Predictors of mortality and differences in clinical features among patients with Cryptococcosis according to immune status

Kyle D Brizendine, John W Baddley, Peter G Pappas, Kyle D Brizendine, John W Baddley, Peter G Pappas

Abstract

Introduction: Cryptococcosis 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.

Methods: We 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.

Results: We 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.

Conclusions: Predictors 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.

Conflict of interest statement

Competing Interests: The authors have the following interests: JWB reports that he is an advisor for Merck, a consultant for Abbott and Pfizer, and a Pfizer research grant recipient. PGP reports that he has received research support from and has been an ad hoc advisor for Merck, Pfizer, Astellas, Schering-Plough, Basilea, and Novartis. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

Figures

Figure 1. Differential site of infection by…
Figure 1. Differential site of infection by host immune status among 302 patients with cryptococcosis at UAB, 1996–2010.
HIV-positive patients presented with significantly more CNS disease and cryptococcemia compared to OTRs and NHNT patients, who more often demonstrated disease confined to the lungs. Note. HIV, human immunodeficiency virus; OTRs, organ transplant recipients; NHNT, non-HIV, non-transplant; CNS, central nervous system.
Figure 2. Kaplan-Meier survival curve of HIV-positive…
Figure 2. Kaplan-Meier survival curve of HIV-positive patients, OTRs, and NHNT patients among 302 patients with cryptococcosis at UAB, 1996–2010.
Non-HIV, non-transplant patients had the lowest survival, but the difference across groups did not reach statistical significance. Note. HIV, human immunodeficiency virus; OTRs, organ transplant recipients; NHNT, non-HIV, non-transplant.

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Source: PubMed

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