Yu Wang , Yu Gu , Kunlu Shen , Xuefan Cui , Rui Min , Siqing Sun , Chunlai Feng , Yanbin Chen , Li Wang , Guoer Ma , Bilin Chen , Yueyan Ni , Huanhuan Zhong , Yi Shi , Xin Su
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The clinical data of patients with proven cryptococcosis were collected and analyzed from 7 tertiary teaching hospitals in Jiangsu Province, China from January, 2013 to December, 2018. Proven cases include pulmonary cryptococcosis, cryptococcal meningitis, cryptococcemia and cutaneous cryptococcosis. Patients were followed up over 24 months. According to their immune status, patients with cryptococcosis were divided into three groups, namely immunocompetent group (IC), mild-to-moderate immunodeficient diseases group (MID), severe immunodeficient diseases group (SID). Meanwhile, pulmonary crypotococcosis (PC) and extrapulmonary crypotococcosis (EPC) were also classified and analyzed.</p></div><div><h3>Results</h3><p>255 proven cases of cryptococcosis were enrolled. Finally, 220 cases completed the follow-up. 143 proven cases (65.0%) were immunocompetent (IC), 41 cases (18.6%) were MID, and 36 cases (16.4%) were SID. 174 cases (79.1%) were PC and 46 cases (20.9%) were EPC. The mortality was significantly higher in SID and MID patients [47.2% (SID) vs. 12.2% (MID) vs. 0.0% (IC), <em>p</em><0.001]. The mortality was also significantly higher in EPC patients [45.7% vs. 0.6% (PC), <em>p</em><0.001]. Patients with alternative initial antifungal treatment had higher mortality than patients with guideline recommended initial treatment [23.1% vs. 9.5%, <em>p</em>=0.041]. In MID group, the mortality of receiving alternative initial antifungal treatment was significantly higher than recommended initial treatment [2/3 vs. 3/34(8.8%), <em>p</em>=0.043]. In pulmonary cryptococcosis patients with MID, the mortality was very similar to IC group [0.0% vs. 0.0% (IC)], lower than SID group [0.0% vs. 11.1% (SID), <em>p</em>=0.555]. However, in extrapulmonary cryptococcosis patients with MID, the mortality was significantly higher than that in IC [62.5% vs. 0.0% (IC)], and similar to SID patients [62.5% vs. 59.3% (SID)].</p></div><div><h3>Conclusion</h3><p>The immune status exert a significant influence on the management and prognosis of cryptococcosis patients. The mortality of cryptococcosis patients with MID is higher than that of immunocompetent patients. For MID patients with pure pulmonary cryptococcosis, it is acceptable to take the treatment recommended as IC patients. For the MID patients with extrapulmonary cryptococcosis, the mortality is high and the initial treatment should follow the regimen for SID patients. Following the recommended treatment regimen in the IDSA guideline can reduce mortality in patients with cryptococcosis. Starting on alternative initial antifungal treatment may bring worse outcomes.</p></div>","PeriodicalId":14824,"journal":{"name":"Journal de mycologie medicale","volume":"33 3","pages":"Article 101389"},"PeriodicalIF":2.2000,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"2","resultStr":"{\"title\":\"The management and outcome of cryptococcosis in patients with different immune statuses and treatment protocols: A multicenter real-world study in Jiangsu Province - China\",\"authors\":\"Yu Wang , Yu Gu , Kunlu Shen , Xuefan Cui , Rui Min , Siqing Sun , Chunlai Feng , Yanbin Chen , Li Wang , Guoer Ma , Bilin Chen , Yueyan Ni , Huanhuan Zhong , Yi Shi , Xin Su\",\"doi\":\"10.1016/j.mycmed.2023.101389\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<div><h3>Objective</h3><p>The incidence of cryptococcosis is increasing in non-immunocompromised patients. However, the evidence on proper management is inadequate in this population. We conducted this multi-center real-world study in pulmonary cryptococcosis patients with different immune statuses, so as to provide practical evidence for optimized clinical management of cryptococcosis, especially for mild-to-moderate immunodeficient diseases patients.