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Aguilar G, Lopez G, Sued O, Medina N, Caceres DH, Pereira J, Jordan A, Lezcano V, Vicenti C, Benitez G, Samudio T, Perez F. Implementation of a rapid diagnostic assay package for cryptococcosis, histoplasmosis and tuberculosis in people living with HIV in Paraguay. BMC Infect Dis 2024; 24:406. [PMID: 38627642 PMCID: PMC11020460 DOI: 10.1186/s12879-024-09257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Opportunistic infections (OIs) are common causes of mortality among people living with HIV (PLHIV). We determined prevalence and 30-day mortality due to histoplasmosis, cryptococcosis, and TB in PLHIV with advanced HIV disease (AHD). METHODS PLHIV 18 years and older, with a CD4 + T-cell count of less than 350 cells/mm3 newly diagnosed with HIV infection or re-engaged in care after being without ART for more than 90 days (Group A). The second group included symptomatic PLHIV regardless of ART status or CD4 + T-cell count (Group B); all followed for 30 days. Detection of Histoplasma Ag (HisAg) in urine was done by enzyme immunoassay (EIA), Cryptococcus antigen (CrAg) was detected in serum and cerebrospinal fluid (CSF) specimens by lateral flow assay (LFA), and lipoarabinomannan (LAM) detection in urine was by LFA (TB LAM) and in sputum by GeneXpert for diagnosis of Mycobacterium infections. RESULTS From August 2021 to June 2022, 491 PLHIV were enrolled; 482 (98%) had a CD4 + T-cell result, and 381 patients (79%) were classified with AHD according to CD4 + T-cell count (< 200 CD4/mm3). Frequency of an OI was 38% (n = 145/381). Antigen test positivity rate was 16% (72/467) for TB-LAM, 9% (43/464) for HisAg, and 11% (51/484) for CrAg. Twenty-one of 34 (62%) patients receiving CSF CrAg tests were positive, confirming meningitis. Significant differences in 30-day mortality were observed in patients with an OI (16%) vs. no OI (7%) (p = 0.002). Mortality was highest in patients with histoplasmosis (25%), co-infection (22%), cryptococcosis (18% overall; 19% for cryptococcal meningitis), and TB (10%). CONCLUSIONS TB and fungal OIs, including co-infection, were common in PLHIV in Paraguay and had high associated mortality. Laboratories and health facilities need access to CD4 + T-cell testing and rapid diagnostic assays.
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Affiliation(s)
- Gloria Aguilar
- National HIV Program, Asunción, Paraguay
- Facultad de Ciencias de la Salud, Universidad Sudamericana, Amambay, Paraguay
| | | | - Omar Sued
- Communicable Diseases Prevention, Control, and Elimination and Environmental Determinants of Health Department, Pan American Health Organization, 525 23rd St. NW, 20037, Washington, DC, USA
| | - Narda Medina
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (DFWED), ASRT, Inc., Centers for Disease Control and Prevention, 30333, Atlanta, GA, USA
| | - Diego H Caceres
- IMMY, Inc., 73069, Norman, OK, USA
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Jose Pereira
- Centro de Especialidades Dermatológicas, Ministerio de Salud Pública y Bienestar Social, San Lorenzo, Paraguay
| | - Alexander Jordan
- Mycotic Diseases Branch-Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | | | | | | | | | - Freddy Perez
- Communicable Diseases Prevention, Control, and Elimination and Environmental Determinants of Health Department, Pan American Health Organization, 525 23rd St. NW, 20037, Washington, DC, USA.
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.
