|Year : 2017 | Volume
| Issue : 1 | Page : 105-108
High prevalence of cryptococcal antigenaemia amongst asymptomatic advanced HIV patients in Pune, India
Dileep Kadam1, Ajay Chandanwale2, Renu Bharadwaj3, Neetal Nevrekar4, Samir Joshi5, Sandesh Patil4, Nikhil Gupte6, Shashi Sangle1, Kavita Chopade4, Vandana Kulkarni4, Usha Balasubramanian4, Nishi Suryavanshi4, Divyashri Jain4, Savita Kanade4, Sujata Dharmashale3, Anju Kagal3, Amita Gupta7, Vidya Mave6
1 Department of Medicine, Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
2 Department of Orthopedics, Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
3 Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
4 Clinical Research Site, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University, Pune, Maharashtra, India
5 Department of Otolaryngology, Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
6 Clinical Research Site, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University, Pune, Maharashtra, India; Division of Infectious Diseases, Johns Hopkins University, Baltimore, USA
7 Division of Infectious Diseases, Johns Hopkins University, Baltimore, USA
|Date of Web Publication||16-Mar-2017|
Department of Microbiology, 1st Floor, Byramjee Jeejeebhoy Medical College, Jai Prakash Narayan Road, Pune - 411 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The World Health Organization recommends routine cryptococcal antigen (CrAg) screening in advanced AIDS patients initiating antiretroviral treatment (ART). India has yet to adopt this strategy as the burden of cryptococcal antigenaemia is unknown. Methods: A prospective study was conducted in a large public sector ART centre and the inpatient wards of Sassoon Hospital, Pune, India. All consenting patients >18 years of age with CD4 count <100 cells/mm3 were screened for CrAg by latex agglutination assay. Those with positive CrAg underwent cerebrospinal fluid analysis, chest radiograph and abdominal ultrasound to rule out cryptococcal disease. The impact of CrAg positivity on all-cause mortality was assessed by logistic regression analysis. Results: Amongst 208 AIDS patients with CD4 cells <100 cells/mm3 who underwent CrAg testing, median age was 40 (interquartile range [IQR], 35–49) years, 134 (64%) were male and median CD4 count was 64.5 cells/mm3 (IQR, 37–82). Overall, 16 (8%, 95% confidence interval [CI], 4–12) patients were positive for CrAg, of which 8 (50%) had CD4 cells <50 cells/mm3 and 3 (19%) CrAg-positive patients had incidental cryptococcal meningitis. At 6-month follow-up, the case fatality rate was higher amongst CrAg-positive patients (38%) compared with CrAg-negative patients (18%) (P = 0.06). After adjusting for age, sex, CD4 count and ART, there was a trend towards increased all-cause mortality (adjusted OR, 3.18, 95% CI, 0.60–16.88,P= 0.17). Conclusions: We found an 8% prevalence of cryptococcaemia amongst adult AIDS patients with CD4 cells <100 cells/mm3. Given the high fatality rates observed, routine screening for CrAg should be considered for all Indian persons with advanced HIV disease.
