scholarly journals High burden of cryptococcal antigenemia and meningitis among patients presenting at an emergency department in Maputo, Mozambique

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0250195
Author(s):  
Robert Deiss ◽  
Carolina V. Loreti ◽  
Ana G. Gutierrez ◽  
Eudoxia Filipe ◽  
Milton Tatia ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cryptococcal Meningitis ◽  
Screening Program ◽  
Point Of Care ◽  
Rapid Assessment ◽  
Vital Signs ◽  
Cd4 Count ◽  
Sub Saharan Africa ◽  
Induction Treatment ◽  
Cryptococcal Antigen

Background Cryptococcal meningitis is a leading cause of HIV-related mortality in sub-Saharan Africa, however, screening for cryptococcal antigenemia has not been universally implemented. As a result, data concerning cryptococcal meningitis and antigenemia are sparse, and in Mozambique, the prevalence of both are unknown. Methods We performed a retrospective analysis of routinely collected data from a point-of-care cryptococcal antigen screening program at a public hospital in Maputo, Mozambique. HIV-positive patients admitted to the emergency department underwent CD4 count testing; those with pre-defined abnormal vital signs or CD4 count ≤ 200 cells/μL received cryptococcal antigen testing and lumbar punctures if indicated. Patients with CM were admitted to the hospital and treated with liposomal amphotericin B and flucytosine; their 12-week outcomes were ascertained through review of medical records or telephone contact by program staff made in the routine course of service delivery. Results Among 1,795 patients screened for cryptococcal antigenemia between March 2018—March 2019, 134 (7.5%) were positive. Of patients with cryptococcal antigenemia, 96 (71.6%) were diagnosed with CM, representing 5.4% of all screened patients. Treatment outcomes were available for 87 CM patients: 24 patients (27.6%) died during induction treatment and 63 (72.4%) survived until discharge; of these, 38 (60.3%) remained in care, 9 (14.3%) died, and 16 (25.3%) were lost-to follow-up at 12 weeks. Conclusions We found a high prevalence of cryptococcal antigenemia and meningitis among patients screened at an emergency department in Maputo, Mozambique. High mortality during and after induction therapy demonstrate missed opportunities for earlier detection of cryptococcal antigenemia, even as point-of-care screening and rapid assessment in an emergency room offer potential to improve outcomes.

scholarly journals Evaluation of a Novel Point-of-Care Cryptococcal Antigen Test on Serum, Plasma, and Urine From Patients With HIV-Associated Cryptococcal Meningitis

2011 ◽  
Vol 53 (10) ◽  
pp. 1019-1023 ◽  
Author(s):  
J. N. Jarvis ◽  
A. Percival ◽  
S. Bauman ◽  
J. Pelfrey ◽  
G. Meintjes ◽  
...  
Keyword(s):  
Cryptococcal Meningitis ◽  
Point Of Care ◽  
Antigen Test ◽  
Cryptococcal Antigen

scholarly journals Short-Course Induction Treatment with Intrathecal Amphotericin B Lipid Emulsion for HIV Infected Patients with Cryptococcal Meningitis

2015 ◽  
Vol 2015 ◽  
pp. 1-6 ◽  
Author(s):  
Gerardo Alvarez-Uria ◽  
Manoranjan Midde ◽  
Raghavakalyan Pakam ◽  
Pradeep Sukumar Yalla ◽  
Praveen Kumar Naik ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Risk Reduction ◽  
Amphotericin B ◽  
Cryptococcal Meningitis ◽  
Lipid Emulsion ◽  
Absolute Risk ◽  
White Blood Cells ◽  
Sub Saharan Africa ◽  
Induction Treatment ◽  
Short Course

Cryptococcal meningitis (CM) is a common cause of death among HIV infected patients in developing countries, especially in sub-Saharan Africa. In this observational HIV cohort study in a resource-limited setting in India, we compared the standard two-week intravenous amphotericin B deoxycholate (AmBd) (Regimen I) with one week of intravenous AmBd along with daily therapeutic lumbar punctures and intrathecal AmB lipid emulsion (Regimen II) during the intensive phase of CM treatment. 78 patients received Regimen I and 45 patients received Regimen II. After adjustment for baseline characteristics (gender, age, altered mental status or seizures at presentation, CD4 cell count, white blood cells, cerebrospinal fluid white cells, and haemoglobin), the use of Regimen II was associated with a significant relative risk reduction in mortality (adjusted hazard ratio 0.4, 95% confidence interval, 0.22–0.76) and 26.7% absolute risk reduction (95% confidence interval, 9.9–43.5) at 12 weeks. The use of Regimen II resulted in lower costs of drugs and hospital admission days. Since the study is observational in nature, we should be cautious about our results. However, the good tolerability of intrathecal administration of AmB lipid emulsion and the clinically important mortality reduction observed with the short-course induction treatment warrant further research, ideally through a randomized clinical trial.

