3390/jof1020217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/17/2015] [Accepted: 08/17/2015] [Indexed: 12/26/2022] Open
Abstract
The diagnosis of invasive candidiasis (IC) and cryptococcosis is often complicated by slow and insensitive culture-based methods. Such delay results in poor outcomes due to the lack of timely therapeutic interventions. Advances in serological, biochemical, molecular and proteomic approaches have made a favorable impact on this process, improving the timeliness and accuracy of diagnosis with resultant improvements in outcome. This paper will serve as an overview of recent developments in the diagnostic approaches to infections due to these important yeast-fungi.
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