Keywords: Asymptomatic cryptococcaemia, cryptococcal meningitis, cryptococcal screening, HIV/AIDS
|How to cite this article:|
Kadam D, Chandanwale A, Bharadwaj R, Nevrekar N, Joshi S, Patil S, Gupte N, Sangle S, Chopade K, Kulkarni V, Balasubramanian U, Suryavanshi N, Jain D, Kanade S, Dharmashale S, Kagal A, Gupta A, Mave V. High prevalence of cryptococcal antigenaemia amongst asymptomatic advanced HIV patients in Pune, India. Indian J Med Microbiol 2017;35:105-8
|How to cite this URL:|
Kadam D, Chandanwale A, Bharadwaj R, Nevrekar N, Joshi S, Patil S, Gupte N, Sangle S, Chopade K, Kulkarni V, Balasubramanian U, Suryavanshi N, Jain D, Kanade S, Dharmashale S, Kagal A, Gupta A, Mave V. High prevalence of cryptococcal antigenaemia amongst asymptomatic advanced HIV patients in Pune, India. Indian J Med Microbiol [serial online] 2017 [cited 2019 Aug 22];35:105-8. Available from: http://www.ijmm.org/text.asp?2017/35/1/105/202329
| ~ Introduction|| |
Cryptococcus neoformans is a pathogenic capsulated yeast with ubiquitous worldwide distribution. It has a predilection for the central nervous system, and infection occurs through inhalation of spores that disseminates haematogenously. It is one of the leading cause of opportunistic infection and mortality amongst persons with advanced HIV in the developing world.,, India and Southeast Asia have a substantial burden of cryptococcal meningitis cases (estimated incidence of 120,000 cases or 3% per year) with high mortality of 20%–50%.,
Amongst hospitalised HIV-infected patients in India with suspected meningitis and CD4 counts <100 cells/mm 3, up to 50% have cryptococcal meningitis., Most cryptococcal meningitis occurs in antiretroviral treatment (ART)-naïve people; however, the unmasking of cryptococcal meningitis within the 1st week of ART initiation (also known as ART-associated cryptococcal meningitis) is also common.
Data from Uganda and South Africa show a high incidence of ART-associated cryptococcal meningitis amongst cryptococcal antigen (CrAg)-positive patients.,,, Therefore, a rapid advice was published by the World Health Organization in December 2011 to use rapid CrAg assays for ART-naïve patients initiating treatment in high burden cryptococcal populations for patients with CD4 cells <100 cells/mm 3. However, India has yet to adopt routine screening for asymptomatic cryptococcal infection, and the burden of asymptomatic cryptococcaemia remains unknown. We conducted a prospective study at a large public hospital in India to determine whether such a screening strategy should be considered amongst Indian patients with advanced HIV disease.
| ~ Methods|| |
We prospectively enrolled inpatient and outpatient HIV-infected adults >18 years of age who had CD4 cells <100 cells/mm 3 that were seen at Sassoon Hospital and Byramjee Jeejeebhoy Government Medical College (BGJMC), Pune, India between January 2011 and January 2012. BGJMC is a public, teaching tertiary care facility that contains one of India's largest ART centres with over 30,000 patients registered since 2004. The study was approved by the Byramjee Jeejeebhoy Medical College Research Ethics Committee, Pune, India and the Johns Hopkins University Institutional Review Board, Baltimore, USA.
All adult patients >18 years of age from inpatient wards and those visiting the outpatient ART centre with a documented CD4 count <100 cells/mm 3 were eligible to enrol in the study. A trained clinician examined each patient for overt clinical symptoms or signs of cryptococcal meningitis that would exclude them from the study. After consenting, participants were tested for CrAg by latex agglutination assay (Meridian Bioscience Inc., USA).
Asymptomatic cryptococcal antigenaemia was defined as the presence of positive CrAg with dilution at >1:2. Baseline demographic and clinical information such as the date of HIV diagnosis and history of ART were collected. The most recent CD4 count was extracted from the patient's medical records at the time of enrolment. Phone follow-ups were conducted at 3 and 6 months after study entry to collect any new history of hospitalisation or death.
Participants with positive CrAg underwent cerebrospinal fluid examination to rule out cryptococcal meningitis. All CrAg-positive patients also underwent skin examination, chest radiography and abdominal ultrasound to rule out cryptococcal disease other than meningitis. At the time of the study, the standard of care for asymptomatic cryptococcaemia was careful observation; therefore, only those with confirmed meningitis were admitted to the hospital for further management. The primary study outcome was the presence of asymptomatic cryptococcal antigenaemia. The secondary outcomes were a diagnosis of incidental cryptococcal meningitis and 6-month all-cause mortality.