Evaluation of a rapid point-of-care HIV screening program in an emergency department setting in Detroit, Michigan

2018 ◽  
Vol 106 ◽  
pp. 11-12 ◽  
Author(s):  
Weiming Zhu ◽  
Kimberly Mumby ◽  
Doreen Dankerlui ◽  
Jake Manteuffel ◽  
Cal Ham ◽  
...  
Keyword(s):  
Emergency Department ◽  
Screening Program ◽  
Point Of Care ◽  
Hiv Screening ◽  
Emergency Department Setting

scholarly journals Point-of-Care Diagnosis and Prognostication of Cryptococcal Meningitis With the Cryptococcal Antigen Lateral Flow Assay on Cerebrospinal Fluid

2013 ◽  
Vol 58 (1) ◽  
pp. 113-116 ◽  
Author(s):  
Taseera Kabanda ◽  
Mark J. Siedner ◽  
Jeffrey D. Klausner ◽  
Conrad Muzoora ◽  
David R. Boulware
Keyword(s):  
Cerebrospinal Fluid ◽  
Cryptococcal Meningitis ◽  
Point Of Care ◽  
Lateral Flow ◽  
Lateral Flow Assay ◽  
Cryptococcal Antigen

scholarly journals Diagnosis of Cryptococcosis and Prevention of Cryptococcal Meningitis Using a Novel Point-of-Care Lateral Flow Assay

2013 ◽  
Vol 2013 ◽  
pp. 1-4 ◽  
Author(s):  
Ashar Dhana
Keyword(s):  
Cryptococcal Meningitis ◽  
Point Of Care ◽  
World Health Organisation ◽  
Lateral Flow ◽  
Sub Saharan Africa ◽  
World Health ◽  
First Case ◽  
Lateral Flow Dipstick ◽  
Life Threatening ◽  
Sub Saharan

Despite access to antiretroviral therapy, mortality from cryptococcal meningitis (CM) is high among persons with advanced HIV infection in sub-Saharan Africa. Cryptococcal antigen (CrAg) is present several weeks to months before the onset of symptoms of meningitis and can be screened to prevent life threatening meningitis. Recently, the World Health Organisation recommended that a new rapid CrAg lateral flow ‘‘dipstick’’ assay (LFA) is to be used to screen HIV-infected persons with CD4 counts of less than 100 cells/µL. In this paper, we describe two cases of cryptococcosis with differing outcomes. In the first case, the new CrAg LFA was used as part of a screen and preemptive treatment strategy to prevent CM. In the second case, our patient had no access to the CrAg LFA and subsequently developed life threatening meningitis. To the best of our knowledge, this is the first case report of cryptococcosis diagnosed using this novel assay.

scholarly journals Magnitude of Cryptococcal Antigenemia among HIV Infected Patients at a Referral Hospital, Northwest Ethiopia

1970 ◽  
Vol 28 (4) ◽  
Author(s):  
Awoke Derbie ◽  
Workneh Ayalew ◽  
Daniel Mekonnen ◽  
Megbaru Alemu ◽  
Yihun Mulugeta
Keyword(s):  
Fungal Infections ◽  
Statistical Significance ◽  
Stage Iv ◽  
Northwest Ethiopia ◽  
Cd4 Count ◽  
Referral Hospital ◽  
Sub Saharan Africa ◽  
Health Concern ◽  
P Value ◽  
Cryptococcal Antigen

