Prevalence of cryptococcal antigenuria at initial HIV diagnosis in KwaZulu-Natal.

OBJECTIVES: The World Health Organization (WHO) recommends screening HIV-infected people for cryptococcal antigens to identify cryptococcosis, a major cause of AIDS-related deaths. As the burden of cryptococcosis is unknown in South Africa's KwaZulu-Natal province, we assessed the cryptococcal antigenuria prevalence among newly diagnosed HIV-infected adults there. METHODS: We conducted a cross-sectional study of newly diagnosed HIV-infected adults who received voluntary HIV testing in an out-patient clinic. Participants provided a urine specimen in a sterile container, and we performed testing with a WHO-endorsed rapid cryptococcal antigen lateral flow assay (Immy Inc., Norman, OK, USA) per the manufacturer's specifications. We assessed cryptococcal antigenuria prevalence among participants with CD4 counts < 200 cells/µL, and stratified results by CD4 count categories. RESULTS: Among 432 participants, the mean (± standard deviation) age was 36.1 ± 9.9 years and 172 (40%) were female. The overall estimated prevalence of cryptococcal antigenuria was 9.0% [95% confidence interval (CI) 6.5-12.1%]. CD4 counts were available for 319 participants (74%); the median CD4 count was 75 cells/µL [interquartile range (IQR) 34-129 cells/µL]. Participants with a negative cryptococcal antigenuria screening test had a median CD4 count of 79 cells/µL (IQR 36-129 cells/µL), while participants with a positive cryptococcal test had a median CD4 count of 41 cells/µL (IQR 10-112 cells/µL). The estimated prevalence of cryptococcal antigenuria among participants with CD4 counts < 50 cells/µL was 12.5% (95% CI 7.0-20.1%), which was significantly higher than that among participants with CD4 counts of 50-200 cells/µL (4.8%; 95% CI 2.3-8.7%). CONCLUSIONS: Nearly 1 in 10 newly diagnosed HIV-infected adults with CD4 counts < 200 cells/µL in KwaZulu-Natal had evidence of cryptococcal antigenuria. Point-of-care CD4 count testing and cryptococcal antigen screening may rapidly identify cryptococcosis at the time of HIV diagnosis.

Evaluation of a new cryptococcal antigen lateral flow immunoassay in serum, cerebrospinal fluid and urine for the diagnosis of cryptococcosis: a meta-analysis and systematic review.

BACKGROUND: A new lateral flow immunoassay (LFA) for the detection of cryptococcal antigen was developed. OBJECTIVE: We aimed to systematically review all relevant studies to evaluate the diagnostic accuracy of the cryptococcal antigen LFA on serum, CSF and urine specimens. METHODS: We searched public databases including PubMed, Web of Science, Elsevier Science Direct and Cochrane Library for the English-language literature published up to September 2014. We conducted meta-analyses of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratios (DOR) and SROC of LFA in serum and CSF, respectively. The sensitivity of LFA in urine was also analyzed. Subgroup analyses were carried out to analyze the potential heterogeneity. RESULTS: 12 studies were included in this study. The pooled sensitivity and specificity values of LFA in serum were 97.6% (95% CI, 95.6% to 98.9%) and 98.1% (95% CI, 97.4% to 98.6%), respectively. The average PLR of LFA in serum was 43.787 (95% CI, 22.60-84.81) and the NLR was 0.03 (95% CI, 0.01-0.09). The pooled DOR was 2180.30 (95% CI, 868.92-5471.00) and the AUC was 0.9968. The pooled sensitivity and specificity values of LFA in CSF were 98.9% (95% CI, 97.9% to 99.5%) and 98.9% (95% CI, 98.0% to 99.5%), respectively. The average PLR of LFA in serum was 48.83 (95% CI, 21.59-110.40) and the NLR was 0.02 (95% CI, 0.01-0.04). The pooled DOR was 2931.10 (95% CI, 1149.20-7475.90) and the AUC was 0.9974. The pooled sensitivity value of LFA in urine was 85.0% (95% CI, 78.7% to 90.1%). CONCLUSIONS: The study demonstrates a very high accuracy of LFA in serum and CSF for the diagnosis of cryptococcosis in patients at risk. LFA in urine can be a promising sample screening tool for early diagnosis of cryptococcosis.

