Abstract
IntroductionCryptococcosis is an invasive fungal infection causing substantial morbidity and mortality. Prognostic factors are largely derived from trials conducted prior to the modern era of antifungal and potent combination antiretroviral therapies, immunosuppression, and transplantation. Data describing the clinical features and predictors of mortality in a modern cohort are needed.MethodsWe conducted a retrospective cohort study of patients at our institution diagnosed with cryptococcosis from 1996 through 2010. Data included demographics, clinical features, diagnostics, treatment, and outcomes.ResultsWe identified 302 individuals: 108 (36%) human immunodeficiency virus (HIV)-positive, 84 (28%) organ transplant recipients (OTRs), and 110 (36%) non-HIV, non-transplant (NHNT) patients including 39 with no identifiable immunodeficiency. Mean age was 49 years, 203 (67%) were male and 170 (56%) were white. All-cause mortality at 90 days was 21%. In multivariable logistic regression analyses, cryptococcemia (OR 5.09, 95% CI 2.54–10.22) and baseline opening pressure >25 cmH2O (OR 2.93, 95% CI 1.25–6.88) were associated with increased odds of mortality; HIV-positive patients (OR 0.46, 95% CI 0.19–1.16) and OTRs (OR 0.46, 95% CI 0.21–1.05) had lower odds of death compared to NHNT patients.ConclusionsPredictors of mortality from cryptococcosis in the modern period include cryptococcemia, high intracranial pressure, and NHNT status while drug(s) used for induction and historical prognostic factors including organ failure syndromes and hematologic malignancy were not associated with mortality.
Highlights
Cryptococcosis is an invasive fungal infection causing substantial morbidity and mortality
Cryptococcosis is an important opportunistic fungal infection causing considerable morbidity and mortality among immunocompromised patients including individuals positive for human immunodeficiency virus (HIV), organ transplant recipients (OTRs), and other immunocompromised patients such as those with sarcoidosis, immunoglobulin disorders, chronic glucocorticoid treatment, disorders characterized by dysfunction of cellmediated immunity, conditions requiring the use of anti-tumor necrosis factor-a therapy and other disease-modifying agents, and hematologic malignancy [1,2,3,4,5]
It is estimated that approximately 1 million cases and 625,000 deaths occur per year worldwide due to central nervous system (CNS) cryptococcosis among HIV-infected individuals [6]
Summary
Cryptococcosis is an invasive fungal infection causing substantial morbidity and mortality. Cryptococcosis is an important opportunistic fungal infection causing considerable morbidity and mortality among immunocompromised patients including individuals positive for human immunodeficiency virus (HIV), organ transplant recipients (OTRs), and other immunocompromised patients such as those with sarcoidosis, immunoglobulin disorders, chronic glucocorticoid treatment, disorders characterized by dysfunction of cellmediated immunity, conditions requiring the use of anti-tumor necrosis factor-a therapy and other disease-modifying agents, and hematologic malignancy [1,2,3,4,5]. Medical and surgical advancements have ushered in a period with a rapidly growing atrisk population of patients who frequently receive specific immunosuppression This new period includes the introduction of triazole antifungal therapy, widespread use of potent combination antiretroviral therapy (cART), institution of steroid-sparing immunosuppression including calcineurin inhibitors and biologic agents, and expansion of both solid organ (SOT) and hematopoietic stem cell transplantation (HSCT). More robust data on the epidemiology and prognostic factors of cryptococcosis in the current era are needed
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