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Elicer I, Eugenin L, Acuña MP, Uslar W, Fernández A, Lasso M. Characteristics of HIV-associated cryptococcal meningitis in a tertiary Chilean hospital: An observational retrospective study. Clin Neurol Neurosurg 2024; 244:108423. [PMID: 38996802 DOI: 10.1016/j.clineuro.2024.108423] [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: 04/22/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Central nervous system opportunistic infections can be the first presentation of an HIV infection. Our aim is to describe clinical and laboratory characteristics of HIV-associated Cryptococcal Meningitis (CM), in-hospital outcomes and analyze associations of these parameters with adverse outcomes. METHODS Observational study of local cohort of HIV-associated cryptococcal meningitis in a high complexity tertiary urban hospital in Santiago, Chile. Descriptive analysis through chart review of all episodes of HIV-associated CM in adults, from 1995 to 2019. Inclusion criteria were confirmed CM with cerebrospinal fluid culture or India ink in the appropriate clinical context and HIV diagnosis. We selected relevant variables that have been described as predictors of adverse outcomes in the literature and explore associations in our cohort. RESULTS There were 37 HIV associated CM cases, occurring from 2000 to 2019. Majority were men (86 %) with a median age of 35 years. CM was the first HIV manifestation in 32 %. Opening pressure was measured in 10 % of patients at admission. Most CSF parameters were mildly altered, and two patients presented with completely normal CSF findings. Most patients -94,4 %- suffered adverse events secondary to antifungal therapy. Despite of recommendations against their use, steroids were frequently prescribed. Mortality was 18,9 %, and was associated with older age, and more days of headache prior to admission. CONCLUSIONS CM clinical presentation and CSF characteristics are variable at presentation, which can lead to delayed diagnosis. Inappropriate use of corticosteroids, antifungal toxicity and suboptimal management of elevated intracranial pressure are key aspects to improve.
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Affiliation(s)
- Isabel Elicer
- Hospital Dr. Sótero del Río, Clínica Las Condes, Red Salud UC Christus City, Santiago, Chile.
| | | | - María Paz Acuña
- Hospital Dr. Sótero del Río, Santiago, Chile. Hospital Eloísa Díaz La Florida, Santiago, Chile.
| | - Wilhelm Uslar
- Hospital Herminda Martín, Chillán, Chile. Red Salud UC Christus, Santiago, Chile.
| | | | - Martin Lasso
- Universidad Católica, Chief of Adult's Infectious Disease Unit, Hospital Dr. Sótero del Río, Chile.
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Tan X, Deng M, Fang Z, Yang Q, Zhang M, Wu J, Chen W. A nomogram to predict cryptococcal meningitis in patients with pulmonary cryptococcosis. Heliyon 2024; 10:e30281. [PMID: 38726150 PMCID: PMC11079104 DOI: 10.1016/j.heliyon.2024.e30281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
Background The most serious manifestation of pulmonary cryptococcosis is complicated with cryptococcal meningitis, while its clinical manifestations lack specificity with delayed diagnosis and high mortality. The early prediction of this complication can assist doctors to carry out clinical interventions in time, thus improving the cure rate. This study aimed to construct a nomogram to predict the risk of cryptococcal meningitis in patients with pulmonary cryptococcosis through a scoring system. Methods The clinical data of 525 patients with pulmonary cryptococcosis were retrospectively analyzed, including 317 cases (60.38 %) with cryptococcal meningitis and 208 cases (39.62 %) without cryptococcal meningitis. The risk factors of cryptococcal meningitis were screened by univariate analysis, LASSO regression analysis and multivariate logistic regression analysis. Then the risk factors were incorporated into the nomogram scoring system to establish a prediction model. The model was validated by receiver operating characteristic (ROC) curve, decision curve analysis (DCA) and clinical impact curve. Results Fourteen risk factors for cryptococcal meningitis in patients with pulmonary cryptococcosis were screened out by statistical method, including 6 clinical manifestations (fever, headache, nausea, psychiatric symptoms, tuberculosis, hematologic malignancy) and 8 clinical indicators (neutrophils, lymphocytes, glutamic oxaloacetic transaminase, T cells, helper T cells, killer T cells, NK cells and B cells). The AUC value was 0.978 (CI 96.2 %∼98.9 %), indicating the nomogram was well verified. Conclusion The nomogram scoring system constructed in this study can accurately predict the risk of cryptococcal meningitis in patients with pulmonary cryptococcosis, which may provide a reference for clinical diagnosis and treatment of patients with cryptococcal meningitis.