BACKGROUND: Cryptococcosis is one of the common opportunistic fungal infections among HIV infected patients living in Sub-Saharan Africa, including Ethiopia. The magnitude of thedisease at Felege Hiwot Referral Hospital (FHRH) in particular and in Ethiopia at large is not well explored.METHODS: A retrospective document review and analysis was done on records of 137 HIV infected patients who visited FHRH ART clinic from 1 Sep to 30 Dec 2016 and had registered data on their sex, age, CD4 count and cryptococcal antigen screening result. The cryptoccocal antigen (CrAg) detection was done by the IMMY CrAg® LFA (Cryptococcal Antigen Lateral Flow Assay) kit from patient serum as per the manufacturer’s instruction. All data were entered, cleared, and analyzed using SPSS v20. Descriptive data analysis and cross tabulation were done to assess factors associated with cryptococcal antigenemia. Statistical significance was set at p-value less than or equal to 0.05.RESULTS: More than half of the participants, 54.7% (75/137), included in the study were females. The median age of the participants was 32.0 years (ranged: 8-52 years). The mean CD4 count was 51.8 with SD of 26.3 (range 3-98). All the patients were HIV stage IV. The proportion of positive cryptococal antigen from serum test was at 11.7% (95% CI: 7.3-18.1%). The IMMYCrAg® LFA result was found statically associated with patient sex (p= 0.045). However, it was not associated with patient age group and the CD4 count (P>0.05)CONCLUSIONS: This study provided baseline data on the magnitude of cryptococcal antigenemia among HIV positive patients that is not touched before in the studied area. The results of the study showed that this opportunistic fungal infection is an important health concern among HIV patients. Further studies with sound design employing adequate sample size should be considered. 

Fulminant diffuse cerebral toxoplasmosis as the first manifestation of HIV infection

2021 ◽  
Vol 14 (1) ◽  
pp. e237120
Author(s):  
Louise Dunphy ◽  
Bret Palmer ◽  
Fabian Chen ◽  
Joanne Kitchen
Keyword(s):  
Emergency Department ◽  
Antiretroviral Therapy ◽  
Hiv Infection ◽  
Cd4 Count ◽  
Sub Saharan Africa ◽  
Cerebral Toxoplasmosis ◽  
Hiv Test ◽  
Ct Head ◽  
Tenofovir Alafenamide ◽  
Multiple Ring

Individuals with HIV may present to the emergency department with HIV-related or HIV-unrelated conditions, toxicity associated with antiretroviral therapy or primary HIV infection (seroconversion). In individuals with HIV infection, central nervous system toxoplasmosis occurs from reactivation of disease, especially when the CD4+ count is <100 cells/μL, whereas in those taking immunosuppressive therapy, this can be either due to newly acquired or reactivated latent infection. It is a rare occurrence in immune-competent patients. Vertical transmission during pregnancy can manifest as congenital toxoplasmosis in the neonate and is often asymptomatic until the second or third decade of life when ocular lesions develop. Toxoplasmosis is an infection caused by the intracellular protozoan parasite Toxoplasma gondii and causes zoonotic infection. It can cause focal or disseminated brain lesions leading to neurological deficit, coma and death. Typical radiological findings are multiple ring-enhancing lesions. Histopathological examination demonstrating tachyzoites of T. gondii and the presence of nucleic material in the spinal cerebrospinal fluid (CSF) confirms the diagnosis. The authors present the case of a 52-year-old male UK resident, born in sub-Saharan Africa, with a 3-week history of visual hallucinations. He attended the emergency department on three occasions. Laboratory investigations and a CT head were unremarkable. He was referred to psychological medicine for further evaluation. On his third presentation, 2 months later, a CT head showed widespread lesions suggestive of cerebral metastasis. Dexamethasone was initiated and he developed rigours. An MRI head showed multiple ring-enhancing lesions disseminated throughout his brain parenchyma. CSF analysis and serology confirmed the diagnosis of HIV and toxoplasmosis, respectively. His CD4 count was 10 and his viral load (VL) was 1 245 003. He was then initiated on Biktarvy 50 mg/200 mg/25 mg, one tablet daily, which contains 50 mg of bictegravir, 200 mg of emtricitabine and tenofovir alafenamide fumarate equivalent to 25 mg of tenofovir alafenamide. After 3 months of antiretroviral therapy, his HIV VL reduced to 42. However, his abbreviated mental test remained at 2/10. Despite presenting with neurocognitive impairment and being born in a HIV prevalent region, an HIV test was not offered. This case highlights missed opportunities to request HIV serology and raises awareness that cerebral toxoplasmosis can occur as the first manifestation of HIV. Prompt diagnosis and early initiation of antiretroviral therapy reduces morbidity and mortality in this patient cohort.

scholarly journals Evaluation of the Dynamiker Cryptococcal Antigen Lateral Flow Assay for the Diagnosis of HIV-Associated Cryptococcosis

