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Cao C, Luo L, Hu Y, Huang T, Gao S, Ling C, He H, Guo Y. Nomogram to Predict the Outcome of Ventriculoperitoneal Shunt Among Patients with Non-HIV Cryptococcal Meningitis. World Neurosurg 2024; 186:e305-e315. [PMID: 38552785 DOI: 10.1016/j.wneu.2024.03.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The ventriculoperitoneal (VP) shunt is widely acknowledged as a treatment option for managing intracranial hypertension resulting from non-human immunodeficiency virus (HIV) cryptococcal meningitis (CM). Nonetheless, there is currently no consensus on the appropriate surgical indications for this procedure. Therefore, it is crucial to conduct a preoperative evaluation of patient characteristics and predict the outcome of the VP shunt to guide clinical treatment effectively. METHODS A retrospective analysis was conducted on data from 85 patients with non-HIV CM who underwent VP shunt surgery at our hospital. The analysis involved studying demographic data, preoperative clinical manifestations, cerebrospinal fluid (CSF) characteristics, and surgical outcomes and comparisons between before and after surgery. A nomogram was developed and evaluated. RESULTS The therapy outcomes of 71 patients improved, whereas 14 cases had worse outcomes. Age, preoperative cryptococcus count, and preoperative CSF protein levels were found to influence the surgical outcome. The nomogram exhibited exceptional predictive performance (area under the curve = 0.896, 95% confidence interval: 0.8292-0.9635). Internal validation confirmed the nomogram's excellent predictive capabilities. Moreover, decision curve analysis demonstrated the nomogram's practical clinical utility. CONCLUSIONS The surgical outcome of VP shunt procedures patients with non-HIV CM was associated with age, preoperative cryptococcal count, and preoperative CSF protein levels. We developed a nomogram that can be used to predict surgical outcomes in patients with non-HIV CM.
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Affiliation(s)
- Cheng'an Cao
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Lun Luo
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuanjun Hu
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Tengchao Huang
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shuangqi Gao
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Cong Ling
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Haiyong He
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ying Guo
- Department of Neurosurgery, The third affiliated hospital, Sun Yat-Sen University, Guangzhou, China.
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Cryptococcus spp. and Cryptococcosis: focusing on the infection in Brazil. Braz J Microbiol 2022; 53:1321-1337. [PMID: 35486354 PMCID: PMC9433474 DOI: 10.1007/s42770-022-00744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 03/25/2022] [Indexed: 11/02/2022] Open
Abstract
Cryptococcosis is a global fungal infection caused by the Cryptococcus neoformans/Cryptococcus gattii yeast complex. This infection is acquired by inhalation of propagules such as basidiospores or dry yeast, initially causing lung infections with the possibility of progressing to the meninges. This infection mainly affects immunocompromised HIV and transplant patients; however, immunocompetent patients can also be affected. This review proposes to evaluate cryptococcosis focusing on studies of this mycosis in Brazilian territory; moreover, recent advances in the understanding of its virulence mechanism, animal models in research are also assessed. For this, literature review as realized in PubMed, Scielo, and Brazilian legislation. In Brazil, cryptococcosis has been identified as one of the most lethal fungal infections among HIV patients and C. neoformans VNI and C. gattii VGII are the most prevalent genotypes. Moreover, different clinical settings published in Brazil were described. As in other countries, cryptococcosis is difficult to treat due to a limited therapeutic arsenal, which is highly toxic and costly. The presence of a polysaccharide capsule, thermo-tolerance, production of melanin, biofilm formation, mechanisms for iron use, and morphological alterations is an important virulence mechanism of these yeasts. The introduction of cryptococcosis as a compulsory notification disease could improve data regarding incidence and help in the management of these infections.
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de Oliveira L, Melhem MDSC, Buccheri R, Chagas OJ, Vidal JE, Diaz-Quijano FA. Early clinical and microbiological predictors of outcome in hospitalized patients with cryptococcal meningitis. BMC Infect Dis 2022; 22:138. [PMID: 35139801 PMCID: PMC8830130 DOI: 10.1186/s12879-022-07118-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cryptococcal 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. Methods Ninety-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. Results The 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. Conclusions Age 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. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07118-7.
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Affiliation(s)
- Lidiane de Oliveira
- Department of Epidemiology, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP, CEP 01246-904, Brazil.
| | - Marcia de Souza Carvalho Melhem
- Mycology Unit of Adolfo Lutz Institute, Public Health Reference Laboratory, Secretary of Health, Av. Dr.Arnaldo, 351, São Paulo, SP, CEP 05411-000, Brazil.,School of Medicine, Federal University of Mato Grosso do Sul, Bairro Universitário, Av. Costa e Silva, s/no, Campo Grande, MS, CEP 79070-900, Brazil
| | - Renata Buccheri
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil
| | - Oscar José Chagas
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil
| | - José Ernesto Vidal
- Department of Neurology, Emílio Ribas Institute of Infectious Diseases, Av. Dr. Arnaldo 165, São Paulo, SP, CEP 05411-000, Brazil.,Department of Infectious Diseases, Hospital das Clinicas, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 470, São Paulo, SP, CEP 01246-904, Brazil
| | - Fredi Alexander Diaz-Quijano
- Department of Epidemiology, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP, CEP 01246-904, Brazil
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HIV-Associated Cryptococcal Meningitis Patients Treated with Amphotericin B Deoxycholate Plus Flucytosine under Routine Care Conditions in a Referral Center in São Paulo, Brazil. Mycopathologia 2020; 186:93-102. [PMID: 33258083 DOI: 10.1007/s11046-020-00512-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/19/2020] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cryptococcal meningitis remains a common cause of mortality in low- and middle-income countries, where amphotericin B deoxycholate (amphotericin) plus fluconazole is the most common treatment. Flucytosine is almost uniformly absent as is outcome data on flucytosine use in routine care. The main goal of this study was identified the cumulative mortality at 2, 4, and 10 weeks after hospital admission. METHODS We conducted a retrospective, observational cohort study among HIV-infected adults with cryptococcal meningitis receiving amphotericin plus flucytosine as induction therapy in Brazil. We assessed cumulative mortality at 2, 4, and 10 weeks and the cumulative proportion discontinuating amphotericin or flucytosine due to toxicity at 2 weeks. We performed multiple logistic regression to identify variables associated with in-hospital mortality. RESULTS In total, 77 individuals (n = 66 men) were included with median baseline CD4 of 29 (IQR, 9-68) cells/mcL. Twenty (26%) had at least one concurrent neurological disease diagnosed. Sixty (78%) patients received at least 14 days of amphotericin plus flucytosine. Cumulative mortality was 5% (4/77) at 2 weeks, 8% (6/77) at 4 weeks, and 19% (15/77) at 10 weeks. Cumulative proportion of patients that discontinuated amphotericin or flucytosine due to toxicity was 20% (16/77) at 2 weeks. In addition, in-hospital mortality was associated with receiving ≤ 10 days of induction therapy (odds ratio = 4.5, 95% CI 1.2-17.1, P = 0.028) or positive cerebrospinal fluid fungal culture after 2 weeks (odds ratio = 3.8, 95% CI 1.1-13.5, P = 0.035). CONCLUSION In this "real-world" study, amphotericin plus flucytosine shows low early mortality of patients with HIV-associated cryptococcal meningitis. Early discontinuation due to adverse events was moderate. More effective and safe antifungals are needed in order to improve the outcome of cryptococcal meningitis.
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