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Affiliation(s)
- Xiaoli Tan
- Department of Respiration, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Min Deng
- Department of Infectious Diseases, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Zhixian Fang
- Department of Respiration, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Qi Yang
- Department of Respiration, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Ming Zhang
- Department of Respiration, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Jiasheng Wu
- Department of Respiratory and Critical Care Medicine, Jiaxing Second Hospital, Jiaxing, China
- Department of Respiratory Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wenyu Chen
- Department of Respiration, The Affiliated Hospital of Jiaxing University, Jiaxing, China
- Department of Respiratory Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Lawrence DS, Ssali A, Moshashane N, Nabaggala G, Maphane L, Harrison TS, Meya D, Jarvis JN, Seeley J. Pathways to care with HIV-associated cryptococcal meningitis in Botswana and Uganda: Findings from a qualitative methods study. SSM. QUALITATIVE RESEARCH IN HEALTH 2023; 4:100350. [PMID: 38106376 PMCID: PMC10719890 DOI: 10.1016/j.ssmqr.2023.100350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 12/19/2023]
Abstract
HIV-associated cryptococcal meningitis remains a key driver of AIDS-related mortality. Mortality is twice as high in those who present later to care and with severe symptoms such as confusion. We embedded a qualitative methods study within a randomised controlled trial in Gaborone, Botswana and Kampala, Uganda with the aim of understanding pathways to care. We conducted in-depth interviews with trial participants and surrogate decision makers and analysed data thematically. Between January 2020 and June 2021 we interviewed 58 individuals. Pathways to care were prolonged because headaches were disregarded by participants and healthcare workers as a common occurrence with a broad differential diagnosis of predominantly benign aetiologies. There was also a lack of awareness of cryptococcal meningitis, and it was often after HIV was diagnosed or disclosed that the pathway accelerated, resulting in hospital admission. We outline key recommendations to reduce mortality and argue for the integration of social and behavioural interventions within differentiated service delivery models for advanced HIV disease.
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Affiliation(s)
- David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Agnes Ssali
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Georgina Nabaggala
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda
| | | | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK
- Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Janet Seeley
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
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Person AK, Crabtree-Ramirez B, Kim A, Veloso V, Maruri F, Wandeler G, Fox M, Moore R, John Gill M, Imran D, Van Nguyen K, Nalitya E, Muyindike W, Shepherd BE, McGowan CC. Cryptococcal Meningitis and Clinical Outcomes in Persons With Human Immunodeficiency Virus: A Global View. Clin Infect Dis 2023; 76:2116-2125. [PMID: 36821489 PMCID: PMC10273391 DOI: 10.1093/cid/ciad076] [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: 11/28/2022] [Revised: 01/31/2023] [Accepted: 02/08/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a major cause of morbidity and mortality in persons with human immunodeficiency virus (HIV; PWH). Little is known about CM outcomes and availability of diagnostic and treatment modalities globally. METHODS In this retrospective cohort study, we investigated CM incidence and all-cause mortality in PWH in the International Epidemiology Databases to Evaluate AIDS cohort from 1996 to 2017. We estimated incidence using quasi-Poisson models adjusted for sex, age, calendar year, CD4 cell count (CD4), and antiretroviral therapy (ART) status. Mortality after CM diagnosis was examined using multivariable Cox models. A site survey from 2017 assessed availability of CM diagnostic and treatment modalities. RESULTS Among 518 852 PWH, there were 3857 cases of CM with an estimated incidence of 1.54 per 1000 person-years. Mortality over a median of 2.6 years of post-CM diagnosis follow-up was 31.6%, with 29% lost to follow-up. In total, 2478 (64%) were diagnosed with CM after ART start with a median of 253 days from ART start to CM diagnosis. Older age (hazard [HR], 1.31 for 50 vs 35 years), lower CD4 (HR, 1.15 for 200 vs 350 cells/mm3), and earlier year of CM diagnosis (HR, 0.51 for 2015 vs 2000) were associated with higher mortality. Of 89 sites, 34% reported access to amphotericin B; 12% had access to flucytosine. CONCLUSIONS Mortality after CM diagnosis was high. A substantial portion of CM cases occurred after ART start, though incidence and mortality may be higher than reported due to ascertainment bias. Many sites lacked access to recommended CM treatment.
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Affiliation(s)
- Anna K Person
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brenda Crabtree-Ramirez
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico
| | - Ahra Kim
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Valdiléa Veloso
- Intituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Fernanda Maruri
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthew Fox
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Richard Moore
- Center for Global Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - M John Gill
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darma Imran
- Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | | | - Elizabeth Nalitya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Winnie Muyindike
- Department of Internal Medicine, Mbarara University of Science and Technology and Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Catherine C McGowan
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Characteristics and prognostic risk factors of patients with sequence type 5 lineage-associated cryptococcosis in China. Int J Infect Dis 2023; 128:244-253. [PMID: 36646413 DOI: 10.1016/j.ijid.2023.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES Cryptococcus neoformans sequence type 5 (ST5) lineage could infect immunocompetent hosts and cause a significant medical burden. We sought to identify characteristics and prognostic risk factors of ST5 lineage-associated cryptococcosis. METHODS Multilocus sequence typing and antifungal susceptibility testing were conducted for Cryptococcus isolates. The clinical and laboratory characteristics of cryptococcosis patients were investigated. The multivariable logistic regression identified variables independently associated with 30-day mortality in patients with ST5 lineage-associated cryptococcosis without HIV. RESULTS The infection rate of the ST5 isolates was 89.4% (370/414) in China. The proportion of ST5 isolates with nonwild-type minimum inhibitory concentrations to amphotericin B, 5-flucytosine, voriconazole, posaconazole, itraconazole, and fluconazole were 0%, 5.4%, 0.3%, 1.4%, 0.3%, and 8.1%, respectively. The ST5 lineage-infected group exhibited significantly higher blood platelet count, lower blood cryptococcal antigen (CrAg) titer, lower cerebrospinal fluid (CSF) CrAg titer than the non-ST5 lineage-infected group, and lower hemoglobin and lower CSF CrAg titer than the Cryptococcus gattii isolates-infected group. Seven baseline parameters, including underlying disease, dyskinesia, anemia, high peripheral blood neutrophils, low platelet count, high CSF fungal burden, and high CSF opening pressure, were associated independently with the 30-day mortality of patients with ST5 lineage-associated cryptococcosis without HIV. CONCLUSION Our study has provided an understanding of the ST5 lineage associated with cryptococcosis.