Point-of-care lateral flow assays for tuberculosis and cryptococcal antigenuria predict death in HIV infected adults in Uganda.

BACKGROUND: Mortality in hospitalized, febrile patients in Sub-Saharan Africa is high due to HIV-infected, severely immunosuppressed patients with opportunistic co-infection, particularly disseminated tuberculosis (TB) and cryptococcal disease. We sought to determine if a positive lateral flow assay (LFA) result for urine lipoarabinomannan (LAM) and cryptococcal antigenuria was associated with mortality. METHODS: 351 hospitalized, HIV-positive adults with symptoms consistent with TB and who were able to provide both urine and sputum specimens were prospectively enrolled at Mulago National Referral Hospital in Uganda as part of a prospective accuracy evaluation of the lateral flow Determine TB LAM test. Stored frozen urine was retrospectively tested for cryptococcal antigen (CRAG) using the LFA. We fitted a multinomial logistic regression model to analyze factors associated with death within 2 months after initial presentation. RESULTS: The median CD4 of the participants was 57 (IQR: 14-179) cells/µl and 41% (145) were microbiologically confirmed TB cases. LAM LFA was positive in 38% (134), 7% (25) were CRAG positive, and 43% (151) were positive for either test in urine. Overall, 21% (75) died within the first 2 months, and a total of 32% (114) were confirmed dead by 6 months. At 2 months, 30% of LAM or CRAG positive patients were confirmed dead compared to 15.0% of those who were negative. In an adjusted model, LAM or CRAG positive results were associated with an increased risk of death (RRR 2.29, 95% CI: 1.29, 4.05; P = 0.005). CONCLUSIONS: In hospitalized HIV-infected patients, LAM or CRAG LFA positivity was associated with subsequent death within 2 months. Further studies are warranted to examine the impact of POC diagnostic 'test and treat' approach on patient-centered outcomes.

Evaluation of a newly developed lateral flow immunoassay for the diagnosis of cryptococcosis.

BACKGROUND: Cryptococcosis is a common opportunistic infection of human immunodeficiency virus (HIV)-infected individuals mostly occurring in resource-limited countries. This study compares the performance of a recently developed lateral flow immunoassay (LFA) to blood culture and enzyme immunoassay (EIA) for the diagnosis of cryptococcosis. METHODS: Archived sera from 704 HIV-infected patients hospitalized for acute respiratory illness in Thailand were tested for cryptococcal antigenemia using EIA. All EIA-positive and a subset of EIA-negative sera were tested by LFA, with results recorded after 5 and 15 minutes incubation. Urine from patients with LFA- and EIA-positive sera was tested by LFA. Antigen results from patients with positive cryptococcal blood cultures were compared. RESULTS: Of 704 sera, 92 (13%) were positive by EIA; among the 91 EIA-positive sera tested by LFA, 82 (90%) and 87 (96%) were LFA positive when read after 5 and 15 minutes, respectively. Kappa agreement of EIA and LFA for sera was 0.923 after 5 minutes and 0.959 after 15 minutes, respectively. Two of 373 EIA-negative sera were LFA positive at both time points. Of 74 urine specimens from EIA-positive patients, 52 (70.3%) were LFA positive. EIA was positive in 16 of 17 sera from blood culture-positive patients (94% sensitivity), and all sera were positive by LFA (100% sensitivity). CONCLUSIONS: A high level of agreement was shown between LFA and EIA testing of serum. The LFA is a rapid, easy-to-perform assay that does not require refrigeration, demonstrating its potential usefulness as a point-of-care assay for diagnosis of cryptococcosis in resource-limited countries.