Data were analysed using Stata version 13.0 (StataCorp, College Town, Texas, USA). Continuous variables were compared across groups using Mann–Whitney (Rank-sum) test, and categorical variables were compared using Fisher's exact test. Logistic regression was used to analyse the risk factors of mortality at the 95% confidence level.
| ~ Results|| |
A total of 208 patients were enrolled, of which 28 (13%) were inpatients. The median age of participants was 40 years (interquartile range [IQR]: 35–49) and 134 (65%) were male. The median CD4 cell count was 64.5 cells/µL (IQR, 37–82) and 81 (40%) had CD4 cell count <50 cells/mm 3. Only 38 (18%) participants were on ART at the time of entry. There was no clinical suspicion of meningitis in any of the participants when CrAg testing was performed. At baseline, 16 (8%; 95% confidence interval [CI], 4%–12%) had a positive CrAg assay result. Of those, eight (53%) occurred in persons with a CD4 count <50 cells/mm 3. CrAg was positive in 1 (3%) of 38 patients on ART compared to 15 (9%) of 170 ART-naïve participants (P = 0.32). Five (18%) inpatients had positive CrAg. Median CD4 count did not differ significantly between CrAg-positive and CrAg-negative persons (P = 0.32). Of 16 persons with a positive CrAg, three had CrAg titres of 1:2048, three had 1:1024, two had 1:62 and one each had titres of 1:256, 1:128, 1:32 and 1:8 and the remaining had CrAg titres above 1:2 and below 1:8. Upon further investigation, three (19%) CrAg-positive participants had incidental cryptococcal meningitis and had titres of 1:128, 1:1024 and 1:2048, respectively. All were treated with intravenous amphotericin. The rest did not show any evidence of cryptococcal disease upon further investigation by skin examination, chest radiography and abdominal ultrasound. As shown in [Table 1], there were no significant differences in gender, median age and median CD4 count between CrAg-positive and negative participants.
|Table 1: Baseline characteristics and outcomes amongst AIDS patients with CD4 ≤100 cells/cumm with or without cryptococcal antigenaemia|
Click here to view
Amongst the 142 participants whose vital status could be ascertained at 6 months, 40 (19%) had died. Mortality was reported in 6 (38%) CrAg-positive participants compared with 34 (17%) CrAg-negative participants (P = 0.06). Mortality was reported in 18 (22%) of the 81 participants with CD4 counts <50 cells/mm 3. All CrAg-positive participants who died were ART-naïve when CrAg testing was performed. CrAg-positive participants had a 2.79 times greater risk of 6-month mortality (95% CI, 0.95–8.19, P = 0.06) [Table 2]. In multivariate analysis, after adjustment for CD4 cell count, age, sex and ART status, the odds ratio for cryptococcal antigenaemia-related mortality at 6 months was 3.18 (95% CI, 0.60–16.88, P = 0.17).
|Table 2: Risk factors for mortality amongst AIDS patients with CD4 <100 cells/cumm|
Click here to view
| ~ Discussion|| |
We found an 8% prevalence of cryptococcal antigenaemia in HIV-infected adults with a CD4 count <100 cells/mL in Pune, India. Moreover, confirmed cryptococcal meningitis was found in nearly one-fifth of those with cryptococcal antigenaemia. A high 6-month all-cause fatality rate was also observed amongst those with cryptococcal antigenaemia. To the best of our knowledge, this is the first study from India assessing the burden of cryptococcal antigenaemia in advanced HIV-infected patients without symptoms of cryptococcal disease.
Consistent with our study, studies from resource-limited settings from Asia and Africa have also reported the prevalence of cryptococcal antigenaemia ranging between 2% (Vietnam) and 21% (Cambodia and Nigeria).,,,, A study from the USA showed cryptococcal antigenaemia prevalent in 2.9% (CI = 2.2%–3.7%) of ART-naïve, advanced HIV patients. Furthermore, our study observed a relatively low prevalence of cryptococcal antigenaemia amongst those on ART compared to ART-naïve participants. These findings are consistent with previous studies suggesting that ART may be protective against cryptococcaemia.