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Mo L, Su G, Su H, Huang W, Luo X, Tao C. Effect of IL-10 in the pathogenesis of HIV/AIDS patients with cryptococcal meningitis. Mol Cell Biochem 2023; 478:1-11. [PMID: 35708865 DOI: 10.1007/s11010-022-04488-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 05/31/2022] [Indexed: 02/08/2023]
Abstract
This study aimed to explore the role of IL-10 in the pathogenesis of HIV/AIDS patients with cryptococcal meningitis (CM).Patients were assigned into 4 groups (n = 40/group): group A (HIV/AIDS with CM), group B (HIV/AIDS with tuberculosis), group C (HIV/AIDS), and group D (CM). The levels of IL-10 and associated indicators were measured and the correlations were analyzed by Pearson correlation and partial correlation method. In plasma and cerebrospinal fluid (CSF), no significant difference was observed on IL-10 level between group A and other groups (P > 0.050). R values for IL-10 and relevant indicators in blood were as follows (P < 0.050): group A, IFN-γ (-0.377), IL-12 (0.743), IL-4 (0.881), and IL-6 (0.843); group B, IL-12 (0.740), IL-4 (0.573), and IL-6 (0.900); group C, IL-12 (0.402) and IL-4 (0.896); group D, IL-12 (0.575), IL-4 (0.852), and CD8 (0.325). R values for IL-10 and related indicators in CSF were as follows (P < 0.050): group A, TNF-α (0.664), IL-4 (0.852), white blood cells (WBCs, 0.321) and total protein (TP, 0.330); group B, TNF-α (0.566), IL-4 (0.702), and lactate dehydrogenase (LDH, 0.382); group D, IFN-γ (0.807) and IL-4 (0.441). IL-10 level was positively correlated with IL-4, IL-6, IL-12, TNF-α, WBC, and TP in blood or CSF, and negatively correlated with IFN-γ in blood, suggesting that IL-10 affected both pro-inflammatory and anti-inflammatory activities in the pathogenesis of HIV/AIDS with CM.
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Affiliation(s)
- Lida Mo
- Department of Laboratory Medicine, Nanning Fourth People's Hospital, Guangxi AIDS Clinical Treatment Center (Nanning), Nanning Infectious Disease Hospital Affiliated to Guangxi Medical University, Nanning, 530023, China
| | - Guosheng Su
- Department of Laboratory Medicine, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China.,Department of Laboratory Medicine, People's Hospital of Guangxi-ASEAN Economic and Technological Development Zone, The Tenth People's Hospital of Nanning, Nanning, 530105, Guangxi, China
| | - Hanzhen Su
- Department of Laboratory Medicine, Nanning Fourth People's Hospital, Guangxi AIDS Clinical Treatment Center (Nanning), Nanning Infectious Disease Hospital Affiliated to Guangxi Medical University, Nanning, 530023, China
| | - Wanhong Huang
- Department of Laboratory Medicine, Nanning Fourth People's Hospital, Guangxi AIDS Clinical Treatment Center (Nanning), Nanning Infectious Disease Hospital Affiliated to Guangxi Medical University, Nanning, 530023, China
| | - Xiaolu Luo
- Department of Laboratory Medicine, Nanning Fourth People's Hospital, Guangxi AIDS Clinical Treatment Center (Nanning), Nanning Infectious Disease Hospital Affiliated to Guangxi Medical University, Nanning, 530023, China.
| | - Chuanmin Tao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China.
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Gao J, Wang Q, Tang YD, Zhai J, Hu W, Zheng C. When ferroptosis meets pathogenic infections. Trends Microbiol 2022; 31:468-479. [PMID: 36496309 DOI: 10.1016/j.tim.2022.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
Apoptosis, necrosis, or autophagy are diverse types of regulated cell death (RCD), recognized as the strategies that host cells use to defend against pathogens such as viruses, bacteria, or fungi. Pathogens can induce or block different types of host cell RCD, promoting propagation or evading host immune surveillance. Ferroptosis is a newly identified RCD. Evidence has demonstrated how pathogens regulate ferroptosis to promote their replication, dissemination, and pathogenesis. However, the interaction between ferroptosis and pathogenic infections still needs to be completely elucidated. This review summarizes the advances in the interaction between pathogenic infections and host ferroptotic processes, focusing on the underlying mechanisms of how pathogens exploit ferroptosis, and discussing possible therapeutic measures against pathogen-associated diseases in a ferroptosis-dependent manner.
