Antifungal Therapy and Management of Complications of Cryptococcosis due to Cryptococcus gattii
Antifungal Therapy and Management of Complications of Cryptococcosis due to Cryptococcus gattii
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DOI：
10.1093/cid/cit341
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发表时间：
2013-08-15
影响因子：
11.8
通讯作者：
Sorrell, Tania C.
中科院分区：
文献类型：
--
作者：
Chen, Sharon C. -A.;Korman, Tony M.;Sorrell, Tania C.
背景我们描述的抗真菌治疗和管理的并发症，由于隐球菌感染的86例澳大利亚患者随访至少12个月。在诊断、6周、6个月和12个月时记录培养确诊病例（2000-2007年）的患者数据。确定与颅内压升高（ICP）和免疫重建炎症综合征（IRIS）相关的临床、实验室和治疗变量。10例肺部感染患者中有7例接受了阿朴霉素B（AMB）诱导治疗（6例接受5-氟胞嘧啶[5-FC]，中位治疗时间为2周）;包括唑类根除治疗在内的中位治疗持续时间为41周，78%的患者完全/部分临床缓解。对于神经系统疾病，88%的患者接受AMB，78%的患者接受5-FC，中位治疗时间为6周。中位总疗程为18个月。9例接受氟康唑诱导治疗的患者因临床失败而再次接受AMB加5-FC诱导治疗。ICP升高（31例患者）与最初的神经学异常、神经学后遗症和/或12个月时的死亡相关（均P = .02）; 58%的患者和64%的22例脑积水患者放置了脑脊液引流/分流管。8例患者在开始抗真菌治疗后2-12个月发生IRIS，这些患者表现为新发/扩大的脑病变。危险因素包括女性、发病时脑部受累和较高的中位CD 4计数（均P <0.05）;皮质类固醇减少隐球菌相关水肿。诱导AMB +5-FC适用于C。Gattii神经性隐球菌病（6周）和局限于肺时（2周）。通常需要分流术来控制升高的ICP。IRIS表现为脑部表现。
Background. We describe antifungal therapy and management of complications due to Cryptococcus gattii infection in 86 Australian patients followed for at least 12 months.Methods. Patient data from culture-confirmed cases (2000-2007) were recorded at diagnosis, 6 weeks, 6 months, and 12 months. Clinical, laboratory, and treatment variables associated with raised intracranial pressure (ICP) and immune reconstitution inflammatory syndrome (IRIS) were determined.Results. Seven of 10 patients with lung infection received amphotericin B (AMB) induction therapy (6 with 5-flucytosine [5-FC] for a median of 2 weeks); median duration of therapy including azole eradication therapy was 41 weeks, with a complete/partial clinical response in 78%. For neurologic disease, 88% of patients received AMB, 78% with 5-FC, for a median of 6 weeks. The median total course was 18 months. Nine patients receiving fluconazole induction therapy were reinduced with AMB plus 5-FC for clinical failure. Raised ICP (31 patients) was associated with initial abnormal neurology, and neurologic sequelae and/or death at 12 months (both P = .02); cerebrospinal fluid drains/shunts were placed in 58% of patients and in 64% of 22 patients with hydrocephalus. IRIS developed 2-12 months after starting antifungals in 8 patients, who presented with new/enlarging brain lesions. Risk factors included female sex, brain involvement at presentation, and higher median CD4 counts (all P < .05); corticosteroids reduced cryptococcoma-associated edema.Conclusions. Induction AMB plus 5-FC is indicated for C. gattii neurologic cryptococcosis (6 weeks) and when localized to lung (2 weeks). Shunting was often required to control raised ICP. IRIS presents with cerebral manifestations.