Osawa, Ryosuke; Alexander, Barbara D.; Lortholary, Olivier; Dromer, Francoise; Forrest, Graeme N.; Lyon, G. Marshall; Somani, Jyoti; Gupta, Krishan L.; del Busto, Ramon; Pruett, Timothy L.; Sifri, Costi D.; Limaye, Ajit P.; John, George T.; Klintmalm, Goran B.; Pursell, Kenneth; Stosor, Valentina; Morris, Michele I.; Dowdy, Lorraine A.; Munoz, Patricia; Kalil, Andre C.; Garcia-Diaz, Julia; Orloff, Susan; House, Andrew A.; Houston, Sally; Wray, Dannah; Huprikar, Shirish; Johnson, Leonard B.; Humar, Atul; Razonable, Raymund R.; Fisher, Robert A.; Husain, Shahid; Wagener, Marilyn M.; Singh, Nina
Abstract
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(2) 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.