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Muzazu SGY, Assefa DG, Phiri C, Getinet T, Solomon S, Yismaw G, Manyazewal T. Prevalence of cryptococcal meningitis among people living with human immuno-deficiency virus and predictors of mortality in adults on induction therapy in Africa: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:989265. [PMID: 36160163 PMCID: PMC9494297 DOI: 10.3389/fmed.2022.989265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cryptococcal meningitis (CM) is a leading cause of adult meningitis in countries with a high burden of HIV. It has remained a significant cause of morbidity and mortality in Africa despite the extensive rollout of HIV antiretroviral therapy (ART). This study aimed to systematically synthesize the evidence on the prevalence of CM among people living with HIV (PLWH) and its predictors of mortality among adults who are on induction antifungal therapy in Africa. Methods PubMed/MEDLINE, Embase, and Google Scholar were searched for randomized clinical trials or observational studies published in Africa from 1995 to April 2021. Pooled prevalence of CM among PLWH was calculated using R-studio Version 1.4.1717 software and the data extracted from eligible studies were pooled as percentage with a 95% confidence interval (CI). Predictors of mortality among adults on induction antifungal therapy were synthesized narratively. Results Out of 364 studies identified, 17 eligible articles were included in the analysis. The prevalence of CM among PLWH in Africa was 5.11% (95% CI 2.71-9.43%; participants = 10,813; studies = 9; I 2 = 97%). In the subgroup analysis, the prevalence was 12.9% (95% CI 4.883-30.0; participants = 533; studies = 3; I 2 = 63%) in the years 1995-2010 and 3.18% (95% CI 1.54-6.45; participants = 10,280; studies = 6; I 2 = 98%) in the years 2011-2021, with the prevalence significantly decreased by 51% (p = 0.02). Predictors of mortality were fluconazole monotherapy, focal neurological signs, low Glasgow coma scale, and delayed diagnosis of CM at varied timepoint. Conclusion Prevalence of CM has significantly decreased from 1996-2010 to 2011-2021 among PLWH on induction therapy in Africa. Fluconazole monotherapy, focal neurological symptoms, diastolic blood pressure < 60 mmHg, and concurrent tuberculosis coinfection were significant predictors of mortality at 2- and 10-weeks timepoints. CM remains a major concern among PLWH despite increases in ART coverage. Improved access to effective antifungal therapies is needed in Africa for timely initiation of combination induction therapy and better treatment outcomes of PLWH. Systematic review registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=254113], identifier [CRD42021254113].
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Affiliation(s)
- Seke G. Y. Muzazu
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Enteric Diseases and Vaccines Research Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Dawit Getachew Assefa
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Christabel Phiri
- Levy Mwanawasa University Teaching Hospital, Department of Internal Medicine, Lusaka, Zambia
| | - Tewodros Getinet
- School of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Samrawit Solomon
- School of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Gizachew Yismaw
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Lawrence DS, Ssali A, Moshashane N, Nabaggala G, Maphane L, Harrison TS, Meya DB, Jarvis JN, Seeley J. Decision making in a clinical trial for a life-threatening illness: Therapeutic expectation, not misconception. Soc Sci Med 2022; 305:115082. [PMID: 35649301 DOI: 10.1016/j.socscimed.2022.115082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 01/10/2023]
Abstract
Potential participants for clinical trials which aim to define treatments for life-threatening conditions are often extremely unwell. When exploring why individuals participate in clinical trials one common observation is a misplaced expectation of personal benefit - a therapeutic misconception. The care offered in some clinical trials is of a higher standard than is routinely available and this has led to criticism around the freedom of choice to enrol - structural coercion. We embedded an ethnographic study within a randomised controlled trial for HIV-associated cryptococcal meningitis in Gaborone, Botswana and Kampala, Uganda. We aimed to gain an understanding of decision-making around the trial and how this was impacted by the study design and broader social context. We conducted in-depth interviews with trial participants, surrogate decision makers and researchers, combined these with direct observations and analysed data using thematic analysis. Between January 2020 and June 2021 we interviewed 89 individuals. We found previous exposure to and awareness of clinical research was limited, as was understanding of the trial objectives and design. Through observations and engagement with healthcare facilities decision-makers were able to identify the trial as providing the best possible chance of survival. Hesitation and reluctance were mostly due to fear of lumbar punctures which was sometimes based on rumours but often based on tragic personal experience. Despite fear, and sometimes conviction that they would die, individuals agreed to consent, often against the wishes of family members. Reassurance and confidence came from trust in routine care staff and the research team but also from fellow participants and their surrogates. We argue that participants made informed decisions based on a therapeutic expectation from the trial and that rather than being the result of structural coercion this was an informed and voluntary choice.
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Affiliation(s)
- David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
| | - Agnes Ssali
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Georgina Nabaggala
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda
| | | | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Janet Seeley
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
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Cryptococcus spp. and Cryptococcosis: focusing on the infection in Brazil. Braz J Microbiol 2022; 53:1321-1337. [PMID: 35486354 PMCID: PMC9433474 DOI: 10.1007/s42770-022-00744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 03/25/2022] [Indexed: 11/02/2022] Open
Abstract
Cryptococcosis is a global fungal infection caused by the Cryptococcus neoformans/Cryptococcus gattii yeast complex. This infection is acquired by inhalation of propagules such as basidiospores or dry yeast, initially causing lung infections with the possibility of progressing to the meninges. This infection mainly affects immunocompromised HIV and transplant patients; however, immunocompetent patients can also be affected. This review proposes to evaluate cryptococcosis focusing on studies of this mycosis in Brazilian territory; moreover, recent advances in the understanding of its virulence mechanism, animal models in research are also assessed. For this, literature review as realized in PubMed, Scielo, and Brazilian legislation. In Brazil, cryptococcosis has been identified as one of the most lethal fungal infections among HIV patients and C. neoformans VNI and C. gattii VGII are the most prevalent genotypes. Moreover, different clinical settings published in Brazil were described. As in other countries, cryptococcosis is difficult to treat due to a limited therapeutic arsenal, which is highly toxic and costly. The presence of a polysaccharide capsule, thermo-tolerance, production of melanin, biofilm formation, mechanisms for iron use, and morphological alterations is an important virulence mechanism of these yeasts. The introduction of cryptococcosis as a compulsory notification disease could improve data regarding incidence and help in the management of these infections.