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Oliveira FG, Nakagawa JADS, de Oliveira JMM, Júnior RML, Marcusso R, Vidal JE. High prevalence of central nervous system cryptococcosis using a fingerprick whole-blood lateral flow assay in individuals with neurological symptoms and advanced HIV disease in a Brazilian emergency department. Med Mycol 2023; 61:myad093. [PMID: 37656871 DOI: 10.1093/mmy/myad093] [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: 06/21/2023] [Revised: 08/10/2023] [Accepted: 08/28/2023] [Indexed: 09/03/2023] Open
Abstract
Timely diagnosis is key in managing central nervous system (CNS) cryptococcosis in people living with HIV/AIDS (PLWHA). There are few data on implementing fingerprick whole-blood cryptococcal antigen (CrAg) lateral flow assay (LFA) as the first test for diagnosing CNS cryptococcosis. We evaluated the prevalence of CNS cryptococcosis and cryptococcal antigenemia using fingerprick whole-blood in a referral emergency department (ED) in São Paulo, Brazil. This was a prospective cohort study of consecutive adult PLWHA with advanced HIV disease and neurological symptoms. Fingerprick whole-blood CrAg LFA was performed at bedside. Seventy-four individuals were enrolled (median age = 40 years; males = 62%). Prevalence of CNS cryptococcosis was 17.6% (13/74); 95% confidence interval (CI), 9.4-30.0%, and prevalence of positive fingerprick whole-blood CrAg LFA was 25.7% (19/74); 95% CI, 15.5-40.1%. Among the six (8.1%) patients with positive fingerprick whole-blood CrAg LFA and negative CSF CrAg LFA, four (5.4%) had isolated asymptomatic cryptococcal antigenemia, one (1.3%) had symptomatic cryptococcal antigenemia, and one (1.3%) had cryptococcemia. Prevalence of CNS cryptococcosis and cryptococcal antigenemia using fingerprick whole-blood CrAg LFA was high. Point-of-care testing was important for diagnosing CNS cryptococcosis in an ED from a middle-income country.
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Affiliation(s)
| | | | | | | | - Rosa Marcusso
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
| | - José E Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica (LIM 49) da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Prevalence and Associated Factors of Cryptococcal Antigenemia in HIV-Infected Patients with CD4 < 200 Cells/µL in São Paulo, Brazil: A Bayesian Analysis. J Fungi (Basel) 2022; 8:jof8121284. [PMID: 36547617 PMCID: PMC9786117 DOI: 10.3390/jof8121284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Cryptococcosis is a severe life-threatening disease and a major cause of mortality in people with advanced AIDS and CD4 ≤ 100 cells/µL. Considering the knowledge gap regarding the benefits of routine application of antigenemia tests in HIV-infected patients with 100−200 CD4 cells/µL for the prevention of cryptococcal meningitis (CM), we aimed to evaluate the prevalence of positive antigenemia through lateral flow assay (LFA) and associated factors in HIV-infected patients with CD4 < 200 cells/µL. Our findings of 3.49% of positive LFA (LFA+) patients with CD4 < 100 cells/µL and 2.24% with CD4 between 100−200 cells/µL have been included in a Bayesian analysis with 12 other studies containing similar samples worldwide. This analysis showed a proportion of 3.6% LFA+ patients (95% credible interval-Ci [2.5−5.7%]) with CD4 < 100 cells/µL and 1.1% (95%Ci [0.5−4.3%]) with CD4 between 100−200 cells/µL, without statistical difference between these groups. The difference between mortality rates in LFA+ and negative LFA groups was e = 0.05013. Cryptococcoma and CM were observed in the LFA+ group with 100−200 and <100 CD4 cells/µL, respectively. Considering the benefits of antifungal therapy for LFA+ patients, our data reinforced the recommendation to apply LFA as a routine test in patients with 100−200 CD4 cells/µL aiming to expand cost-effectiveness studies in this group.
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Epidemiology and Mortality of Cryptococcal Disease in Guatemala: Two-Year Results of a Cryptococcal Antigen Screening Program. Microorganisms 2022; 10:microorganisms10071388. [PMID: 35889106 PMCID: PMC9323764 DOI: 10.3390/microorganisms10071388] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 12/10/2022] Open
Abstract
Cryptococcal disease is an important opportunistic infection among people living with HIV. The cryptococcal antigen (CrAg) can be detected before the clinical onset of meningitis and its screening is recommended. Here, we evaluated CrAg frequency, and describe the epidemiological characteristics and mortality at 180 days in a cohort of HIV patients from Guatemala. A total of 3457 patients were screened with a CrAg lateral flow assay in serum between January 2017 and December 2018. CrAg positivity was 11.5% in patients with ≤100 CD4/mm3, 8.7% in patients with <200 CD4/mm3, and 6.3% in patients with <350 CD4/mm3. In Latin America, we estimated 9.2% CrAg positivity (IC95% 7.9−10.7%) in patients with ≤100 CD4/mm3. Among patients newly diagnosed with HIV, we estimated 4416 incident cases per year in Latin America in those with <200 CD4/mm3 and 5289 in those with <350 CD4/mm3. In addition, we calculated the burden in people not on ARV or without viral suppression and found 28,672 cases. CrAg screening should be considered in patients who have a CD4 cell count < 350 cells/mm3. Cryptococcal meningitis was associated with 30.8% mortality in Guatemala. Global access to diagnosis as well as to liposomal amphotericin B and flucytosine is a priority.
