Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
Mycoses. 2021 Feb;64(2):174-180. doi: 10.1111/myc.13199. Epub 2020 Oct 28.
Determining the extent of cryptococcal disease (CD) is key to therapeutic management. Treatment with fluconazole is only recommended for localised pulmonary disease. Induction therapy with amphotericin B (AmB) and flucytosine is recommended for disease at other sites, irrespective of central nervous system (CNS) involvement, but this is not often followed in patients without meningitis. In this study, we compared treatment and mortality between patients with CD of the CNS and other extrapulmonary (OE) sites.
This is a retrospective, single-centre study of all hospitalised patients with nonpulmonary cryptococcal infection from 2002 to 2015 who underwent lumbar puncture. Demographics, predisposing factors, comorbidities, clinical presentation, laboratory values, antifungal treatment and mortality data were collected to evaluate 90-day mortality and treatment differences between patients with OE and CNS CD. Survival analysis was performed using multivariable Cox regression analysis.
Of 193 patients analysed, 143 (74%) had CNS CD and 50 (26%) had OE CD. Ninety-day mortality was 23% and similar between the OE and CNS CD groups (22% vs 23%, p = .9). In the comorbidity-adjusted multivariable Cox regression model, mortality risk was similar in the OE and CNS groups. Fewer patients with OE CD received induction therapy with AmB and flucytosine compared to those with CNS disease (28% vs 71.3%, p < .001).
Patients with OE CD had similar 90-day mortality compared to those with CNS disease. Despite current guideline recommendations, patients with OE disease were less likely to receive appropriate induction therapy with AmB and flucytosine compared to patients with CNS disease.
确定隐球菌病（CD）的范围是治疗管理的关键。氟康唑治疗仅推荐用于局部肺部疾病。对于其他部位的疾病，建议使用两性霉素 B（AmB）和氟胞嘧啶进行诱导治疗，无论是否涉及中枢神经系统（CNS），但在没有脑膜炎的患者中，这通常并未得到遵循。在这项研究中，我们比较了 CNS 和其他肺外（OE）部位 CD 患者的治疗和死亡率。
这是一项回顾性、单中心研究，纳入了 2002 年至 2015 年期间所有因非肺部隐球菌感染住院并接受腰椎穿刺的患者。收集了人口统计学、易患因素、合并症、临床表现、实验室值、抗真菌治疗和死亡率数据，以评估 OE 和 CNS CD 患者的 90 天死亡率和治疗差异。使用多变量 Cox 回归分析进行生存分析。
在分析的 193 名患者中，143 名（74%）患有 CNS CD，50 名（26%）患有 OE CD。90 天死亡率为 23%，OE 和 CNS CD 组之间相似（22% vs 23%，p=.9）。在合并症调整的多变量 Cox 回归模型中，OE 和 CNS 组的死亡率风险相似。与 CNS 疾病患者相比，OE CD 患者接受 AmB 和氟胞嘧啶诱导治疗的比例较低（28% vs 71.3%，p<.001）。
OE CD 患者的 90 天死亡率与 CNS 疾病患者相似。尽管存在当前指南建议，但与 CNS 疾病患者相比，OE 疾病患者接受 AmB 和氟胞嘧啶适当诱导治疗的可能性较小。