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Nelles R, Britton S, John GT, Denaro C. Parkinsonism and prolonged cognitive decline as a manifestation of cryptococcal meningitis in a renal transplant patient. BMJ Case Rep 2022; 15:e245788. [PMID: 35046073 PMCID: PMC8772404 DOI: 10.1136/bcr-2021-245788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 11/04/2022] Open
Abstract
We report a case of a 67-year-old male recipient of a second renal allograft, presenting with a 9-month history of progressive cognitive and physical decline with features of Parkinsonism. He was HIV-negative. Serum and cerebrospinal fluid (CSF) cryptococcal antigen was positive though CSF culture was sterile. He had progressive deterioration despite induction and consolidation antifungal treatment. Postmortem brain examination confirmed a large burden of yeast forms in the substantia nigra with widespread chronic meningitis. The significant delay in presentation and diagnosis owing to the atypical, subacute neurocognitive features serves as a timely reminder of the variety of neurological presentations that may be associated with cryptococcal infection in solid organ transplant recipients.
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Affiliation(s)
- Ricky Nelles
- Haematology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Sumudu Britton
- Infectious Disease Unit, Royal Brisbane Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
| | - George Tharayil John
- Faculty of Medicine, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
- Renal Unit, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - Charles Denaro
- Faculty of Medicine, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
- Department of Internal Medicine & Aged Care, Royal Brisbane Hospital, Herston, Queensland, Australia
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12
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Yang L, Tian Z, Zhou L, Zhu L, Sun C, Huang M, Peng J, Guo G. In vitro Antifungal Activity of a Novel Antimicrobial Peptide AMP-17 Against Planktonic Cells and Biofilms of Cryptococcus neoformans. Infect Drug Resist 2022; 15:233-248. [PMID: 35115792 PMCID: PMC8800587 DOI: 10.2147/idr.s344246] [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: 10/13/2021] [Accepted: 01/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background Cryptococcus neoformans is a common human fungal pathogen in immunocompromised people, as well as a prevalent cause of meningitis in HIV-infected individuals. With the emergence of clinical fungal resistance and the shortage of antifungal drugs, it is urgent to discover novel antifungal agents. AMP-17, a novel antimicrobial peptide from Musca domestica, has antifungal activity against C. neoformans. However, its antifungal and anti-biofilm activities remain unclear. Thus, this study aimed to evaluate the antifungal activity of AMP-17 against planktonic cells and biofilms of C. neoformans. Methods The minimum inhibitory concentration (MIC), the biofilm inhibitory and eradicating concentration (BIC and BEC) were determined by the broth microdilution assay or the 2, 3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide (XTT) reduction assay, respectively. The inhibitory and killing activities of AMP-17 against C. neoformans were investigated through the time-inhibition/killing kinetic curves. The potential antifungal mechanism of AMP-17 was detected by flow cytometry, scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). The efficiency of AMP-17 against biofilm formation or preformed biofilm was evaluated by crystal violet staining and XTT reduction assays. The morphology of pre-biofilms was tested by optical microscopy (OM) and CLSM. Results AMP-17 exhibited in vitro antifungal activity against C. neoformans planktonic cells and biofilms, with MICs of 4~16 μg/ml, BIC80 and BEC80 of 16~32 μg/ml, 64~128 μg/ml, respectively. In addition, the 2× and 4× MIC of AMP-17 exhibited similar inhibition levels compared to the 2× and 4× MIC of the clinical drugs FLC and AMB in C. neoformans growth. Moreover, the time-kill results showed that AMP-17 (8× MIC) did not significantly eliminate colony forming units (CFU) after 6 h of treatment; however, there was 2.9-log reduction in CFU of C. neoformans. Furthermore, increasing of the permeability of the fungal cell membrane was observed with the treatment of AMP-17, since the vast change as fungal leakage and cell membrane disruption. However, the DNA binding assay of AMP-17 indicated that the peptide did not target DNA. Besides, AMP-17 was superior in inhibiting and eradicating biofilms of C. neoformans compared with FLC. Conclusion AMP-17 exhibited potential in vitro antifungal activity against the planktonic cells and biofilms of C. neoformans, and it may disrupt fungal cell membranes through multi-target interactions, which provides a promising therapeutic strategy and experimental basis for Cryptococcus-associated infections.
