Identifying predictors of central nervous system disease in solid organ transplant recipients with cryptococcosis.
BACKGROUND
Cerebrospinal fluid (CSF) analysis is often deferred in patients with cryptococcal disease, particularly in the absence of neurologic manifestations. We sought to determine whether a subset of solid organ transplant (SOT) recipients with high likelihood of central nervous system (CNS) disease could be identified in whom CSF analysis must be performed.


METHODS
Patients comprised a multicenter cohort of SOT recipients with cryptococcosis.


RESULTS
Of 129 (88%) of 146 SOT recipients with cryptococcosis who underwent CSF analysis, 80 (62%) had CNS disease. In the overall study population, abnormal mental status, time to onset of cryptococcosis more than 24 months posttransplantation (late-onset disease), serum cryptococcal antigen titer more than 1:64, and fungemia were independently associated with an increased risk of CNS disease. Of patients with abnormal mental status, 95% had CNS cryptococcosis. When only patients with normal mental status were considered, three predictors (serum antigen titer >1:64, fungemia, and late-onset disease) independently identified patients with CNS cryptococcosis; the risk of CNS disease was 14% if none, 39% if one, and 94% if two of the aforementioned predictors existed (chi for trend P<0.001).


CONCLUSIONS
CSF analysis should be strongly considered in SOT recipients with cryptococcosis who have late-onset disease, fungemia, or serum cryptococcal antigen titer more than 1:64 even in the presence of normal mental status.
Osawa
Ryosuke
R
VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
Alexander
Barbara D
BD
Lortholary
Olivier
O
Dromer
Françoise
F
Forrest
Graeme N
GN
Lyon
G Marshall
GM
Somani
Jyoti
J
Gupta
Krishan L
KL
Del Busto
Ramon
R
Pruett
Timothy L
TL
Sifri
Costi D
CD
Limaye
Ajit P
AP
John
George T
GT
Klintmalm
Goran B
GB
Pursell
Kenneth
K
Stosor
Valentina
V
Morris
Michele I
MI
Dowdy
Lorraine A
LA
Muñoz
Patricia
P
Kalil
Andre C
AC
Garcia-Diaz
Julia
J
Orloff
Susan
S
House
Andrew A
AA
Houston
Sally
S
Wray
Dannah
D
Huprikar
Shirish
S
Johnson
Leonard B
LB
Humar
Atul
A
Razonable
Raymund R
RR
Fisher
Robert A
RA
Husain
Shahid
S
Wagener
Marilyn M
MM
Singh
Nina
N
D000328:Adult; D000946:Antigens, Fungal / Q000097:blood; D002493:Central Nervous System Diseases / Q000453:epidemiology*; D016009:Chi-Square Distribution; D015331:Cohort Studies; D003453:Cryptococcosis / Q000150:complications / Q000453:epidemiology*; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D016377:Organ Transplantation / Q000009:adverse effects*; D011183:Postoperative Complications / Q000453:epidemiology / Q000382:microbiology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012044:Regression Analysis
D000946:Antigens, Fungal; D007166:Immunosuppressive Agents