Cryptococcal antigenemia prevalence and clinical data in HIV‐infected patients from the reference centre at INI‐FIOCRUZ, Rio de Janeiro, Southeast of Brazil

Abstract

Summary Cryptococcal meningitis is a several disease common in late stage of HIV infection. Detection of cryptococcal antigen (CrAg) is an important for early diagnosis of this invasive mycosis. The pre‐emptive treatment for isolated antigenemia prevents the onset of meningoencephalitis. Screening CrAg in patients with low CD4 count is cost‐effective in countries with prevalence of antigenemia above 3%. However, in Brazil, the number of prevalence studies on cryptococcosis and HIV is insufficient. The objective of this study is to estimate the prevalence of CrAg and describe clinical characteristics from a cohort of patients followed at a reference center in Brazil. CrAg screening was performed in 89 inpatients with CD4 count ≤200 cells/mm3 or WHO stage III/IV from the National Institute of Infecttious Disease, Rio de Janeiro. Patients with isolated antigenemia received pre‐emptive therapy with fluconazole and patients with meningoencephalitis were treated with Amphotericin B. Individuals were followed up for 12 months. Prevalence of serum CrAg was 11.23%, cryptococcal meningoencephalitis 6.74% and isolated antigenemia 4.81%. None of the patients with isolated antigenemia developed meningoencephalitis during the follow up. Signs and symptoms of meningoencephalitis were unspecific or absent. Our study suggests the need of CrAg screening in Brazil and highlights that lumbar puncture is mandatory in all individuals CrAg positive to exclude asymptomatic meningoencephalitis.

Epidemiology and Mortality of Cryptococcal Disease in Guatemala: Two-Year Results of a Cryptococcal Antigen Screening Program

“…For more information about the reporting criteria in each country, see Supplementary Data (Supplementary Material) . Considering all regional publications, four reported the frequency of CrAg in patients with ≤100 cells/mm 3 [ 9 , 10 , 11 , 12 ] and three in patients with <200 cells/mm 3 [ 9 , 13 , 14 ]. Using these results and ours, the estimated overall CrAg frequency in the region for PLWHIV with <100 CD4 cells/mm 3 was 9.2% (IC95% 7.9–10.7%) and 8.1% in those with AHD (IC95% 7.9–10.7%).…”

“…Among Latin American people with HIV, we estimated that CrAg positivity is 9.2% (IC95% 7.9–10.7%) in patients with <100 CD4/mm 3 [ 9 , 10 , 11 , 12 , 13 , 14 ]. This number is 3.2% higher than the global estimation by Rajasingham et al in asymptomatic patients [ 2 ], which is an uncertain denomination considering the deep immunosuppressed status of such HIV patients.…”

“…This number is 3.2% higher than the global estimation by Rajasingham et al in asymptomatic patients [ 2 ], which is an uncertain denomination considering the deep immunosuppressed status of such HIV patients. In published articles from Brazil, Argentina and Honduras, the criteria to establish the burden of cryptococcal disease were similar, with CD4 thresholds of <100 or <200 cells/mm 3 [ 10 , 11 , 13 ]. However, in Guatemala, we screened patients regardless of the CD4 cell count, symptoms, or hospitalized status, with an overall incidence of 4.8% ( Table 2 ), which is a real measurement of the burden of disease in PLWHIV.…”

“…Evaluating the absence or the presence of symptoms in highly immunosuppressed populations is a risky exercise. For instance, only asymptomatic hospitalized patients were included in the study by Vidal et al [ 13 ], where only a 3.1% incidence was ascertained, and this may mean that patients had another diseases that caused hospitalization and cryptococcal cases diagnosed were comorbidities more than a burden of this disease in asymptomatic people at risk. Thus, to establish the burden of disease, we can choose an objective entry criterion, such as CD4 threshold.…”

“… Frequencies of cryptococcal antigenemia in LATAM among patients with ≤100 cells/mm 3 and those with AHD (<200 CD4/mm 3 ) [ 9 , 10 , 11 , 12 , 13 , 14 ]. …”