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Zhao H, Lu Y, Li S, Qin J, Xu M, Ye H, Yang Z, Rao J, Chen G, Su F, Hu Z, Xu L. Voriconazole plus flucytosine is not superior to amphotericin B deoxycholate plus flucytosine as an induction regimen for cryptococcal meningitis treatment. Mycoses 2024; 67:e13674. [PMID: 37986630 DOI: 10.1111/myc.13674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The efficacy and side effects of voriconazole plus 5-flucytosine (Vori + 5-FC) versus amphotericin B deoxycholate plus 5-flucytosine (AmBd + 5-FC) as an induction treatment for cryptococcal meningitis are unknown. METHODS Forty-seven patients treated with Vori + 5-FC and 92 patients treated with AmBd + 5-FC were included in the current study after propensity score matching (PSM) at a ratio of 1:2. Two-week laboratory test results and 90-day mortality were compared between the two groups. RESULTS After 2 weeks of induction treatment, the CSF Cryptococcus sterile culture rate was 57.1% in the Vori + 5-FC group and 76.5% in the AmBd + 5-FC group (p = .026). No difference was found in the normalization of CSF indicators (glucose, total protein, intracranial pressure and India ink sterile rate) between the two groups. Both the Vori + 5FC regimen and AmBd + 5-FC regimen obviously decreased haemoglobin concentrations, platelet counts and serum potassium levels (all p ≤ .010). Notably, the Vori + 5FC regimen did not influence serum creatinine levels (p = .263), while AmBd + 5FC increased serum creatinine levels (p = .019) after 2-week induction treatment. The Vori + 5-FC group and AmBd + 5-FC group had similar 90-day cumulative survival rates (89.9% vs. 87.8%, p = .926). CONCLUSION The Vori + 5-FC regimen was associated with low 2-week CSF sterile culture and was not superior to AmBd + 5-FC as induction therapy in terms of the 90-day cumulative survival rate of CM patients.
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Affiliation(s)
- Handan Zhao
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yanqiu Lu
- Chongqing Public Health Medical Center, Southwest University Public Health Hospital, Chongqing, China
| | - Shan Li
- Department of Infectious Diseases, The Ninth Hospital of Nanchang, Nanchang, China
| | - Jiangying Qin
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Miaomiao Xu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Hui Ye
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
| | - Zongxing Yang
- Xixi Hospital of Hangzhou, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianfeng Rao
- Department of Infectious Diseases, The Ninth Hospital of Nanchang, Nanchang, China
| | - Guochun Chen
- Department of Infectious Diseases, The Third Peoples' Hospital of Changzhou, Changzhou, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Lijun Xu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Namie H, Takazono T, Hidaka Y, Morimoto S, Ito Y, Nakada N, Ashizawa N, Hirayama T, Takeda K, Iwanaga N, Tashiro M, Hosogaya N, Tanaka T, Fushimi K, Yanagihara K, Mukae H, Izumikawa K. The prognostic factors for cryptococcal meningitis in non-human immunodeficiency virus patients: An observational study using nationwide database. Mycoses 2024; 67:e13658. [PMID: 37807638 DOI: 10.1111/myc.13658] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Cryptococcal meningitis (CM) is an invasive fungal infection with a poor prognosis that often occurs in both healthy individuals and compromised hosts, such as patients infected with human immunodeficiency virus (HIV). Unlike CM in HIV patients, evidence regarding CM in non-HIV patients is limited to small retrospective studies. OBJECTIVE To identify the pretreatment prognostic factors for CM in non-HIV patients. METHODS We conducted a large retrospective analysis of CM in non-HIV patients using data from a nationwide Japanese database. The study included hospitalized patients diagnosed with CM between 1 April 2010 and 31 March 2017. All-cause mortality was compared between patients with CM with and without HIV infection. Poor diagnostic factors were analysed in the non-HIV CM group. RESULTS Overall, 533 (64 HIV and 469 non-HIV) patients met the criteria. The mortality rate at 90 days was significantly lower in the HIV group (6.3% vs. 25.4% p = .0002). In a logistic regression analysis of the non-HIV group, age ≥ 65 y (odds ratio [OR] 2.37, 95% CI 1.17-4.78), impaired consciousness (Japan Coma Scale ≥1) (OR 2.25, 95% CI 1.29-3.93), haemodialysis (OR 3.53, 95% CI 1.12-11.20) and previous corticosteroid usage (OR 2.40, 95% CI 1.37-4.19) were associated with poor prognosis at 30 days after diagnosis. CONCLUSION More caution is suggested when treating non-HIV with CM in older patients with impaired consciousness, previous corticosteroid usage and haemodialysis.
