Identifying predictors of central nervous system disease in solid organ transplant recipients with cryptococcosis.
BACKGROUND: Cerebrospinal fluid (CSF) analysis is often deferred in patients with cryptococcal disease, particularly in the absence of neurologic manifestations. We sought to determine whether a subset of solid organ transplant (SOT) recipients with high likelihood of central nervous system (CNS) disease could be identified in whom CSF analysis must be performed. METHODS: Patients comprised a multicenter cohort of SOT recipients with cryptococcosis. RESULTS: Of 129 (88%) of 146 SOT recipients with cryptococcosis who underwent CSF analysis, 80 (62%) had CNS disease. In the overall study population, abnormal mental status, time to onset of cryptococcosis more than 24 months posttransplantation (late-onset disease), serum cryptococcal antigen titer more than 1:64, and fungemia were independently associated with an increased risk of CNS disease. Of patients with abnormal mental status, 95% had CNS cryptococcosis. When only patients with normal mental status were considered, three predictors (serum antigen titer >1:64, fungemia, and late-onset disease) independently identified patients with CNS cryptococcosis; the risk of CNS disease was 14% if none, 39% if one, and 94% if two of the aforementioned predictors existed (chi for trend P<0.001). CONCLUSIONS: CSF analysis should be strongly considered in SOT recipients with cryptococcosis who have late-onset disease, fungemia, or serum cryptococcal antigen titer more than 1:64 even in the presence of normal mental status.
Osawa, R; Alexander, BD; Lortholary, O; Dromer, F; Forrest, GN; Lyon, GM; Somani, J; Gupta, KL; Del Busto, R; Pruett, TL; Sifri, CD; Limaye, AP; John, GT; Klintmalm, GB; Pursell, K; Stosor, V; Morris, MI; Dowdy, LA; Muñoz, P; Kalil, AC; Garcia-Diaz, J; Orloff, S; House, AA; Houston, S; Wray, D; Huprikar, S; Johnson, LB; Humar, A; Razonable, RR; Fisher, RA; Husain, S; Wagener, MM; Singh, N
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