A Study On Cryptococcosis Or Penicilliosis Marneffei Among Patients With Acquired Immunodeficiency Syndrome

Part Ⅰ The diagnosis, treatment and prognosis analysis of cryptococcosis in patients with AIDSObjective To study the diagnosis, treatment and prognosis of cryptococcosis in patients with AIDS, and analyze the risk factors for mortality of the patients, including the factor of genotyping.Methods Collected the medical history data of the cryptococcosis patients with AIDS from September 2006 to August 2014, and followed-up the patients. Analyzed the risk factors of mortality and the relation between MLST of Cryptococcus neoformans and the prognosis of cryptococcosis patients.Results From 2006 to 2014, there were 1178 patients with AIDS admitted Zhongnan Hospital of Wuhan University, of whom,58 patients were diagnosed with cryptococcosis by ink stain or/and the fungus culture of blood, bone marrow and cerebrospinal fluid. The cryptococcosis patients accounted for 4.9%(58/1178) of the AIDS patients. The median of CD4+ T lymphocytes of cryptococcosis patients was 11cells/ul (range:1-136/ul),89.7%(52/58) of them CD4+ T lymphocytes was less than 50 cells/ul, only 3 patients were with neutropenia. Thirty-four(58.6%,34/58) cryptococcosis patients were the newly diagnosed with HIV infection in hospital; forty-three cryptococcosis patients (74.1%,43/58) had not received cART before the opportunistic infections. Among 58 cryptococcosis patients,21 patients died within 12 weeks, the mortality was 36.2%(21/58), and the multi-factor logistic regression analysis showed that the absence of cART (OR 9.293,95% CI:1.162-74.311, P=0.036), disturbance of consciousness (OR 17.717,95% CI:2.834-110.765, P=0.002), Cr> 100 umol/L (OR 26.791,95% CI:1.789-401.208, P=0.017) independently predicted the early mortality of the patients. We collected 27 strains Cryptococcus Neoformans from 27 cryptococcosis patients, and the sequence type of most strains was ST-5 (85.2%,23/27), the others as follow, ST-31(7.4%,2/27), ST-53(3.7%,1/27), ST-175(3.7%,1/27); we found the survival rate of patients who were infected with ST-5 stains was higher than that of ST-31 (P= 0.027) by the Log Rank (Mantel-Cox) test.Conclusion The incidence of cryptococcosis was high in AIDS patients in this region, most patients were with CD4+ T lymphocyte cells less than 50cells/ul but without neutropenia; the CD4+ T lymphocyte cells of most patients were less than 50cells/ul, but without neutropenia, it showed that low CD4+ T lymphocyte cells were the main host risk factors for AIDS patients infected with Cryptococcus.The primary cause of death was cryptococcosis, the multi-factor logistic regression analysis showed that the absence of c ART, disturbance of consciousness, Cr> 100 umol/L independently predicted the early mortality of the patients. It suggested that the prognosis of the patients who admitted with disturbance of consciousness and impairment of renal function was poor. The CD4+ T lymphocytes of all deaths were less than 50 cells/ul, the prognosis of cryptococcosis patients was associated with levels of theirs CD4+T lymphocytes. As early diagnosed cryptococcosis/AIDS and treated them with standardized antifungal therapy and combined antiretroviral therapy played an important role to improve their prognosis. Cerebrospinal fluid cryptococcal antigen detection was a sensitive and rapid method for diagnosis of cryptococcosis. The sequence type of most Cryptococcus Neoformans was ST-5 (85.2%,23/27) in our hospital, and the survival rate of patients who were infected with ST-5 stains was higher than that of ST-31.Part Ⅱ A clinical study of AIDS-associated Penicilliosis marneffeiObjective To investigate the clinical characteristics, diagnosis, treatment and prognosis of penicilliosis among the patients with acquired immunodeficiency syndrome (AIDS) in non-endemic areas of China, and analyze the interval from patients leaving endemic areas to onset of penicilliosis and whether P.Marneffei was communicated by contacting with penicilliosis patients.Methods Collected the medical records and travel history of penicilliosis patients in Zhongnan Hospital of Wuhan University from September 2006 to August 2014, and followed-up the patients. Analyzed the risk factors of mortality and the interval from the patients left the endemic area to the onset of the disease. Detected serum Mplp antigen and antibody from the people who contacting with penicilliosis patients by ELISA.Results A total of 57 AIDS-associated penicilliosis were confirmed by fungal culture, which accounted for 4.8% of 1178 AIDS-related admissions. Most of the penicilliosis patients presented with respiratory symptoms,59.6%(33/57) of patients had cough, sputum production, and dyspnea; 85.2%(46/54) of patients had abnormal chest CT characteristics; the high positive rate of P. marneffei from sputum (14/20) and BAL (9/10) cultures. The median of CD4+ T lymphocytes of cryptococcosis patients was 8 cells/ul,93.0%(53/57) of them CD4+ T lymphocytes was less than 50 cells/ul, no patients were with neutropenia. A delayed diagnosis (OR 1.023,95%CI: 1.006-1.041, P=0.009) and without antifungal therapy (OR 