The prevalence of cryptococcal antigenemia in newly diagnosed HIV patients in a Southwest London cohort

Sheel Patel,Gee Yen Shin,Ishan Wijewardana,Sasiri Rivinda Vitharana,Ian Cormack,Mark Pakianathan,Thomas S Harrison,Tihana Bicanic

doi:10.1016/j.jinf.2012.09.014

Abstract

SummaryObjectivesTo determine the prevalence of cryptococcal antigenemia in a UK HIV cohort and compare baseline characteristics of patients with and without cryptococcal antigenemia.MethodsStored sera were retrospectively tested for cryptococcal antigen (CRAG) among newly diagnosed HIV-infected persons with CD4 < 100 cells/μL, who presented to Croydon University and St George's Hospitals, London, between January 2004 and October 2010. We assessed risk factors for cryptococcal antigenemia and patient outcomes by extracting demographic and clinical information from medical records.Results157 patients were identified with a median age of 47 and CD4 count of 26 cells/μL. 102 (65%) were of Black race and 91 (58%) of African origin. Eight patients (5%) had positive serum CRAG. 7/8 had cryptococcal meningitis (CM) as first presentation of HIV, and 1 had sub-clinical infection. 7/8 (88%) CRAG positives were of African origin compared to 84/149 (54%) of CRAG negatives (p = 0.14). Other baseline characteristics did not differ significantly.ConclusionWe found a 5% prevalence of cryptococcal antigenemia in newly diagnosed HIV patients with CD4 < 100 cells/μL in southwest London, the first such data for a UK HIV cohort. Cryptococcal antigenemia occurred almost exclusively in African-born individuals. We recommend a UK CRAG screening strategy targeting newly diagnosed African HIV-infected patients with CD4 < 100 cells/μL.

Highlights

Cryptococcal meningitis (CM) is a major opportunistic infection and a leading cause of mortality in HIV-infected patients throughout the world, causing an estimated 600,000 deaths annually, in resource-limited countries.[1]
In resource-limited countries, where patients frequently present late with advanced disease and CD4 count below 100 cells/mL, disease burden remains high despite availability of antiretroviral therapy (ART).[2,5]
We aimed to determine the prevalence of cryptococcal antigenemia in newly diagnosed HIV patients with CD4 < 100 cells/mL in an urban Southwest London population

Summary

Introduction

Cryptococcal meningitis (CM) is a major opportunistic infection and a leading cause of mortality in HIV-infected patients throughout the world, causing an estimated 600,000 deaths annually, in resource-limited countries.[1] Treatment remains inadequate, with 10-week mortality between 20 and 40%, even with optimal current antifungal combinations.[2] CM usually occurs at an advanced stage of immunosuppression, with median CD4 count below 50 cells/mL in large cohorts from developed and developing countries.[3,4]. In resource-limited countries, where patients frequently present late with advanced disease and CD4 count below 100 cells/mL, disease burden remains high despite availability of ART.[2,5]. Cryptococcal antigenemia (presence of cryptococcal capsular polysaccharide antigen (CRAG) in blood), can precede onset of CM by weeks to months,[8] and presents an opportunity for early intervention with pre-emptive fluconazole therapy to prevent development of CM

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