Cryptococcal antigenaemia is reported to be a strong predictor of mortality in ART-naïve, advanced HIV-infected patients across all types (high resource and resource limited) of settings.,, In multivariate analysis, cryptococcal antigenaemia was associated with a 3.5-fold greater risk of all-cause mortality which is clinically significant though it did not reach statistical significance at the 95% confidence level. Our study did not investigate what portion of the mortality was related to cryptococcal disease. Tuberculosis is the leading cause for early mortality amongst advanced HIV-infected patients, and since India has the world's largest burden of TB, we cannot assume that cryptococcal disease was the primary cause of death in all our study participants.
Nonetheless, cryptococcal-related deaths can be prevented by CrAg screening at entry to care, as majority of deaths due to cryptococcal disease occur within a few months of first seeking HIV care.,, India is estimated to have the world's third largest burden of HIV, and over 35% of them enter HIV care with CD4 counts <200 cells/mm 3., Thus, a routine CrAg screening strategy as part of India's National AIDS Control programme may help to avert significant morbidity and mortality. The cost efficiency of such a programme is likely to be great, due to the high burden of cryptococcal antigenaemia in India, as demonstrated by earlier studies.,
Our study has some limitations. First, we could not ascertain the causes of death amongst all those who were followed up to 6 months. Second, we were only able to track two-thirds of our advanced HIV patients by phone, and the outcomes of the remaining one-third could not be verified. Finally, we may have missed subtle clinical signs and symptoms for mild cryptococcal meningitis at baseline despite the clinician's use of a standardised checklist. Despite these limitations, our study is the first in India to confirm the significance of screening advanced HIV patients for asymptomatic cryptococcal antigenaemia, as recommended by the WHO.
| ~ Conclusions|| |
The high prevalence of cryptococcal antigenaemia and associated all-cause mortality amongst ART-naïve patients with CD4 count <100 cells/cumm without a history of cryptococcal disease may signify the importance of targeted, routine CrAg screening in India. With the advent of a rapid, low-cost urine test for CrAg, this would be especially important to consider for India's National HIV programme.
We would like to acknowledge the National AIDS Control Organization, India. We thank the study participants and study staffs for their immense contribution.
Financial support and sponsorship
This study was supported by Gilead Foundation (US) and Ujala Foundation (US). VM, NG, NS, SP, RCB and AG are also supported by the NIH BJMC HIV Clinical Trials Unit (U01 AI069497) and Baltimore Washington India Clinical Trials Unit (BWI CTU, UM1AI069465).
Conflicts of interest
There are no conflicts of interest.
| ~ References|| |
Abhilash KP, Mitra S, Arul JJ, Raj PM, Balaji V, Kannangai R, et al.
Changing paradigm of cryptococcal meningitis: An eight-year experience from a tertiary hospital in South India. Indian J Med Microbiol 2015;33:25-9.
] [Full text]
Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector. Progress Report, 2005, 2006, 2007, 2008, 2009, 2010, WHO, UNAIDS, UNICEF. Available from: www.who.int/hiv/pub/2010progressreport/en/
. [Last accessed on 2014 Jun 23].
Park BJ, Wannemuehler KA, Marston BJ, Govender N, Pappas PG, Chiller TM. Estimation of the current global burden of cryptococcal meningitis among persons living with HIV/AIDS. AIDS 2009;23:525-30.
Kumarasamy N, Solomon S, Flanigan TP, Hemalatha R, Thyagarajan SP, Mayer KH. Natural history of human immunodeficiency virus disease in southern India. Clin Infect Dis 2003;36:79-85.
Sobhani R, Basavaraj A, Gupta A, Bhave AS, Kadam DB, Sangle SA, et al.
Mortality and clinical characteristics of hospitalized adult patients with HIV in Pune, India. Indian J Med Res 2007;126:116-21.
] [Full text]
Bicanic T, Meintjes G, Wood R, Hayes M, Rebe K, Bekker LG, et al.
Fungal burden, early fungicidal activity, and outcome in cryptococcal meningitis in antiretroviral-naive or antiretroviral-experienced patients treated with amphotericin B or fluconazole. Clin Infect Dis 2007;45:76-80.
Liechty CA, Solberg P, Were W, Ekwaru JP, Ransom RL, Weidle PJ, et al.
