隐球菌感染的表现和死亡率因易患疾病而异：一项回顾性队列研究。
Presentation and Mortality of Cryptococcal Infection Varies by Predisposing Illness: A Retrospective Cohort Study.
机构信息
Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Mo.
Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Mo.
出版信息
Am J Med. 2019 Aug;132(8):977-983.e1. doi: 10.1016/j.amjmed.2019.04.026. Epub 2019 May 8.
BACKGROUND
Cryptococcal epidemiology is changing in the modern antiretroviral era, and immune status informs outcomes. We describe the differences in clinical presentation and mortality of cryptococcosis by immune status in the antiretroviral therapy era.
METHODS
We conducted a single-center retrospective cohort study of patients diagnosed with cryptococcosis from 2002 through 2017. Data included demographics, clinical features, diagnostics, and mortality.
RESULTS
We identified 304 patients with Cryptococcus neoformans infections: 105 (35%) were people living with human immunodeficiency virus (HIV), 41 (13%) had a history of transplantation, and 158 (52%) were non-HIV nontransplant (NHNT). Age analysis showed that people living with HIV were younger (40 years) than transplant (53 years) and NHNT (61 years) (P < .001). Fevers and headache were more common in people living with HIV (70% and 57%) than in transplant (49% and 29%) and NHNT (49% and 38%) (P = .003 and P = .001), respectively. Meningitis was more common in people living with HIV (68%) than in transplant recipients (32%) or NHNT (39%, P < .001). Disseminated cryptococcosis was more common in people living with HIV (97%) as compared with transplant (66%) or NHNT (73%) (P < .001). Time to diagnosis from hospitalization was longer for transplant (median 2 days, interquartile range [IQR] ± 9 days) and NHNT patients (median 2 days, IQR ± 7 days) as compared with people living with HIV (median 1 day, IQR ± 2 days) (P = .003). NHNT patients had a higher risk of 90-day mortality (hazard ratio 3.3; 95% confidence interval, 1.9-5.8) as compared with people living with HIV.
CONCLUSIONS
The majority of cryptococcosis occurs in NHNT patients. NHNT patients had more localized pulmonary cryptococcosis and significantly higher 90-day mortality. Cryptococcosis in NHNT patients appears to be a distinct entity that needs further study and requires a higher level of clinical suspicion than it currently receives.
背景
在现代抗逆转录病毒时代，隐球菌病的流行病学正在发生变化，免疫状态决定了结局。我们描述了在抗逆转录病毒治疗时代，根据免疫状态，隐球菌病的临床表现和死亡率的差异。
方法
我们对 2002 年至 2017 年间确诊为隐球菌病的患者进行了一项单中心回顾性队列研究。数据包括人口统计学、临床特征、诊断和死亡率。
结果
我们共发现 304 例新型隐球菌感染患者：105 例（35%）为人类免疫缺陷病毒（HIV）感染者，41 例（13%）有移植史，158 例（52%）为非 HIV 非移植（NHNT）患者。年龄分析显示，HIV 感染者较移植（53 岁）和 NHNT（61 岁）患者年轻（40 岁）（P<.001）。发热和头痛在 HIV 感染者中更为常见（70%和 57%），而在移植患者（49%和 29%）和 NHNT 患者（49%和 38%）中则更为常见（P=.003 和 P=.001）。HIV 感染者的脑膜炎更为常见（68%），而移植患者（32%）或 NHNT 患者（39%）则相对较少（P<.001）。与移植患者（66%）或 NHNT 患者（73%）相比，HIV 感染者更易发生播散性隐球菌病（97%）（P<.001）。与 HIV 感染者（中位 1 天，IQR ± 2 天）相比，移植患者（中位 2 天，IQR ± 9 天）和 NHNT 患者（中位 2 天，IQR ± 7 天）从住院到诊断的时间更长（P=.003）。NHNT 患者 90 天死亡率较高（风险比 3.3；95%置信区间，1.9-5.8），与 HIV 感染者相比。
结论
大多数隐球菌病发生在 NHNT 患者中。NHNT 患者的肺部局限性隐球菌病更多，90 天死亡率明显更高。NHNT 患者的隐球菌病似乎是一种独特的实体，需要进一步研究，并需要比目前更高的临床怀疑度。
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