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Affiliation(s)
- Longbing Yang
- School of Basic Medical Sciences, The Key and Characteristic Laboratory of Modern Pathogen Biology, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
| | - Zhuqing Tian
- School of Basic Medical Sciences, The Key and Characteristic Laboratory of Modern Pathogen Biology, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
| | - Luoxiong Zhou
- School of Basic Medical Sciences, The Key and Characteristic Laboratory of Modern Pathogen Biology, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
- School of Public Health, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
| | - Lijuan Zhu
- School of Basic Medical Sciences, The Key and Characteristic Laboratory of Modern Pathogen Biology, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
| | - Chaoqin Sun
- School of Basic Medical Sciences, The Key and Characteristic Laboratory of Modern Pathogen Biology, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
| | - Mingjiao Huang
- School of Basic Medical Sciences, The Key and Characteristic Laboratory of Modern Pathogen Biology, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
| | - Jian Peng
- School of Basic Medical Sciences, The Key and Characteristic Laboratory of Modern Pathogen Biology, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
- Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
| | - Guo Guo
- School of Basic Medical Sciences, The Key and Characteristic Laboratory of Modern Pathogen Biology, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
- Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
- Translational Medicine Research Center, Guizhou Medical University, Guiyang, 550025, People’s Republic of China
- Correspondence: Guo Guo, Building Wuben, School of Basic Medical Sciences, Guizhou Medical University, College Town, Gui’an New District, Guiyang, 550025, People’s Republic of China, Tel/fax +86 851 882 59268, Email
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13
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Yukuyama MN, Ishida K, de Araujo GLB, Spadari CDC, de Souza A, Löbenberg R, Henostroza MAB, Folchini BR, Peroni CM, Peters MCC, de Oliveira IF, Miyagi MYS, Bou-Chacra NA. Rational design of oral flubendazole-loaded nanoemulsion for brain delivery in cryptococcosis. Colloids Surf A Physicochem Eng Asp 2021. [DOI: 10.1016/j.colsurfa.2021.127631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Cuetara MS, Jusdado Ruiz-Capillas JJ, Nuñez-Valentin MP, Rodríguez Garcia E, Garcia-Benayas E, Rojo-Amigo R, Rodriguez-Gallego JC, Hagen F, Colom MF. Successful Isavuconazole Salvage Therapy for a Cryptococcus deuterogattii (AFLP6/VGII) Disseminated Infection in a European Immunocompetent Patient. Mycopathologia 2021; 186:507-518. [PMID: 34115285 DOI: 10.1007/s11046-021-00566-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/24/2021] [Indexed: 12/29/2022]
Abstract
Members of the Cryptococcus gattii species complex are notorious causes of cryptococcosis as they often cause severe, life-threatening infections. Here we describe a case of a severe disseminated C. deuterogattii infection in a previously healthy patient who was initially treated with amphotericin B, 5-fluorocytosine and fluconazole, which led to a good neurological response, but the infection in the lungs remained unaltered and was not completely resolved until switching the antifungal therapy to isavuconazole. The infection was likely acquired during a one-month stay at the Azores Islands, Portugal. Environmental sampling did not yield any cryptococcal isolate; therefore, the source of this apparent autochthonous case could not be determined. Molecular typing showed that the cultured C. deuterogattii isolates were closely related to the Vancouver Island outbreak-genotype.
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Affiliation(s)
- Maria Soledad Cuetara
- Department of Microbiology, Hospital Universitario Severo Ochoa, Avda. de Orellana S/N. 28914, Leganés, Madrid, Spain.
| | | | | | | | - Elena Garcia-Benayas
- Department of Pharmacy, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Ricardo Rojo-Amigo
- Department of Immunology, Hospital Materno-Infantil-CHUAC, La Coruña, Spain
| | | | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Laboratory of Medical Mycology, Jining No. 1 People's Hospital, Jining, Shandong, People's Republic of China
| | - María Francisca Colom
- Medical Mycology Laboratory, Department of Plant Production and Microbiology, University Miguel Hernández, Campus of Sant Joan D'Alacant, 03550, Alicante, Spain. .,Institute for Healthcare and Biomedical Research of Alicante, Isabial, Spain.
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15
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Li Y, Lu Y, Nie J, Liu M, Yuan J, Li Y, Li H, Chen Y. Potential Predictors and Survival Analysis of the Relapse of HIV-Associated Cryptococcal Meningitis: A Retrospective Study. Front Med (Lausanne) 2021; 8:626266. [PMID: 34041249 PMCID: PMC8141581 DOI: 10.3389/fmed.2021.626266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: We intend to investigate the relapse of HIV-associated cryptococcal meningitis (CM), assess potential predictors and conduct survival analysis, with a view to establishing a valid reference for the management of the relapse of CM. Method: This is a retrospective study in Chinese patients with HIV-associated CM and those who experience relapse of CM. Baseline demographic, laboratory and clinical characteristics of patients with HIV-associated CM were collected. Predictors for relapse of HIV-associated CM were analyzed using univariate and multivariate logistic regression. Survival probability in relapse cases was determined by Kaplan-Meier survival curves. Results: During the study period, 87 of 348 (25.0%) HIV patients experienced the relapse of CM. CD4+ T-cell counts, antiretroviral therapy (ART) status and the time from symptom onset to presentation were all statistically associated with the relapse of CM (p = 0.013, 0.018 and 0.042, respectively). The overall survival among 46 HIV CM relapse patients whose survival information were obtained, was 78.3%. The proportion of patients who died after antifungal treatment for CM was greater in those whose interval from symptom onset to presentation ≥4 weeks, compared with those <4 weeks (p = 0.0331). Conclusions: In order to reduce the relapse of CM and increase the survival possibility of these patients, we can promote the importance of ART before CM occurs, emphasize timely consultation when any CM-associated clinical symptoms occurs, and individualized the timing of ART initiation according to indicators which can reflect the severity of CM.