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Affiliation(s)
- Hotaka Namie
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takahiro Takazono
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yusuke Hidaka
- Department of General Internal Medicine, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Shimpei Morimoto
- Innovation Platform & Office for Precision Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuya Ito
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Nana Nakada
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Health Center, Nagasaki University, Nagasaki, Japan
| | - Nobuyuki Ashizawa
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Tatsuro Hirayama
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Pharmacotherapeutics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuaki Takeda
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Naoki Iwanaga
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Naoki Hosogaya
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Takeshi Tanaka
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
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Yoon H, Nakouzi AS, Duong VA, Hung LQ, Binh TQ, Tung NLN, Day JN, Pirofski LA. Shared and unique antibody and B cell profiles in HIV-positive and HIV-negative individuals with cryptococcal meningoencephalitis. Med Mycol 2023; 61:myad102. [PMID: 37771088 PMCID: PMC10599321 DOI: 10.1093/mmy/myad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/07/2023] [Accepted: 09/27/2023] [Indexed: 09/30/2023] Open
Abstract
Host non-T cell markers to aid in the diagnosis of cryptococcal meningoencephalitis (CM) have not been identified. In this case-control study, we characterized antibody and B cell profiles in HIV-negative and HIV-positive Vietnamese individuals of the Kinh ethnicity recently diagnosed with CM and controls. The study included 60 HIV-negative with no known immunocompromising condition and 60 HIV-positive individuals, with 30 CM cases and 30 controls in each group. Participants were matched by age, sex, HIV serostatus, and CD4 count in the HIV-positive group. Plasma immunoglobulin (Ig) levels, including IgG1, IgG2, IgM, and IgA, Cryptococcus spp. glucuronoxylomannan (GXM)- and laminarin (branched ${\rm{\beta }}$-[1-3]-glucan)-binding IgG, IgM, IgA levels, and peripheral blood B cell subsets were measured. Logistic regression, principal component, and mediation analyses were conducted to assess associations between antibody, B cell levels, and CM. The results showed that GXM-IgG levels were higher and IgG1 and IgG2 were lower in CM cases than controls, regardless of HIV status. In HIV-negative individuals, IgG2 mediated an inverse association between CD19+CD27+CD43+CD5- (B-1b-like) cells and CM. In HIV-positive individuals, lower levels of IgA, laminarin-IgA, and CD19+CD27+IgM+IgD- (IgM+ memory B) cells were each associated with CM. The shared and distinct antibody and B cell profiles identified in HIV-negative and HIV-positive CM cases may inform the identification of non-T-cell markers of CM risk or unsuspected disease, particularly in HIV-negative individuals.
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Affiliation(s)
- Hyunah Yoon
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA
| | - Antonio S Nakouzi
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA
| | - Van Anh Duong
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City Q5, Vietnam
| | - Le Quoc Hung
- Department of Tropical Diseases, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tran Quang Binh
- Department of Tropical Diseases, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Le Nhu Tung
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Ho Chi Minh City Q5, Vietnam
| | - Jeremy N Day
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City Q5, Vietnam
- Department of Microbiology and Infection, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK
| | - Liise-anne Pirofski
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA
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Approach to the diagnosis of invasive fungal infections of the respiratory tract in the immunocompromised host. Curr Opin Pulm Med 2023; 29:149-159. [PMID: 36917216 DOI: 10.1097/mcp.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
PURPOSE OF REVIEW The burden of invasive fungal infection is increasing worldwide, largely due to a growing population at-risk. Most serious human fungal pathogens enter the host via the respiratory tract. Early identification and treatment of invasive fungal respiratory infections (IFRIs) in the immunocompromised host saves lives. However, their accurate diagnosis is a difficult challenge for clinicians and mortality remains high. RECENT FINDINGS This article reviews IFRIs, focussing on host susceptibility factors, clinical presentation, and mycological diagnosis. Several new diagnostic tools are coming of age including molecular diagnostics and point-of-care antigen tests. As diagnosis of IFRI relies heavily on invasive procedures like bronchoalveolar lavage and lung biopsy, several novel noninvasive diagnostic techniques are in development, such as metagenomics, 'volatilomics' and advanced imaging technologies. SUMMARY Where IFRI cannot be proven, clinicians must employ a 'weights-of-evidence' approach to evaluate host factors, clinical and mycological data. Implementation studies are needed to understand how new diagnostic tools can be best applied within clinical pathways. Differentiating invasive infection from colonization and identifying antifungal resistance remain key challenges. As our diagnostic arsenal expands, centralized clinical mycology laboratories and efforts to ensure access to new diagnostics in low-resource settings will become increasingly important.
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