Cryptococcosis in non-HIV infected patients: A multicemer survey

Cryptococcosis (crypto) is an important invasive fungal pathogen among HIV infected pts. Since the development of fluconazole (Flu) and itraconazole (Itra), the treatment of crypto has evolved, largely based on studies in these pts. In an effort to better define the current epidemiology and management of crypto in non-HIV pts, we conducted a retrospective survey of all pts with crypto between 7/90 and 12/96 at 17 centers. A diagnosis of crypto was based on the isolation of C. neoformans from any site and/or hisiopathologic evidence of crypto. To date, 204 pts have been enrolled with complete data available on 153 pts. Seventy-four pts (49%) had CNS crypto including 47 (31%) with CNS crypto alone. 55 pts (36%) had only pulmonary crypto, and 24 pts (16%) had involvement at other sites. Most common underlying conditions included chronic glucocorticosteroid therapy (48%), diabetes mellitus (18%). chronic lung dz (18%), and organ transplant (12%). Thirty pts (20%) had no underlying conditions. 110 (71%) had lumbar punctures at baseline, and among those with CNS crypto, 55 (79%) were CSF CrAg positive (≥ 1:1), 21 (30%) were India ink-positive, and 44 (63%) were culture positive for C. neoformans, AMB and 5-FC are given to most pts with CNS crypto for a median of 21 d and 11 d, respectively, followed by Flu for a median of 31 d (dose range 100-800 mg/d). Pts with pulmonary crypto were treated similarly. Only 4 pts received Itra for crypto. A detailed analysis of response to Rx is not available, but 68 pts (45%) are alive without evidence of dz. and 8 pts (5%) alive with evidence of disease. 63 pts (41%) have died including 22 (14%) from crypto. We conclude that crypto remains a relatively common and frequently fatal invasive fungal infection among non-HIV pis. AMB +/- 5FC are still important as initial therapy, but Flu is widely used in all forms of crypto. Clinical studies are needed to better define the role of azoles for crypto in non-HIV pts.

Duke Scholars

Author John Robert Perfect Medicine, Infectious Diseases