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Affiliation(s)
- Yao Li
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yanqiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jingmin Nie
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Min Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jing Yuan
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yan Li
- Department of Hygiene Toxicology, School of Public Health, Zunyi Medical University, Zunyi Guizhou, China
| | - Huan Li
- Division of Respiratory Geriatrics, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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16
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Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections associated with HIV remain significant contributors to morbidity and mortality, particularly among people living with HIV (PLWH) in resource-limited settings worldwide. In this review, we discuss several recent important scientific discoveries in the prevention, diagnosis, and management around two of the major causes of CNS opportunistic infections-tuberculous meningitis (TBM) and cryptococcal meningitis including immune reconstitution syndrome (IRIS) associated with cryptococcal meningitis. We also discuss the CNS as a possible viral reservoir, highlighting Cerebrospinal fluid viral escape. RECENT FINDINGS CNS infections in HIV-positive people in sub-Saharan Africa contribute to 15-25% of AIDS-related deaths. Morbidity and mortality in those is associated with delays in HIV diagnosis, lack of availability for antimicrobial treatment, and risk of CNS IRIS. The CNS may serve as a reservoir for replication, though it is unclear whether this can impact peripheral immunosuppression. SUMMARY Significant diagnostic and treatment advances for TBM and cryptococcal meningitis have yet to impact overall morbidity and mortality according to recent data. Lack of early diagnosis and treatment initiation, and also maintenance on combined antiretroviral treatment are the main drivers of the ongoing burden of CNS opportunistic infections. The CNS as a viral reservoir has major potential implications for HIV eradication strategies, and also control of CNS opportunistic infections.
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17
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Li Y, Huang X, Qin Y, Wu H, Yan X, Chen Y. What Is the Most Appropriate Induction Regimen for the Treatment of HIV-Associated Cryptococcal Meningitis When the Recommended Regimen Is Not Available? Evidence From a Network Meta-Analysis. Front Pharmacol 2020; 11:963. [PMID: 32714189 PMCID: PMC7344322 DOI: 10.3389/fphar.2020.00963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/12/2020] [Indexed: 02/06/2023] Open
Abstract
Aims Our object was to find the most appropriate, most effective, and most readily available of four induction regimens for HIV-associated cryptococcal meningitis (CM) (Regimen A: 1 week of AmB plus 5-FC followed by 1 week of fluconazole, Regimen B: 1 week of AmB plus fluconazole followed by 1 week of fluconazole, Regimen C: 2 weeks of AmB plus 5-FC, Regimen D: 2 weeks of AmB plus fluconazole), given the vast differences between resource-limited and resource-abundant settings regarding therapeutic drug accessibility, availability, and affordability for HIV-associated (CM). Methods We conducted a network meta-analysis to compare the therapeutic efficacy and safety of four different induction treatment regimens. Results The 10-week mortality of Regimen A was significantly lower than that of Regimen B and D, and the 2-week mortality of Regimen A was significantly lower than that of Regimen B. Furthermore, there were no statistically significant differences in 10-week mortality, 2-week mortality, as well as in effective fungicidal activity (EFA) over the first 2 weeks among Regimens B, C, and D. The statistical differences in adverse events between Regimen B and Regimen D, and Regimen C and Regimen D were not calculated to be significant. Conclusions Our results indicate that, 1 week of AmB plus 5-FC followed by 1 week of fluconazole is superior to the three other studied regimens, and that when 5-FC is not available, accessible, or affordable, 2 weeks of AmB plus fluconazole or 1 week of AmB plus fluconazole followed by 1 week of fluconazole is an appropriate substitution for 2 weeks of AmB plus 5-FC.
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Affiliation(s)
- Yao Li
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Qin
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiaofeng Yan
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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18
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Derbie A, Mekonnen D, Woldeamanuel Y, Abebe T. Cryptococcal antigenemia and its predictors among HIV infected patients in resource limited settings: a systematic review. BMC Infect Dis 2020; 20:407. [PMID: 32527231 PMCID: PMC7291525 DOI: 10.1186/s12879-020-05129-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 05/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Cryptococcosis is an opportunistic fungal infection that primarily affects people with advanced HIV/AIDS and is an important cause of morbidity and mortality around the globe. By far the most common presentation of the disease is cryptococcal meningitis (CM), which leads to an estimated 15–20% of all HIV related deaths worldwide, 75% of which are in sub-Saharan Africa. However, to the best of our knowledge there is quite limited reviewed data on the epidemiology of cryptococcal antigenemia in a large HIV-infected population in resource limited settings. Methods Articles published in English irrespective of the time of publication were systematically searched using comprehensive search strings from PubMed/Medline and SCOPUS. In addition, Google Scholar and Google databases were searched manually for grey literature. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. The pooled prevalence of cryptococcal antigenemia was determined with 95% confidence interval (CI). Results Among 2941 potential citations, we have included 22 studies with a total of 8338 HIV positive individuals. The studies were reported in ten different countries during the year (2007–2018). Most of the articles reported the mean CD4 count of the participants below 100 cells/μl. The pooled prevalence of cryptococcal antigenemia at different CD4 count and ART status was at 8% (95%CI: 6–10%) (ranged between 1.7 and 33%). Body mass index (BMI) < 18.5 kg/m2, CD4 count < 100 cells, patients presenting with headache and male gender were reported by two or more articles as an important predictors of cryptococcal antigenemia. Conclusions Implementing a targeted screening of HIV patients with low BMI, CD4 count < 100 cells, having headache and males; and treatment for asymptomatic cryptococcal disease should be considered. Additional data is needed to better define the epidemiology of cryptococcal antigenemia and its predictors in resource limited settings in order to optimize the prevention, diagnosis, and treatment strategies.
