Abstract
BackgroundCryptococcal meningitis causes high mortality in immunocompromised and immunocompetent patients. The objective of this study was to identify early predictors of clinical outcome, available at the first days of hospitalization, in patients with cryptococcal meningitis in a tertiary center in Brazil.MethodsNinety-six cases of cryptococcal meningitis with clinical, epidemiological and laboratory data, and identification and antifungal susceptibility of the strains were analyzed. Quantitative CSF yeast counts were performed by direct microscopic exam with a Fuchs-Rosenthal cell counting chamber using an institutional protocol. Univariable and multiple analyses using logistic regression were performed to identify predictors, available at the beginning of hospitalization, of in-hospital mortality. Moreover, we performed a secondary analysis for a composite outcome defined by hospital mortality and intensive care unit transfer.ResultsThe species and the antifungal susceptibility were not associated with the outcomes evaluated. The variables significantly associated with the mortality were age (OR = 1.08, 95% CI 1.02–1.15), the cerebrospinal fluid (CSF) yeasts count (OR = 1.65, 95% CI 1.20–2.27), systemic arterial hypertension (OR = 22.63, 95% CI 1.64–312.91) and neurological impairment identified by computed tomography (OR = 41.73, 95% CI 3.10–561.65). At the secondary analysis, CSF yeast count was also associated with the composite outcome, in addition to the culture of Cryptococcus spp. from bloodstream and cerebral toxoplasmosis. The associations were consistent with survival models evaluated.ConclusionsAge and CSF yeast count were independently associated with in-hospital mortality of patients with cryptococcal meningitis but Cryptococcus species identification and antifungal susceptibility were not associated with the outcomes. Quantitative CSF yeast counts used in this study can be evaluated and implemented in other low and middle-income settings.
Highlights
Cryptococcal meningitis causes high mortality in immunocompromised and immunocompetent patients
The new classification includes the species C. neoformans sensu strictu (s.s), hybrids between C. neoformans and C. deneoformans and C. deneoformans, and C. gattii complex is formed by C. gattii s.s (VGI), C. deuterogattii (VGII), C. bacillisporus (VGIII), C. tetragattii (VGIV), and C. decagattii (VGIIIc/ VGIV) [8, 16]
We studied a cohort of patients with cryptococcal meningitis, which were predominantly from people living with HIV/AIDS (PLWHA) and, as in other studies, the majority were males, reflecting the population most affected by the AIDS epidemic [51,52,53,54,55,56,57]
Summary
Cryptococcal meningitis causes high mortality in immunocompromised and immunocompetent patients. Cryptococcosis is one of the major invasive diseases in humans It is acquired by inhalation of fungal propagules, which can be deposited in the pulmonary alveoli to disseminate to cutaneous tissue, internal organs, and to the central nervous system, where is observed the most severe clinical form [1]. The major agents of cryptococcosis are members of C. neoformans and C. gattii complex. This complex was recognized in 2015 into seven species, based on phenotypic and genotypic, geographic, epidemiological and virulence characteristics [8,9,10,11,12,13,14,15]. C. gattii and C. deuterogattii are known to affect apparently immunocompetent individuals due to increased virulence and less antifungal susceptibility [16,17,18,19]
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