HIV-associated pneumocystis pneumonia (PCP) is increasingly recognized as an important cause of severe respiratory illness in sub-Saharan Africa. Outcomes of HIV-infected patients with PCP, especially those requiring intensive care unit (ICU) admission, have not been adequately studied in sub-Saharan Africa. The aim of this study was to describe the clinical phenotype and outcomes of HIV-associated PCP in a group of hospitalized South African patients, and to identify predictors of mortality. We conducted a retrospective record review at an academic referral center in Cape Town. HIV-infected patients over the age of 18 years with definite (any positive laboratory test) or probable PCP (defined according to the WHO/CDC clinical case definition) were included. The primary outcome measure was 90-day mortality. Logistic regression and Cox proportional hazards models were constructed to identify factors associated with mortality. We screened 562 test requests between 1 May 2004 and 31 April 2015; 124 PCP cases (68 confirmed and 56 probable) were included in the analysis. Median age was 34 years (interquartile range, IQR, 29 to 41), 89 (72%) were female, and median CD4 cell count was 26 cells/mm3 (IQR 12 to 70). Patients admitted to the ICU (n = 42) had more severe impairment of gas exchange (median ratio of arterial to inspired oxygen (PaO2:FiO2) 158 mmHg vs. 243 mmHg, p < 0.0001), and increased markers of systemic inflammation compared to those admitted to the ward (n = 82). Twenty-nine (23.6%) patients were newly-diagnosed with tuberculosis during their admission. Twenty-six (61.9%) patients admitted to ICU and 21 (25.9%) admitted to the ward had died at 90-days post-admission. Significant predictors of 90-day mortality included PaO2:FiO2 ratio (aOR 3.7; 95% CI, 1.1 to 12.9 for every 50 mgHg decrease), serum LDH (aOR 2.1; 95% CI, 1.1 to 4.1 for every 500 U/L increase), and concomitant antituberculosis therapy (aOR 82; 95% CI, 1.9 to 3525.4; P = 0.021). PaO2:FiO2 < 100 mmHg was significantly associated with inpatient death (aHR 3.8; 95% CI, 1.6 to 8.9; P = 0.003). HIV-associated PCP was associated with a severe clinical phenotype and high rates of tuberculosis co-infection. Mortality was high, particularly in patients admitted to the ICU, but was comparable to other settings. Prognostic indictors could be used to inform ICU admission policy for patients with this condition.
Background: Although tuberculous meningitis (TM) represents near 1% of the cases of tuberculosis disease, it is the most severe form of tuberculosis, with high mortality rate.Purpose: Description of tuberculosis meningitis cases and evaluation of infection outcome.Methods & Materials: Retrospective observational study in adults diagnosed with tuberculous meningitis at Centro Hospitalar do Porto, between January 2009 and October 2016.Results: During that period, 21 patients had a diagnosis of tuberculous meningitis, 81% (n = 17) were males and the mean age was 52,6 years-old (min 22; max 84). More prevalent risk factors identified were: chronic alcoholism (>60 g/day) in 23,8% (n = 5), drug use in 14,3% (n = 3) and iatrogenic immunosuppression in 14,3%. HIV infection was present in 28,6% (n = 6) On hospital admission, 23,8% (n = 5) patients had a stage III on BMRC score (British Medical Research Council). Regarding the cerebrospinal fluid (CSF), the mean protein level was 2,06 g/L (min. 0,30; max 4,53) and mean glucose de 0,34 g/L (min. 0,06; max. 0,81), mean pleocitosis of 233 cels/uL (mín. 0; máx. 911) with predominance of mononuclear cells (mean 140/uL; min. 0; max. 594). Microbiological diagnosis was based in PCR-assay (47,4%, n = 9), followed by culture (38,9%, n = 7).There was concomitant pulmonary tuberculosis in 19,0% (n = 4) of patients and 19,0% with disseminated disease. Tuberculostatic drugs were started in 20 patients (one died early) and 89,5% of them with adjunctive corticosteroids. External ventricular drain was needed in 42,9% (n = 9). Ischemic stroke (28,6%; n = 6) was the most common complication.Mortality rate at two-years was 47,6% (n = 10), with 6 deaths during hospitalization, 5 of them TM-related. At discharge, 9 of surviving patients had neurological sequelae with loss of autonomy.Conclusion: Even though it was a rare diagnosis in hospitalized patients, TM had a high mortality rate with significant loss of autonomy.
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