Cryptococcal Antigen Screening and Preemptive Treatment in a US Cohort of Patients With AIDS: Table 1.
Year: 2015
Type: article
Abstract: To the Editor—We read the recent article by McKenney and colleagues with great interest [1]. Several studies in resource-limited settings have shown that asymptomatic cryptococcal antigenemia is an independent predictor of mortality [2, 3] and that the higher likelihood of death in cryptococcal antigen (CrAg)–positive individuals is not completely abrogated by highly active antiretroviral therapy (HAART) [3, 4]. We and others have shown that treatment with fluconazole at the time of antiretroviral therapy can decrease the likelihood that asymptomatic CrAg-positive patients will develop cryptococcal meningitis (CM) [5–7] and that this strategy is cost-effective [8]. Most consider this to be an issue for resource-limited settings despite >2400 cases of CM annually among hospitalized patients with human immunodeficiency virus (HIV)/AIDS in the United States [9]. We analyzed longitudinal data collected in the Johns Hopkins HIV Clinical Cohort, a nested clinical cohort of persons who have received longitudinal care from the Johns Hopkins HIV/AIDS Service. Data on all measures used in this analysis have been collected by trained abstractors from the patient, the medical record, and electronic institutional sources over time with quality assurance mechanisms. Development of CM was determined from review of all ambulatory and inpatient clinical records. Medication use was abstracted from clinical records; the data reflect prescribing of the medication. Mortality was determined through clinical records supplemented by both state and national vital statistics. The sample for this study included all patients who were not on HAART with a CD4 count of ≤100 cells/µL from January 2005 to January 2013. All patients who had a CrAg test during the period were determined, and outcomes (CM, mortality) at 1 year were also collected. Medical records of all CrAg-positive patients were reviewed (Y. C. M.). There were 207 patients who were not on HAART with a CD4 count <100 cells/µL in the Moore clinic cohort from 2005 to 2013. Of these, 117 were CrAg tested and 90 were untested. Eighteen patients were found to be CrAg positive. Ten were symptomatic, of whom 9 had CM; 2 had a history of CM. There was a 5.7% (6/105) prevalence among asymptomatic patients who were CrAg tested. The 6 patients who were CrAg positive were all treated with antifungal regimens at the discretion of the treating physician (Table 1). The 3 who were adherent did not develop CM. Three were nonadherent: 1 developed CM, another developed cryptococcemia despite a negative viral load on HAART, and 1 started HAART 6 months after the positive CrAg result and died within 3 months of HAART initiation. Among the 99 CrAg-negative patients, 24 (25%) died. Cryptococcal Antigen–Positive Patients With CD4 Count <100 Cells/µL Abbreviations: 5FC, flucytosine; ALT, alanine aminotransferase; CM, cryptococcal meningitis; CrAg, cryptococcal antigen; CSF, cerebrospinal fluid; HAART, highly active antiretroviral therapy; HIV, human immunodeficiency virus; IV, intravenous; LP, lumbar puncture; MIC, minimum inhibitory concentration; VL, viral load; WBC, white blood cell. Cryptococcal Antigen–Positive Patients With CD4 Count <100 Cells/µL Abbreviations: 5FC, flucytosine; ALT, alanine aminotransferase; CM, cryptococcal meningitis; CrAg, cryptococcal antigen; CSF, cerebrospinal fluid; HAART, highly active antiretroviral therapy; HIV, human immunodeficiency virus; IV, intravenous; LP, lumbar puncture; MIC, minimum inhibitory concentration; VL, viral load; WBC, white blood cell. Among asymptomatic patients in our cohort who had received CrAg testing, 5.7% were positive. If we assume that all of those untested were negative, the positivity rate was 3.1%, similar to but slightly higher than that reported by McKenney et al. Preemptive treatment with various regimens followed by fluconazole secondary prophylaxis was effective in preventing CM in this series. Our data provide further observational evidence that cryptococcal testing in asymptomatic individuals with a low CD4 count may be a reasonable recommendation in AIDS patients not on HAART in high-income settings, similar to the recommendations being adopted in resource-limited settings [10]. Further data on the best preemptive treatment regimen are still needed. Potential conflict of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Source: Clinical Infectious Diseases
DOI: 10.1093/cid/civ559
Authors: Yukari C. Manabe, Richard D. Moore
Institutions: Johns Hopkins University, Johns Hopkins Medicine
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2279012204