Asymptomatic serum cryptococcal antigenemia and early mortality during antiretroviral therapy in rural Uganda. Trop Med Int Health 2007;12:929-35.
Castelnuovo B, Manabe YC, Kiragga A, Kamya M, Easterbrook P, Kambugu A. Cause-specific mortality and the contribution of immune reconstitution inflammatory syndrome in the first 3 years after antiretroviral therapy initiation in an urban African cohort. Clin Infect Dis 2009;49:965-72.
French N, Gray K, Watera C, Nakiyingi J, Lugada E, Moore M, et al.
Cryptococcal infection in a cohort of HIV-1-infected Ugandan adults. AIDS 2002;16:1031-8.
WHO. Rapid Advice: Diagnosis, Prevention and Management of Cryptococcal Disease in HIV-Infected Adults, Adolescents and Children. World Health Organization; 2011. Available from: http://www.who.int/hiv/pub/cryptococcal_disease2011/en/
. [Last accessed on 2015 Jun 23; Last cited on 2012 Dec 10].
Smith RM, Nguyen TA, Ha HT, Thang PH, Thuy C, Lien TX, et al.
Prevalence of cryptococcal antigenemia and cost-effectiveness of a cryptococcal antigen screening program – Vietnam. PLoS One 2013;8:e62213.
Osazuwa F, Dirisu JO, Okuonghae PE, Ugbebor O. Screening for cryptococcal antigenemia in anti-retroviral naïve AIDS patients in Benin city, Nigeria. Oman Med J 2012;27:228-31.
Micol R, Lortholary O, Sar B, Laureillard D, Ngeth C, Dousset JP, et al.
Prevalence, determinants of positivity, and clinical utility of cryptococcal antigenemia in Cambodian HIV-infected patients. J Acquir Immune Defic Syndr 2007;45:555-9.
Pongsai P, Atamasirikul K, Sungkanuparph S. The role of serum cryptococcal antigen screening for the early diagnosis of cryptococcosis in HIV-infected patients with different ranges of CD4 cell counts. J Infect 2010;60:474-7.
Ganiem AR, Indrati AR, Wisaksana R, Meijerink H, van der Ven A, Alisjahbana B, et al.
Asymptomatic cryptococcal antigenemia is associated with mortality among HIV-positive patients in Indonesia. J Int AIDS Soc 2014;17:18821.
McKenney J, Smith RM, Chiller TM, Detels R, French A, Margolick J, et al.
Prevalence and correlates of cryptococcal antigen positivity among AIDS patients – United States, 1986-2012. MMWR Morb Mortal Wkly Rep 2014;63:585-7.
Beyene T, Woldeamanuel Y, Asrat D, Ayana G, Boulware DR. Comparison of cryptococcal antigenemia between antiretroviral naïve and antiretroviral experienced HIV positive patients at two hospitals in Ethiopia. PLoS One 2013;8:e75585.
Jarvis JN, Lawn SD, Vogt M, Bangani N, Wood R, Harrison TS. Screening for cryptococcal antigenemia in patients accessing an antiretroviral treatment program in South Africa. Clin Infect Dis 2009;48:856-62.
Gupta A, Nadkarni G, Yang WT, Chandrasekhar A, Gupte N, Bisson GP, et al.
Early mortality in adults initiating antiretroviral therapy (ART) in low- and middle-income countries (LMIC): A systematic review and meta-analysis. PLoS One 2011;6:e28691.
Shastri S, Boregowda PH, Rewari BB, Tanwar S, Shet A, Kumar AM. Scaling up antiretroviral treatment services in Karnataka, India: Impact on CD4 counts of HIV-infected people. PLoS One 2013;8:e72188.
Meya DB, Manabe YC, Castelnuovo B, Cook BA, Elbireer AM, Kambugu A, et al.
Cost-effectiveness of serum cryptococcal antigen screening to prevent deaths among HIV-infected persons with a CD4+ cell count or = 100 cells/microL who start HIV therapy in resource-limited settings. Clin Infect Dis 2010;51:448-55.
[Table 1], [Table 2]