Comparación de los hallazgos clínicos y de supervivencia entre pacientes VIH positivos y VIH negativos con criptococosis meníngea en un hospital de tercer nivel

Abstract

Introduction: an increased incidence of cryptococcosis has been documented in Colombia, as well as a high prevalence of Cryptococcus gattii in Cucuta. Objective: to analyze patients with cryptococcal meningitis treated at a tertiary care hospital in Cucuta, Colombia, according to the HIV carrier status. Materials and methods: we performed a retrospective review of medical records in which we evaluated the clinical characteristics and outcomes of patients diagnosed with cryptococcal meningitis during the study period of 15 years (1996-2010). Results: we analyzed 90 cases, 63 (70%) HIV positive and 27 (30%) HIV negative. Most HIV positive patients were young adults (81.0% versus 25.9% of HIV negative patients, p = <0.001). There was a high prevalence of children among HIV-negative patients (29.6 versus 0%, p = <0.001). The male: female ratio was higher in HIV positive patients (3.8 versus 2.4, p = 0.001). No risk factor was found in 88.9% of HIV negative patients. Among the HIV-positive patients, mos of them (76.2%) were not receiving antiretroviral therapy, very few (7.9%) were taking prophylaxis with fluconazole and 68.8% had <100 CD4 + cells. Intracranial hypertension without hydrocephalus (83.3 versus 48.0%, p = 0.009), visual changes (48.1 versus 20.6%, p = 0.02) and extraneural cryptococcosis (22.2 versus 6, 4%, p = 0.06) were more frequent in HIV-negative patients. HIV-negative patients had higher numbers of leukocytes (124.2 /ml versus 43.0 /ml, p = 0.002) and protein (113.6 versus 89.7 mg/dL, p <0.001) in the CSF. C. neoformans var. grubii was isolated more frequently in HIV-positive patients (100 versus 40%, p <0.001) and C. gattii was predominant in HIV-negative (60% versus 0%, p <0.001). CT skull was more frequently abnormal in HIV-positive patients (73.3 versus 22.7%, p <0.001). Most patients in both groups received amphotericin B as primary therapy (96.8% of HIV positive versus 85.2% of HIV negative). The hospital mortality was higher in HIV positive patients (49.2 versus 16.0%, p = 0.004). HIV infection, altered state of consciousness, lack of antiretroviral therapy in HIV-positive patients, seizures and low CSF cellularity were factors of poor prognosis. Neurological sequelae were common in both groups of patients (40.6% vs 32.0%) without significant difference. The probability of survival was significantly higher in HIV-negative patients (82% vs 46%, p = 0.0066). Conclusions: cryptococcosis has a high morbidity and mortality, especially in HIV positive patients. The prevalence of Cryptococcus gattii in the HIV negative population and in children is very high.