Comparison and temporal trends of three groups with cryptococcosis: HIV-infected, solid organ transplant, and HIV-negative/non-transplant.

Emily W Bratton,Cody A Chastain,Michael S Lee,Jonathan J Juliano,Til Stürmer,Nada El Husseini,Charles Poole,David J Weber,John R Perfect,Michael Scheurer

doi:10.1371/journal.pone.0043582

Abstract

BackgroundThe Infectious Disease Society of America (IDSA) 2010 Clinical Practice Guidelines for the management of cryptococcosis outlined three key populations at risk of disease: (1) HIV-infected, (2) transplant recipient, and (3) HIV-negative/non-transplant. However, direct comparisons of management, severity and outcomes of these groups have not been conducted.Methodology/Principal FindingsAnnual changes in frequency of cryptococcosis diagnoses, cryptococcosis-attributable mortality and mortality were captured. Differences examined between severe and non-severe disease within the context of the three groups included: demographics, symptoms, microbiology, clinical management and treatment. An average of nearly 15 patients per year presented at Duke University Medical Center (DUMC) with cryptococcosis. Out of 207 study patients, 86 (42%) were HIV-positive, 42 (20%) were transplant recipients, and 79 (38%) were HIV-negative/non-transplant. HIV-infected individuals had profound CD4 lymphocytopenia and a majority had elevated intracranial pressure. Transplant recipients commonly (38%) had renal dysfunction. Nearly one-quarter (24%) had their immunosuppressive regimens stopped or changed. The HIV-negative/non-transplant population reported longer duration of symptoms than HIV-positive or transplant recipients and 28% (22/79) had liver insufficiency or underlying hematological malignancies. HIV-positive and HIV-negative/non-transplant patients accounted for 89% of severe disease cryptococcosis-attributable deaths and 86% of all-cause mortality.Conclusions/SignificanceIn this single-center study, the frequency of cryptococcosis did not change in the last two decades, although the underlying case mix shifted (fewer HIV-positive cases, stable transplant cases, more cases with neither). Cryptococcosis had a relatively uniform and informed treatment strategy, but disease-attributable mortality was still common.

Highlights

Cryptococcus neoformans is an invasive mycoses that can cause meningoencephalitis, among those who are immunocompromised, but in some cases it can infect immunocompetent individuals [1]
Retrospective single-center study, our goal was to provide an in-depth look at how cryptococcosis was managed clinically in the HIV-positive, transplant recipient and HIV-negative/non-transplant patient groups in order to improve our understanding of this disease
Participants We identified all consecutive adult patients ($18 years old) discharged from Duke University Medical Center (DUMC) with International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes of cryptococcosis (117.5), and cryptococcal meningitis (321.0) between January 1, 1996 and October 31, 2009 through electronic medical records

Summary

Introduction

Cryptococcus neoformans is an invasive mycoses that can cause meningoencephalitis, among those who are immunocompromised, but in some cases it can infect immunocompetent individuals [1]. The 2010 IDSA Cryptococcal Guidelines defined three distinct risk groups for induction treatment of cryptococcosis [2]: (1) HIV-positive; (2) transplant recipients; and (3) a heterogeneous group with neither of these conditions (i.e., HIVnegative/non-transplant). A major component of this review was to describe outcomes of recent management of these three groups. In 2000 the original IDSA Guidelines were published as a standard of treatment [5]. There was an active Infectious Disease group at our institution with a particular interest in the pathogenesis and treatment of cryptococcosis. The Infectious Disease Society of America (IDSA) 2010 Clinical Practice Guidelines for the management of cryptococcosis outlined three key populations at risk of disease: (1) HIV-infected, (2) transplant recipient, and (3) HIVnegative/non-transplant. Direct comparisons of management, severity and outcomes of these groups have not been conducted

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