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Affiliation(s)
- Awoke Derbie
- Department of Medical Microbiology, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia. .,Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia. .,Department of Health Biotechnology, Biotechnology Research Institute, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Daniel Mekonnen
- Department of Medical Microbiology, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.,Department of Health Biotechnology, Biotechnology Research Institute, Bahir Dar University, Bahir Dar, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia.,Department of Medical Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tamrat Abebe
- Department of Medical Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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19
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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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20
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Ponatshego PL, Lawrence DS, Youssouf N, Molloy SF, Alufandika M, Bango F, Boulware DR, Chawinga C, Dziwani E, Gondwe E, Hlupeni A, Hosseinipour MC, Kanyama C, Meya DB, Mosepele M, Muthoga C, Muzoora CK, Mwandumba H, Ndhlovu CE, Rajasingham R, Sayed S, Shamu S, Tsholo K, Tugume L, Williams D, Maheswaran H, Shiri T, Boyer-Chammard T, Loyse A, Chen T, Wang D, Lortholary O, Lalloo DG, Meintjes G, Jaffar S, Harrison TS, Jarvis JN, Niessen LW. AMBIsome Therapy Induction OptimisatioN (AMBITION): High dose AmBisome for cryptococcal meningitis induction therapy in sub-Saharan Africa: economic evaluation protocol for a randomised controlled trial-based equivalence study. BMJ Open 2019; 9:e026288. [PMID: 30940760 PMCID: PMC6500286 DOI: 10.1136/bmjopen-2018-026288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cryptococcal meningitis is responsible for around 15% of all HIV-related deaths globally. Conventional treatment courses with amphotericin B require prolonged hospitalisation and are associated with multiple toxicities and poor outcomes. A phase II study has shown that a single high dose of liposomal amphotericin may be comparable to standard treatment. We propose a phase III clinical endpoint trial comparing single, high-dose liposomal amphotericin with the WHO recommended first-line treatment at six sites across five counties. An economic analysis is essential to support wide-scale implementation. METHODS AND ANALYSIS Country-specific economic evaluation tools will be developed across the five country settings. Details of patient and household out-of-pocket expenses and any catastrophic healthcare expenditure incurred will be collected via interviews from trial patients. Health service patient costs and related household expenditure in both arms will be compared over the trial period in a probabilistic approach, using Monte Carlo bootstrapping methods. Costing information and number of life-years survived will be used as the input to a decision-analytic model to assess the cost-effectiveness of a single, high-dose liposomal amphotericin to the standard treatment. In addition, these results will be compared with a historical cohort from another clinical trial. ETHICS AND DISSEMINATION The AMBIsome Therapy Induction OptimisatioN (AMBITION) trial has been evaluated and approved by the London School of Hygiene and Tropical Medicine, University of Botswana, Malawi National Health Sciences, University of Cape Town, Mulago Hospital and Zimbabwe Medical Research Council research ethics committees. All participants will provide written informed consent or if lacking capacity will have consent provided by a proxy. The findings of this economic analysis, part of the AMBITION trial, will be disseminated through peer-reviewed publications and at international and country-level policy meetings. TRIAL REGISTRATION ISRCTN 7250 9687; Pre-results.
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Affiliation(s)
| | - David Stephen Lawrence
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Nabila Youssouf
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Sile F Molloy
- Research Centre for Infection and Immunity, St. George's University of London, London, UK
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
| | - Funeka Bango
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Boulware
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minnesota, USA
| | | | - Eltas Dziwani
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
| | - Ebbie Gondwe
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
| | - Admire Hlupeni
- Department of Medicine, University of Zimbabwe, Harare, Zimbabwe
| | | | - Cecilia Kanyama
- Lilongwe Medical Relief Trust (UNC Project), Lilongwe, Malawi
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mosepele Mosepele
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Charles Muthoga
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Conrad K Muzoora
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Henry Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Sumaya Sayed
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shepherd Shamu
- Department of Medicine, University of Zimbabwe, Harare, Zimbabwe
| | - Katlego Tsholo
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Darlisha Williams
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minnesota, USA
| | - Hendramoorthy Maheswaran
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
- Population Evidence and Technologies, University of Warwick, Coventry, UK
| | - Tinevimbo Shiri
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Timothée Boyer-Chammard
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Angela Loyse
- Research Centre for Infection and Immunity, St. George's University of London, London, UK
| | - Tao Chen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Duolao Wang
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Olivier Lortholary
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - David G Lalloo
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shabbar Jaffar
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas S Harrison
- Research Centre for Infection and Immunity, St. George's University of London, London, UK
| | - Joseph N Jarvis
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Louis Wilhelmus Niessen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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21
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Falci DR, Pasqualotto AC. Clinical mycology in Latin America and the Caribbean: A snapshot of diagnostic and therapeutic capabilities. Mycoses 2019; 62:368-373. [PMID: 30614600 DOI: 10.1111/myc.12890] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/03/2019] [Indexed: 01/10/2023]
Abstract
Despite the existence of endemic mycoses in Latin America and the Caribbean, in addition to a large population of patients at risk for invasive mycoses, the capability of medical centres to perform a proper diagnosis in mycology has not been studied in the region. Moreover, availability of antifungal drugs in the region is unknown. Here, we report the results of a survey involving 129 centres in 24 countries. Only 9% of centres would have the potential to apply for the minimum standards in mycology, as determined by the European Confederation of Medical Mycology. There is an urgent need to improve diagnostic conditions in Latin America and the Caribbean, as well as providing access to safer and more efficacious antifungal drugs.
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Affiliation(s)
- Diego R Falci
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Universidade La Salle, Canoas, Brazil
| | - Alessandro C Pasqualotto
- Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.,Fellow of the European Confederation of Medical Mycology (FECMM), Porto Alegre, Brazil
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