title: Predictors of mortality and differences in clinical features among patients with Cryptococcosis according to immune status.
abstract: BACKGROUND
  Cryptococcosis is an invasive fungal infection causing substantial morbidity and mortality. Prognostic factors are largely derived from trials conducted prior to the modern era of antifungal and potent combination antiretroviral therapies, immunosuppression, and transplantation. Data describing the clinical features and predictors of mortality in a modern cohort are needed.
  
  
  METHODS
  We conducted a retrospective cohort study of patients at our institution diagnosed with cryptococcosis from 1996 through 2010. Data included demographics, clinical features, diagnostics, treatment, and outcomes.
  
  
  RESULTS
  We identified 302 individuals: 108 (36%) human immunodeficiency virus (HIV)-positive, 84 (28%) organ transplant recipients (OTRs), and 110 (36%) non-HIV, non-transplant (NHNT) patients including 39 with no identifiable immunodeficiency. Mean age was 49 years, 203 (67%) were male and 170 (56%) were white. All-cause mortality at 90 days was 21%. In multivariable logistic regression analyses, cryptococcemia (OR 5.09, 95% CI 2.54-10.22) and baseline opening pressure >25 cmH2O (OR 2.93, 95% CI 1.25-6.88) were associated with increased odds of mortality; HIV-positive patients (OR 0.46, 95% CI 0.19-1.16) and OTRs (OR 0.46, 95% CI 0.21-1.05) had lower odds of death compared to NHNT patients.
  
  
  CONCLUSIONS
  Predictors of mortality from cryptococcosis in the modern period include cryptococcemia, high intracranial pressure, and NHNT status while drug(s) used for induction and historical prognostic factors including organ failure syndromes and hematologic malignancy were not associated with mortality.
authors.affiliation: Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, United States of America. brizenk@ccf.org
authors.forename: Kyle D
authors.initials: KD
authors.lastname: Brizendine
authors.forename: John W
authors.initials: JW
authors.lastname: Baddley
authors.forename: Peter G
authors.initials: PG
authors.lastname: Pappas
mesh_terms: D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use; D003453:Cryptococcosis / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality*; D003455:Cryptococcus neoformans / Q000302:isolation & purification*; D005260:Female; D006678:HIV / Q000302:isolation & purification; D015658:HIV Infections / Q000150:complications; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D019737:Transplants; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents
references.citation: Med Mycol. 2008 Jun;46(4):393-5
references.pmid: 18415850
references.citation: PLoS Med. 2007 Feb;4(2):e21
references.pmid: 17284154
references.citation: Clin Infect Dis. 2001 Sep 1;33(5):690-9
references.pmid: 11477526
references.citation: Medicine (Baltimore). 2001 Sep;80(5):308-12
references.pmid: 11552084
references.citation: Chest. 2006 Feb;129(2):333-340
references.pmid: 16478849
references.citation: Transpl Infect Dis. 2009 Oct;11(5):432-7
references.pmid: 19638005
references.citation: Transplantation. 2005 Oct 27;80(8):1033-9
references.pmid: 16278582
references.citation: Clin Infect Dis. 2008 Jul 1;47(1):123-30
references.pmid: 18505387
references.citation: Clin Infect Dis. 2010 Feb 1;50(3):338-44
references.pmid: 20038244
references.citation: N Engl J Med. 1979 Jul 19;301(3):126-31
references.pmid: 449951
references.citation: BMC Infect Dis. 2010 Jul 09;10:199
references.pmid: 20618932
references.citation: N Engl J Med. 1987 Aug 6;317(6):334-41
references.pmid: 3299095
references.citation: N Engl J Med. 1997 Jul 3;337(1):15-21
references.pmid: 9203426
references.citation: J Infect Dis. 2007 Mar 1;195(5):756-64
references.pmid: 17262720
references.citation: PLoS One. 2012;7(8):e43582
references.pmid: 22937064
references.citation: J Microbiol Immunol Infect. 2009 Jun;42(3):220-6
references.pmid: 19812855
references.citation: J Infect. 2010 Nov;61(5):419-26
references.pmid: 20732350
references.citation: J Microbiol Immunol Infect. 2012 Aug;45(4):296-304
references.pmid: 22608531
references.citation: QJM. 2002 Aug;95(8):511-8
references.pmid: 12145390
references.citation: Clin Infect Dis. 2003 Sep 1;37(5):673-8
references.pmid: 12942399
references.citation: Emerg Infect Dis. 2001 May-Jun;7(3):375-81
references.pmid: 11384512
references.citation: N Engl J Med. 1992 Jan 9;326(2):83-9
references.pmid: 1727236
references.citation: Clin Infect Dis. 2009 Dec 1;49(11):1721-8
references.pmid: 19886800
references.citation: Clin Infect Dis. 2007 Jul 1;45(1):76-80
references.pmid: 17554704
references.citation: Clin Infect Dis. 1996 May;22 Suppl 2:S154-60
references.pmid: 8722844
references.citation: Clin Infect Dis. 2010 Feb 1;50(3):291-322
references.pmid: 20047480
references.citation: Chest. 2003 Dec;124(6):2395-7
references.pmid: 14665529
references.citation: Chest. 1999 Mar;115(3):734-40
references.pmid: 10084485
references.citation: PLoS One. 2008 Aug 06;3(8):e2870
references.pmid: 18682846
references.citation: Jpn J Infect Dis. 2008 Mar;61(2):111-5
references.pmid: 18362398
references.citation: AIDS. 2009 Feb 20;23(4):525-30
references.pmid: 19182676