Cryptococcocal immune reconstitution disease: a major cause of early mortality in a South African antiretroviral programme

Abstract

We read with interest the recent paper by Lortholary et al. describing cryptococcocal immune reconstitution disease (IRD) in France. This is an increasingly recognized complication of the initial weeks of antiretroviral treatment (ART). However to our knowledge the frequency of cryptococcocal IRD in low-income countries has not previously been reported. We run a community-based ART programme in Gugulethu Cape Town South Africa. Between September 2002 and November 2004 434 treatmentnaive patients started triple-drug ART according to WHO 2002 treatment guidelines. The patients mean age was 34 years their median blood CD4 cell count was 86 cells/µl [interquartile range (IQR) 46-146 cells/µl] and the median plasma HIV load was 76 337 copies/ml (IQR 32 723-192 772 copies/ml). A total of 137 patients (32%) had WHO stage 4 disease and among these cryptococcal meningitis was the AIDS-defining illness in 18 (13%). These diagnoses were made a median of 7 months (range 2-24 months) before the initiation of ART. According to national guidelines cryptococcal meningitis was treated with fluconazole 400 mg/day for 8 weeks followed by 200 mg/day as secondary prophylaxis. (excerpt)