Presentation and Outcome of Cryptococcal Infection Varies by Predisposing Illness

Abstract

Background Better treatment for HIV has led to the changing epidemiology of cryptococcosis. Important differences in outcomes have recently been demonstrated based on immune status. In this study, we describe the differences in presentation and outcome of cryptococcal infection by immune status in the post-HAART era.MethodsWe conducted a retrospective cohort study of patients diagnosed with cryptococcosis from 2002 through 2014 at our institution. Data included demographics, clinical features, diagnostics, and outcomes. Comparisons were made with χ 2 and one-way ANOVA. Survival analysis was performed with Cox regression with survival censored at 90 days.ResultsWe enrolled 243 patients with cryptococcosis: 91 (37.4%) with HIV, 24 (9%) with prior organ transplantation, and 128 (52.6%) with non-HIV non-transplant (NHNT). Age analysis showed HIV patients were younger (40 years) than transplant (53 years) and NHNT (60 years) (P < 0.001). Fevers and headache were more common in HIV (71 and 52%, P = 0.001) than in transplant (33 and 25%, P 0.001) and NHNT (51 and 39%, P 0.001), respectively. Meningitis (71%) was more common in HIV+ than in transplant recipients (45%) or NHNT (43%, P < 0.001). NHNT (37.5%) and transplant (45.8%) had more pulmonary cryptococcosis than HIV (10%, P < 0.001). Patients with NHNT had a higher risk of mortality (HR 2.642, 95% CI 1.481–4.713) as compared with HIV+. However, transplant recipients with cryptococcosis had risk of 90-day mortality (HR 0.99, 95% CI 0.33–2.99) similar to HIV+ patients.ConclusionCryptococcosis in HIV+ and transplant recipients was less common than in NHNT in our institution and the presentation was different, with meningitis being less prominent. Cryptococcosis in NHNT was associated with higher risk of death than HIV+ patients or transplant recipients. NHNT patients comprise an important group that requires a high degree of clinical suspicion.Survival curve of 243 patients with cryptococcosis by immune status: blue (NHNT), green (HIV), and red (any transplant). Patients in non-HIV non-transplant cohort had a higher mortality than those with HIV or transplant. Vertical dashes represent censored data (P < .001).Disclosures A. Spec, Astellas Pharma US, Inc.: Grant Investigator, Research grant