</p></div><div><h3>Methods</h3><p>This is a prospective observational study. The clinical data of patients with proven cryptococcosis were collected and analyzed from 7 tertiary teaching hospitals in Jiangsu Province, China from January, 2013 to December, 2018. Proven cases include pulmonary cryptococcosis, cryptococcal meningitis, cryptococcemia and cutaneous cryptococcosis. Patients were followed up over 24 months. According to their immune status, patients with cryptococcosis were divided into three groups, namely immunocompetent group (IC), mild-to-moderate immunodeficient diseases group (MID), severe immunodeficient diseases group (SID). Meanwhile, pulmonary crypotococcosis (PC) and extrapulmonary crypotococcosis (EPC) were also classified and analyzed.</p></div><div><h3>Results</h3><p>255 proven cases of cryptococcosis were enrolled. Finally, 220 cases completed the follow-up. 143 proven cases (65.0%) were immunocompetent (IC), 41 cases (18.6%) were MID, and 36 cases (16.4%) were SID. 174 cases (79.1%) were PC and 46 cases (20.9%) were EPC. The mortality was significantly higher in SID and MID patients [47.2% (SID) vs. 12.2% (MID) vs. 0.0% (IC), <em>p</em><0.001]. The mortality was also significantly higher in EPC patients [45.7% vs. 0.6% (PC), <em>p</em><0.001]. Patients with alternative initial antifungal treatment had higher mortality than patients with guideline recommended initial treatment [23.1% vs. 9.5%, <em>p</em>=0.041]. In MID group, the mortality of receiving alternative initial antifungal treatment was significantly higher than recommended initial treatment [2/3 vs. 3/34(8.8%), <em>p</em>=0.043]. In pulmonary cryptococcosis patients with MID, the mortality was very similar to IC group [0.0% vs. 0.0% (IC)], lower than SID group [0.0% vs. 11.1% (SID), <em>p</em>=0.555]. However, in extrapulmonary cryptococcosis patients with MID, the mortality was significantly higher than that in IC [62.5% vs. 0.0% (IC)], and similar to SID patients [62.5% vs. 59.3% (SID)].</p></div><div><h3>Conclusion</h3><p>The immune status exert a significant influence on the management and prognosis of cryptococcosis patients. The mortality of cryptococcosis patients with MID is higher than that of immunocompetent patients. For MID patients with pure pulmonary cryptococcosis, it is acceptable to take the treatment recommended as IC patients. For the MID patients with extrapulmonary cryptococcosis, the mortality is high and the initial treatment should follow the regimen for SID patients. Following the recommended treatment regimen in the IDSA guideline can reduce mortality in patients with cryptococcosis. 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引用次数: 2
摘要
目的隐球菌病在非免疫功能低下患者中的发病率呈上升趋势。然而，对这一人群进行适当管理的证据不足。我们对不同免疫状态的肺隐球菌病患者进行了多中心的现实研究，以期为隐球菌病的临床优化管理，特别是对轻中度免疫缺陷疾病患者提供实践依据。方法前瞻性观察性研究。收集2013年1月至2018年12月江苏省7家三级教学医院确诊隐球菌病患者的临床资料并进行分析。已证实的病例包括肺隐球菌病、隐球菌脑膜炎、隐球菌血症和皮肤隐球菌病。患者随访超过24个月。根据患者免疫状态将隐球菌病患者分为免疫功能正常组(IC)、轻中度免疫缺陷组(MID)、重度免疫缺陷组(SID) 3组。同时对肺隐球菌病(PC)和肺外隐球菌病(EPC)进行分类和分析。结果入选255例确诊隐球菌病病例。220例患者完成随访。免疫能力(IC) 143例(65.0%)，MID 41例(18.6%)，SID 36例(16.4%)。PC 174例(79.1%)，EPC 46例(20.9%)。SID和MID患者的死亡率明显更高[47.2% (SID) vs. 12.2% (MID) vs. 0.0% (IC)， p<0.001]。EPC患者的死亡率也明显更高[45.7% vs. 0.6% (PC)， p<0.001]。采用替代初始抗真菌治疗的患者死亡率高于采用指南推荐初始治疗的患者[23.1%比9.5%，p=0.041]。MID组初始抗真菌替代治疗的死亡率明显高于初始推荐治疗[2/3 vs. 3/34(8.8%)， p=0.043]。肺隐球菌病合并MID患者的死亡率与IC组非常相似[0.0%比0.0% (IC)]，低于SID组[0.0%比11.1% (SID)， p=0.555]。然而，肺外隐球菌病合并MID患者的死亡率明显高于IC患者[62.5%比0.0% (IC)]，与SID患者相似[62.5%比59.3% (SID)]。结论免疫状况对隐球菌病患者的治疗和预后有重要影响。隐球菌病合并MID患者的死亡率高于免疫正常患者。对于合并纯肺隐球菌病的MID患者，可采用IC患者推荐的治疗方法。对于合并肺外隐球菌病的MID患者，死亡率较高，初始治疗应遵循SID患者的治疗方案。遵循IDSA指南中推荐的治疗方案可以降低隐球菌病患者的死亡率。开始替代初始抗真菌治疗可能会带来更糟糕的结果。
The management and outcome of cryptococcosis in patients with different immune statuses and treatment protocols: A multicenter real-world study in Jiangsu Province - China
Objective
The incidence of cryptococcosis is increasing in non-immunocompromised patients. However, the evidence on proper management is inadequate in this population. We conducted this multi-center real-world study in pulmonary cryptococcosis patients with different immune statuses, so as to provide practical evidence for optimized clinical management of cryptococcosis, especially for mild-to-moderate immunodeficient diseases patients.
