Prevalence of cryptococcal infection among advanced HIV patients in Argentina using lateral flow immunoassay

Abstract

BackgroundGlobally, Latin America ranks third among regions with most cases of AIDS related cryptococcal meningitis. In 2009, a lateral flow immunoassay (LFA) for the detection of cryptococcal antigen (CrAg) was developed as a potential point-of-care test for diagnosis of cryptococcal infection. In 2011 World Health Organizations recommended on CrAg screening for HIV positive persons with CD4 below 100 cells/μL, followed by preemptive fluconazole treatment. However, in Argentina no formal recommendations for CrAg screening have been issued.MethodsHIV positive patients > = 18 years with advanced immunosuppression (CD4 counts ≤100 cells/μL within 3 months or WHO stage III/IV), who visited the hospital between April 1, 2014 and January 31, 2015, were included. The LFA was performed according to the manufacturer’s instructions on all serum samples. When CrAg detection was positive, a lumbar puncture was performed to rule out cryptococcal meningitis. Patients without evidence of meningeal involvement were treated with preemptive oral fluconazole in ambulatory care.ResultsWe included 123 patients. Prevalence of CrAg-positivity was 8.1%. Among the 10 CrAg-positive patients, 6 had meningeal involvement detected through the CSF analysis (CSF India-ink testing, CSF CrAg and culture). The remaining 4 patients with positive CrAg received targeted preemptive treatment with oral fluconazole and were free of cryptococcal disease during the follow-up period. None of the 113 patients with a negative CrAg test result developed cryptococcal disease.ConclusionsThis is the first study in Argentina, to our knowledge, describing the prevalence of cryptococcosis and usefulness of CrAg screening. LFA provided early diagnosis to determine a high prevalence of CrAg in our hospital, and that screening for subclinical infection with preemptive antifungal treatment, prevented a substantial proportion of meningeal disease.

Impact of Routine Cryptococcal Antigen Screening and Targeted Preemptive Fluconazole Therapy in Antiretroviral-naive Human Immunodeficiency Virus–infected Adults With CD4 Cell Counts <100/μL: A Systematic Review and Meta-analysis

“…In other words, the observed incident CM cases during follow-up despite pre-emptive fluconazole therapy might be a resultant of insufficient treatment and unmasking secondary to immune reconstitution inflammatory syndrome [61]. We therefore suggest that the objective is not only to identify CrAg-positive [40,42,43,45,48,[51][52][53]55]. In some, fluconazole was initiated at 800 mg/day and provided for four weeks only [41] or for two weeks then 400 mg/day for another two weeks and stopped [22]; these short courses seemed to be due to local realities of insufficient fluconazole availability.…”

“…On further assessment of 60 citations, 29 more were excluded. A total of 31 studies were included for estimating the prevalence of CrAg positivity [14,22,23,26,, of which ten to evaluate the prevalence of asymptomatic CM in CrAg-positive participants [31,33,40,41,45,48,50,51,55,57], four to evaluate the incidence of CM and all-cause mortality in the context of no fluconazole pre-emptive therapy [14,32,35,49], and twenty to evaluate the incidence of CM and/or all-cause mortality in the context of pre-emptive fluconazole therapy [14, 22, 23, 32, 33, 35, 39-45, 48-51, 53, 55, 56]. The quality of included studies is summarised in Supplementary text and Supplementary Figure 1.…”

Epidemiological characteristics of cryptococcal meningoencephalitis associated with Cryptococcus neoformans var. grubii from HIV-infected patients in Madagascar: A cross-sectional study

“…The recent development of antigenic and molecular techniques has greatly improved the diagnosis of cryptococcal infection. The lateral flow immunoassay (LFA) has proved to be a sensitive point-of-care test capable of detecting the cryptococcal antigen (CrAg) rapidly, which should make it possible to implement treatment early, to reduce mortality [10].…”

Evaluation of lateral flow immunochromatographic assay for diagnostic accuracy of cryptococcosis

“…The reasons for exclusion as shown in Figure 1. Finally, we included 15 quali ed articles [9,11,[13][14][15][16][17][18][19][20][21][22][23][24][25] .…”