2020 ◽  
Author(s):  
Richard Kwizera ◽  
Denis Omali ◽  
Kiiza Tadeo ◽  
John Kasibante ◽  
Morris K. Rutakingirwa ◽  
...  
Keyword(s):  
Predictive Value ◽  
Diagnostic Performance ◽  
Point Of Care ◽  
Lateral Flow ◽  
Lateral Flow Assay ◽  
Sub Saharan Africa ◽  
Serum Samples ◽  
Cryptococcal Antigen ◽  
Asymptomatic Patients ◽  
Sub Saharan

Background: Cryptococcal meningitis is a leading cause of meningitis in sub-Saharan Africa. Given the need for rapid point of care testing, we evaluated the diagnostic performance of the Dynamiker cryptococcal antigen (CrAg) lateral flow assay (LFA). Methods: We assessed the diagnostic performance of the Dynamiker CrAg-LFA compared to the IMMY CrAg-LFA as the reference standard. We tested 150 serum, 115 plasma, 100 cerebrospinal fluid (CSF) samples from HIV patients with symptomatic meningitis and 113 serum samples from patients with suspected asymptomatic cryptococcal antigenemia. Results: Compared to the IMMY CrAg-LFA, sensitivity of Dynamiker CrAg-LFA was 98% in serum, 100% in plasma, 100% in CSF from symptomatic patients and 96% in serum from asymptomatic patients. Specificity was 66% in serum, 61% in plasma, 91% in CSF from symptomatic patients, and 86% in serum from asymptomatic patients. The positive predictive value was 85% in serum, 82% in plasma, 96% in CSF from symptomatic patients, and 69% in serum from asymptomatic patients. The negative predictive value was 94% in serum, 100% in plasma, 100% in CSF from symptomatic patients, and 99% in serum from asymptomatic patients. The inter-assay reproducibility was 100% across the four sample types with no observed discordant results when Dynamiker CrAg-LFA was tested in duplicate. However, a high number of false positives were observed on serum of symptomatic patients (11%), serum of asymptomatic patients (11%) and plasma of symptomatic patients (14%). Conclusion: The Dynamiker CrAg-LFA had excellent sensitivity but poor specificity, particularly when tested on serum and plasma.

scholarly journals Can an emergency department clinical “triggers” program based on abnormal vital signs improve patient outcomes?

CJEM ◽  
2016 ◽  
Vol 19 (04) ◽  
pp. 249-255 ◽  
Author(s):  
Jason Imperato ◽  
Tyler Mehegan ◽  
Daniel J. Henning ◽  
John Patrick ◽  
Chase Bushey ◽  
...  
Keyword(s):  
Emergency Department ◽  
Inpatient Care ◽  
Rapid Assessment ◽  
Vital Signs ◽  
Special Care ◽  
Special Care Unit ◽  
Post Intervention ◽  
Care Level ◽  
Inpatient Outcomes ◽  
Improve Patient

AbstractBackgroundBecause abnormal vital signs indicate the potential for clinical deterioration, it is logical to make emergency physicians immediately aware of those patients who present with abnormal vital signs.ObjectivesTo determine if a clinical triggers program in the emergency department (ED) setting that utilized predetermined abnormal vital signs to activate a rapid assessment by an emergency physician-led multidisciplinary team had a measurable effect on inpatient hospital metrics.MethodsThe study design was a retrospective pre and post intervention study. The intervention was the implementation of an ED clinical “triggers” program. Abnormal vital sign criteria that warranted a trigger response included: heart rate &lt;40 beats/minute or&gt;130 beats/minutes, respiratory rate &lt;8 breaths/minute or&gt;30 breaths/minute, systolic blood pressure &lt;90 mm Hg, or oxygen saturation &lt;90% on room air. The primary outcome investigated was the median days admitted with secondary outcomes of median days in special care unit, in-hospital 30-day mortality and proportion of patients who required an upgrade in inpatient care level.ResultsThere was no difference in median days admitted for inpatient care (3.8 v. 4.0 days,p=0.21) or median days spent in a special care unit (5.0 v. 5.6 days,p=0.42) between the groups. There was no difference in the percentage of in-hospital patient deaths (6.0% v. 5.6%,p=0.66) or frequency of upgrade in level of care within 24 hours (4.9% v. 4.0%,p=0.52).ConclusionsIn our study, the implementation of an ED clinical triggers program did not result in a significant change in measured inpatient outcomes.

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