Methods
This is a prospective observational study. The clinical data of patients with proven cryptococcosis were collected and analyzed from 7 tertiary teaching hospitals in Jiangsu Province, China from January, 2013 to December, 2018. Proven cases include pulmonary cryptococcosis, cryptococcal meningitis, cryptococcemia and cutaneous cryptococcosis. Patients were followed up over 24 months. According to their immune status, patients with cryptococcosis were divided into three groups, namely immunocompetent group (IC), mild-to-moderate immunodeficient diseases group (MID), severe immunodeficient diseases group (SID). Meanwhile, pulmonary crypotococcosis (PC) and extrapulmonary crypotococcosis (EPC) were also classified and analyzed.
Results
255 proven cases of cryptococcosis were enrolled. Finally, 220 cases completed the follow-up. 143 proven cases (65.0%) were immunocompetent (IC), 41 cases (18.6%) were MID, and 36 cases (16.4%) were SID. 174 cases (79.1%) were PC and 46 cases (20.9%) were EPC. The mortality was significantly higher in SID and MID patients [47.2% (SID) vs. 12.2% (MID) vs. 0.0% (IC), p<0.001]. The mortality was also significantly higher in EPC patients [45.7% vs. 0.6% (PC), p<0.001]. Patients with alternative initial antifungal treatment had higher mortality than patients with guideline recommended initial treatment [23.1% vs. 9.5%, p=0.041]. In MID group, the mortality of receiving alternative initial antifungal treatment was significantly higher than recommended initial treatment [2/3 vs. 3/34(8.8%), p=0.043]. In pulmonary cryptococcosis patients with MID, the mortality was very similar to IC group [0.0% vs. 0.0% (IC)], lower than SID group [0.0% vs. 11.1% (SID), p=0.555]. However, in extrapulmonary cryptococcosis patients with MID, the mortality was significantly higher than that in IC [62.5% vs. 0.0% (IC)], and similar to SID patients [62.5% vs. 59.3% (SID)].
Conclusion
The immune status exert a significant influence on the management and prognosis of cryptococcosis patients. The mortality of cryptococcosis patients with MID is higher than that of immunocompetent patients. For MID patients with pure pulmonary cryptococcosis, it is acceptable to take the treatment recommended as IC patients. For the MID patients with extrapulmonary cryptococcosis, the mortality is high and the initial treatment should follow the regimen for SID patients. Following the recommended treatment regimen in the IDSA guideline can reduce mortality in patients with cryptococcosis. Starting on alternative initial antifungal treatment may bring worse outcomes.
期刊介绍：
The Journal de Mycologie Medicale / Journal of Medical Mycology (JMM) publishes in English works dealing with human and animal mycology. The subjects treated are focused in particular on clinical, diagnostic, epidemiological, immunological, medical, pathological, preventive or therapeutic aspects of mycoses. Also covered are basic aspects linked primarily with morphology (electronic and photonic microscopy), physiology, biochemistry, cellular and molecular biology, immunochemistry, genetics, taxonomy or phylogeny of pathogenic or opportunistic fungi and actinomycetes in humans or animals. Studies of natural products showing inhibitory activity against pathogenic fungi cannot be considered without chemical characterization and identification of the compounds responsible for the inhibitory activity.
JMM publishes (guest) editorials, original articles, reviews (and minireviews), case reports, technical notes, letters to the editor and information. Only clinical cases with real originality (new species, new clinical present action, new geographical localization, etc.), and fully documented (identification methods, results, etc.), will be considered.
Under no circumstances does the journal guarantee publication before the editorial board makes its final decision.
The journal is indexed in the main international databases and is accessible worldwide through the ScienceDirect and ClinicalKey platforms.
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