17.178,95% CI:1.276-231.233,.P=0.032) were two independent predictors for the early mortality (death within 12 weeks) of the patients (21.1%,12/57). Among 14 patients who became ill after leaving endemic areas, ten patients presented the onset symptoms within 12 months (from 11 days to 360 days) after leaving the endemic areas; a patient with asymptomatic P. marneffei fungemia had not received any antifungal therapy, but without penicilliosis associated symptoms until 18 months’ follow up. This study investigated 24 health care workers,17 relatives of PSM/AIDS patients and 1 laboratory worker who had contacted with P. marneffei, all these people had no penicilliosis-related symptoms. The Mplp antigen and antibody of 41 people was negative. The Mplp antigen of the other 1 laboratory worker who had contacted with P. marneffei was negative and had never gone to endemic areas of penicilliosis before, but his Mplp antibody was positive.Conclusion The co-infection of P. Marneffei and HIV is not uncommon in the non-endemic areas of penicilliosis in China. Penicilliosis patients often have severe cellular immune dysfunction but scarcely present with agranulocytosis, it showed that low CD4+ T lymphocyte cells were the main host risk factors for AIDS patients infected with P.Marneffei. Most of the penicilliosis patients presented with respiratory symptoms, suggested that it might be acquired through inhalation from the environment. When AIDS patients were with respiratory symptoms and signs, the PSM must be included in the differential diagnosis. The incubation period of penicillosis may be quite different from one patients to another, and there do exist the latent form of infection for P.Marneffei. As early diagnosed penicilliosis/AIDS and treated them with standardized antifungal therapy and combined antiretroviral therapy played an important role to improve their prognosis. PSM is systemic disseminated fungal disease, it often causes serious infection. The one cause of PSM patients’ death was that PSM was not diagnosed in time, improved the medical staff for the diagnosis of PSM in non-endemic area and developed a rapid specific serum diagnostic methods may play an important role for early diagnosis and treatment of PSM and improvement of patients’prognosis. No people who contacting with penicilliosis patients was infected with PM, but a laboratory staff who contacting with P.Marneffei was infected with PM (Mp1p antibody positive, but without any sign and symptom).Part Ⅲ The evaluation of serum specific and non-specific antigen diagnosis method for cryptococcosis or penicilliosis marneffei in AIDS patientsObjective Fungal culture need more time and the sensitivity of morphological microscopy is low, so these methods are not suitable for early diagnosis. To study the diagnosis value of serum cryptococcal antigen, Penicillium marneffei Mplp antigen and antibody, GM test and G test for cryptococcosis or penicilliosis in AIDS patients.Methods Collected the serum samples of cryptococcosis patients, penicilliosis patients and fever patients in Zhongnan Hospital of Wuhan University in recent years. The serum samples were determined by cryptococcal antigen latex agglutination, Mplp antigen and antibody enzyme-linked immunoassay, GM test and G test, and compared the sensitivity and specificity of all kinds of method for diagnosis of cryptococcosis or penicilliosis in AIDS patients.Results In patients with AIDS, the sensitivity and specificity of serum cryptococcal antigen detection for diagnosis of cryptococcosis were 100.0% and 96.2%, respectively; the serum Mplp antigen and antibody of cryptococcosis patients were all negative; only 4 cryptococcosis patients were with positive serum GM antigen; the sensitivity of serum G test for diagnosis of cryptococcosis were 45.0%. The sensitivity and specificity of serum Mplp antigen detection for diagnosis of penicilliosis were 94.4% and 98.5%, respectively; the sensitivity and specificity of serum Mplp antibody detection for diagnosis of penicilliosis were 25.0% and 98.5%, respectively; only 1 penicilliosis patient was with positive serum cryptococcal antigen; the sensitivity and specificity of serum GM antigen detection for diagnosis of penicilliosis were 95.8% and 91.7%, respectively; the sensitivity of serum G test for diagnosis of penicilliosis was 23.8%.Conclusion Among AIDS patients, the sensitivity and specificity of cryptococcal antigen test for diagnosis of cryptococcosis/AIDS was high; serum GM antigen, Mplp antigen and antibody test and G test should not be used for the clinical diagnosis of cryptococcosis. The sensitivity and specificity of serum Mplp antigen detection was high, it was expected to become early diagnosis of rapid serological methods for the diagnosis of penicilliosis; but the sensitivity of serum Mplp antibody detection for diagnosis of penicilliosis was low, it was not suitable for the diagnosis of penicilliosis. In the current lack of commercial kit for diagnosis of penicilliosis, serum GM antigen detection had certain reference value to the diagnosis of penicilliosis. Serum cryptococcal antigen test and G test were not suitable for the diagnosis of penicilliosis.