Musubire Abdu K, Boulware David R, Meya David B, Rhein Joshua
Infectious Disease Institute, Makerere University, Kampala, Uganda.
University of Minnesota, Minneapolis, MN, USA.
J AIDS Clin Res. 2013 Apr 29;Suppl 3(3). doi: 10.4172/2155-6113.s3-003.
Despite improvements in the antifungal regimens and the roll out of antiretroviral therapy (ART) in sub-Saharan Africa, mortality due to cryptococcal meningitis remains high. Relapse of an initially successfully treated infection contributes to this mortality and is often a clinical dilemma in differentiating between paradoxical immune reconstitution inflammatory syndrome (IRIS) and culture-positive relapse or treatment failure. Herein, we present a clinical case scenario and review the case definitions, differential diagnosis, and management of relapse with an emphasis on the current diagnostic and management strategies. We also highlight the challenges of resistance testing and management of refractory relapse cases. The risk of relapse is influenced by: 1) the choice of induction therapy, with higher mortality risk with fluconazole monotherapy which can select for resistance; 2) non-adherence to or lack of secondary prophylaxis; 3) failure of linkage-to-care or retention-in-care of HIV ART programs.
尽管撒哈拉以南非洲地区的抗真菌治疗方案有所改进，抗逆转录病毒疗法（ART）也已推广，但隐球菌性脑膜炎导致的死亡率仍然很高。最初成功治疗的感染复发导致了这种死亡率，并且在区分矛盾的免疫重建炎症综合征（IRIS）与培养阳性复发或治疗失败时，常常是一个临床难题。在此，我们呈现一个临床病例，并回顾复发的病例定义、鉴别诊断及管理，重点关注当前的诊断和管理策略。我们还强调了耐药性检测及难治性复发病例管理的挑战。复发风险受以下因素影响：1）诱导治疗的选择，氟康唑单药治疗的死亡风险较高，因为其可能会导致耐药；2）不坚持或缺乏二级预防；3）HIV抗病毒治疗项目的治疗衔接失败或治疗留存率低。