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Zuniga-Moya JC, Romero-Reyes LE, Saavedra EB, Montoya S, Varela D, Borjas M, Cerna A, Bejarano S, Martinez P, Lujan K, Erazo K, Lainez I, Pineda L, Yanes D, O'Halloran JA, Spec A. Prevalence of Cryptococcal Antigen and Outcomes in People With Human Immunodeficiency Virus in Honduras: A Cohort Study. Open Forum Infect Dis 2020; 8:ofaa557. [PMID: 33447630 PMCID: PMC7794649 DOI: 10.1093/ofid/ofaa557] [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: 09/02/2020] [Accepted: 11/06/2020] [Indexed: 11/12/2022] Open
Abstract
Background Cryptococcal meningitis is a major cause of death among people with human immunodeficiency virus (PWH). Cryptococcal antigen (CrAg) testing of asymptomatic patients is an important public health measure to reduce mortality in high-incidence areas. However, limited data exist on CrAg prevalence in Central America. Methods We conducted a prospective cohort study at the 2 largest human immunodeficiency virus (HIV) clinics and hospitals in Honduras. Cryptococcal antigen in serum and cerebrospinal fluid was performed in individuals with HIV who had CD4 ≤100 cells/mm3 between 2017 and 2018. After CrAg testing, individuals were observed for 12 months to assess mortality using adjusted Cox proportional hazard models. Results A total of 220 PWH were tested for CrAg, 12.7% (n = 28) of which tested positive. Cryptococcal antigen prevalence was higher among hospitalized individuals in 40% (n = 10 of 25) of the cases. The proportion (35.8%) of individuals taking antiretroviral therapy was significantly (P < .01) lower among those who tested positive for CrAg. Overall mortality among the cohort was 11.4% (n = 25 of 220) by 12 months. Cryptococcal antigen-positive cases were at a significantly higher risk of death (adjusted hazard ratio, 2.69; 95% confidence interval, 1.07-6.84) compared with CrAg-negative participants. Conclusions Cryptococcal antigen prevalence in Honduras was high among PWH. Moreover, individuals who tested positive for CrAg testing were at a higher risk of death. Systemic CrAg of PWH with a CD4 ≤100 cells/mm3 should be routinely performed in Central America.
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Affiliation(s)
- Julio C Zuniga-Moya
- Universidad Catolica de Honduras Campus San Pedro Sula Pablo, San Pedro Sula, Honduras
| | | | | | | | - Diana Varela
- Hospital Escuela Universitario, Tegucigalpa, Honduras
| | | | - Alicia Cerna
- Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Suyapa Bejarano
- Universidad Catolica de Honduras Campus San Pedro Sula Pablo, San Pedro Sula, Honduras
| | - Paola Martinez
- Universidad Catolica de Honduras Campus San Pedro Sula Pablo, San Pedro Sula, Honduras
| | - Karen Lujan
- Clinica de Servicios de Atencion Integral, Tegucigalpa, Honduras
| | - Karen Erazo
- Clinica de Servicios de Atencion Integral, Tegucigalpa, Honduras
| | - Isis Lainez
- Hospital Dr. Mario Catarino Rivas, San Pedro Sula, Honduras
| | | | - David Yanes
- Universidad Catolica de Honduras Campus San Pedro Sula Pablo, San Pedro Sula, Honduras
| | - Jane A O'Halloran
- Department of Medicine, Division of Infection, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Andrej Spec
- Department of Medicine, Division of Infection, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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