免疫功能看似正常的患者中的隐球菌病。

Cryptococcosis in apparently immunocompetent patients.

作者信息

Lui G, Lee N, Ip M, Choi K W, Tso Y K, Lam E, Chau S, Lai R, Cockram C S

机构信息

Division of Infectious Diseases, Department of Medicine and Therapeutics, 9/F Clinical Sciences Building, Prince of Wales Hospital, Hong Kong.

出版信息

QJM. 2006 Mar;99(3):143-51. doi: 10.1093/qjmed/hcl014. Epub 2006 Feb 27.

DOI:10.1093/qjmed/hcl014

PMID:16504989

Abstract

BACKGROUND

Few reports have described the clinical and microbiological features of cryptococcosis in immunocompetent patients.

AIM

To compare clinical presentations and outcomes of cryptococcosis in immunocompetent vs. immunocompromised patients.

DESIGN

Retrospective case series.

METHODS

All culture- or histology-confirmed cases (n = 46) of cryptococcosis in two acute hospitals in Hong Kong (1995-2005) were included. Clinical presentations, rates of fungaemia, cerebrospinal fluid (CSF) parameters and clinical outcomes were recorded.

RESULTS

Twenty patients (43.5%) were apparently immunocompetent, 17 (37.0%) had predisposing factors other than HIV infection, and 9 (19.6%) were HIV-positive. Thirty-one (67.4%) presented with meningitis, four (8.7%) with pulmonary cryptococcosis, and 11 (23.9%) with extraneural, extrapulmonary cryptococcosis. Of the immunocompetent patients with retrievable isolates (n = 8), three (37.5%) were Cryptococcus gattii; all isolates (n = 6) from immunocompromised patients were Cryptococcus neoformans var. grubii. Immunocompetent patients more commonly presented with meningitis (80.0% vs. 47.1%, p = 0.03), and tended toward lower rates of fungaemia (10.0% vs. 35.3%, p = 0.06) and mortality (25.0% vs. 52.9%, p = 0.06). Death was associated with fungaemia (p = 0.01) and underlying malignancy (p < 0.01). In cryptococcal meningitis, immunocompetent patients had longer mean time from illness onset to presentation (34.4 vs. 12.6 days, p = 0.02), more intense inflammatory responses (CSF: white blood cells 108 vs. 35 x 10(9)/l, p = 0.03; protein 1.61 g/l vs. 0.79 g/l, p = 0.07), less fungaemia (0% vs. 26.7%, p = 0.04) and more satisfactory clinical outcomes (81.3% vs. 46.7%, p = 0.04).

DISCUSSION

A substantial proportion of patients with cryptococcosis are apparently immunocompetent. C. neoformans var. grubii and C. gattii are the common causes. Immunocompetent patients tend to present with localized, indolent neurological disease, with more intense inflammatory responses but better clinical outcomes.

摘要

背景

关于免疫功能正常患者隐球菌病的临床和微生物学特征的报道较少。

目的

比较免疫功能正常与免疫功能低下患者隐球菌病的临床表现和结局。

设计

回顾性病例系列研究。

方法

纳入香港两家急症医院（1995 - 2005年）所有经培养或组织学确诊的隐球菌病病例（n = 46）。记录临床表现、真菌血症发生率、脑脊液参数和临床结局。

结果

20例患者（43.5%）表面上免疫功能正常，17例（37.0%）有除HIV感染以外的易感因素，9例（19.6%）为HIV阳性。31例（67.4%）表现为脑膜炎，4例（8.7%）为肺隐球菌病，11例（23.9%）为神经外、肺外隐球菌病。在可获得分离株的免疫功能正常患者中（n = 8），3例（37.5%）为加氏隐球菌；免疫功能低下患者的所有分离株（n = 6）均为新生隐球菌格鲁比变种。免疫功能正常患者更常表现为脑膜炎（80.0%对47.1%，p = 0.03），真菌血症发生率倾向于较低（10.0%对35.3%，p = 0.06），死亡率也较低（25.0%对52.9%，p = 0.06）。死亡与真菌血症（p = 0.01）和潜在恶性肿瘤（p < 0.01）相关。在隐球菌性脑膜炎中，免疫功能正常患者从发病到就诊的平均时间更长（34.4天对12.6天，p = 0.02），炎症反应更强烈（脑脊液：白细胞108对35×10⁹/L，p = 0.03；蛋白质1.61g/L对0.79g/L，p = 0.07），真菌血症较少（0%对26.7%，p = 0.04），临床结局更令人满意（81.3%对46.7%，p = 0.04）。