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Kalata N, Ellis J, Kanyama C, Kuoanfank C, Temfack E, Mfinanga S, Lesikari S, Chanda D, Lakhi S, Nyazika T, Chan AK, van Oosterhout JJ, Chen T, Hosseinipour MC, Lortholary O, Wang D, Jaffar S, Loyse A, Heyderman RS, Harrison TS, Molloy SF. Short-term Mortality Outcomes of HIV-Associated Cryptococcal Meningitis in Antiretroviral Therapy-Naïve and -Experienced Patients in Sub-Saharan Africa. Open Forum Infect Dis 2021; 8:ofab397. [PMID: 34646905 PMCID: PMC8501291 DOI: 10.1093/ofid/ofab397] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/27/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND An increasing proportion of patients with HIV-associated cryptococcal meningitis have received antiretroviral therapy (ART) before presentation. There is some evidence suggesting an increased 2-week mortality in those receiving ART for <14 days compared with those on ART for >14 days. However, presentation and outcomes for cryptococcal meningitis patients who have recently initiated ART, and those with virologic failure and/or nonadherence, are not well described. METHODS Six hundred seventy-eight adults with a first episode of cryptococcal meningitis recruited into a randomized, noninferiority, multicenter phase 3 trial in 4 Sub-Saharan countries were analyzed to compare clinical presentation and 2- and 10-week mortality outcomes between ART-naïve and -experienced patients and between patients receiving ART for varying durations before presentation. RESULTS Over half (56%; 381/678) the study participants diagnosed with a first episode of cryptococcal meningitis were ART-experienced. All-cause mortality was similar at 2 weeks (17% vs 20%; hazard ratio [HR], 0.85; 95% CI, 0.6-1.2; P = .35) and 10 weeks (38% vs 36%; HR, 1.03; 95% CI, 0.8-1.32; P = .82) for ART-experienced and ART-naïve patients. Among ART-experienced patients, using different cutoff points for ART duration, there were no significant differences in 2- and 10-week mortality based on duration of ART. CONCLUSIONS In this study, there were no significant differences in mortality at 2 and 10 weeks between ART-naïve and -experienced patients and between ART-experienced patients according to duration on ART.
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Affiliation(s)
- Newton Kalata
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Jayne Ellis
- Division of Infection and Immunity, University College London, London, UK
| | - Cecilia Kanyama
- University of North Carolina Project, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | - Sayoki Mfinanga
- Muhimbili Centre, National Institute for Medical Research, Dar Es Salaam, Tanzania
| | - Sokoine Lesikari
- Muhimbili Centre, National Institute for Medical Research, Dar Es Salaam, Tanzania
| | | | | | - Tinashe Nyazika
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Adrienne K Chan
- Dignitas International, Zomba Central Hospital, Zomba, Malawi
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Tao Chen
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mina C Hosseinipour
- University of North Carolina Project, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Olivier Lortholary
- Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Angela Loyse
- Centre for Global Health, Institute of Infection and Immunity, St George University of London, London, UK
| | - Robert S Heyderman
- Division of Infection and Immunity, University College London, London, UK
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George University of London, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Síle F Molloy
- Centre for Global Health, Institute of Infection and Immunity, St George University of London, London, UK
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Abstract
PURPOSE OF REVIEW Defective cell-mediated immunity is a major risk factor for cryptococcosis, a fatal disease if untreated. Cryptococcal meningitis (CM), the main presentation of disseminated disease, occurs through hematogenous spread to the brain from primary pulmonary foci, facilitated by yeast virulence factors. We revisit remarkable recent improvements in the prevention, diagnosis and management of CM. RECENT FINDINGS Cryptococcal antigen (CrAg), main capsular polysaccharide of Cryptococcus spp. is detectable in blood and cerebrospinal fluid of infected patients with point of care lateral flow assays. Recent World Health Organization guidelines recommend 7-day amphotericin B plus flucytosine, then 7-day high dose (1200 mg/day) fluconazole for induction treatment of HIV-associated CM. Management of raised intracranial pressure, a consequence of CM, should rely mainly on daily therapeutic lumbar punctures until normalisation. In HIV-associated CM, following introduction of antifungal therapy, (re)initiation of antiretroviral therapy should be delayed by 4-6 weeks to prevent immune reconstitution inflammatory syndrome, common in CM. CM is a fatal disease whose diagnosis has recently been simplified. Treatment should always include antifungal combination therapy and management of raised intracranial pressure. Screening for immune deficiency should be mandatory in all patients with cryptococcosis.
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