Detection of Cryptococcus by conventional, serological and molecular methods.

The rising incidence of cryptococcosis in India is posing a serious threat. Due to lack of sensitive methods for diagnosis, high morbidity and mortality are associated with the disease. Early diagnosis is essential to prevent serious complications. Therefore, we attempted to find highly sensitive and specific detection methods. A comparative evaluation of the detection of cryptococcosis was done by conventional (direct microscopy and culture) and rapid diagnostic [latex agglutination test (LAT), enzyme immunoassay (EIA) and PCR] methods. The study was done on 359 samples from 52 positive patients and 30 negative controls in an Indian set-up. Evaluation was done for cerebrospinal fluid (CSF), serum and urine separately. The diagnostic value of the tests was assessed in pre-treatment samples, and follow-up tests were also done on samples obtained after initiation of treatment. PCR had the highest sensitivity, followed by EIA and LAT, both before and after treatment. The positive detection by LAT, EIA and PCR was the longest in CSF (>90 days), followed by serum ( approximately 65 days) then urine ( approximately 45 days) after initiation of treatment. Our results indicated that the sensitivity and specificity of PCR and EIA were comparable in urine, CSF and serum for diagnosis of cryptococcosis.

Cryptococcus arboriformis Sp. Nov., a novel anamorphic basidiomycetous yeast species isolated from a patient's urine.

A basidiomycetous yeast strain isolated from the urine of a 73-year-old Japanese patient with chronic renal failure was revealed to be a novel species by sequencing the D1/D2 26S rDNA and ITS regions of the rRNA gene. The name Cryptococcus arboriformis sp. nov. is proposed for the isolate, with IFM 54862(T) (=CBS 1044(T) =JCM 14201(T)) as the type strain. A phylogenetic analysis positioned Cryptococcus arboriformis in the Trichosporonales lineage and showed that it is closely related to C. haglerorum.

[Importance of culture of urine in the diagnosis of AIDS associated cryptococcosis]. / Criptococose associada à Aids: a importância do cultivo da urina no seu diagnóstico.

In this retrospective study we analyzed 70 HIV patients with cryptococcosis over a 16-years period. The specimens with the best positivity were CSF (97.8%) followed by the culture of urine sediment (86.7%) and blood culture (58.8%). We conclude that the urine could be a useful tool for the diagnosis of cryptococcosis.

Criptococose associada à Aids: a importância do cultivo da urina no seu diagnóstico / Importance of culture of urine in the diagnosis of AIDS associated cryptococcosis

Neste estudo retrospectivo analisamos 70 pacientes HIV positivos com criptococose em um período de 16 anos. Os espécimes com melhor rendimento diagnóstico foram o LCR (97,8 por cento), seguido do cultivo do sedimento urinário (86,7 por cento) e sangue (58,8 por cento). Concluímos que a urina pode ser uma ferramenta útil para o diagnostico da criptococose.

Cryptococcuria as a manifestation of disseminated cryptococcosis and isolated urinary tract infection.

Fungal infection of the genitourinary system is a relatively uncommon presentation. Cryptococcuria has rarely been recognized in clinical practice. Patients with positive urine culture for Cryptococcus neoformans from 1992 to 2003 were retrospectively reviewed. Sixteen patients were identified. Nine (56%) patients were male, with a mean age of 44 +/- 21 (range, 16-88) years. Fifteen (94%) patients had underlying conditions such as HIV infection, diabetes mellitus, hypertension, and/or systemic lupus erythematosus. Thirteen (81%) patients had cryptococcuria as a manifestation of disseminated cryptococcosis, and the rest had only isolated cryptococcuria. Urinary analysis revealed proteinuria (75%), pyuria (31%), and budding yeast (13%). Nine (56%) patients received antifungal therapy. Other patients were misdiagnosed or died before treatment. The mortality rate was 64%. In conclusion, cryptococcuria is not extremely rare and can present as a manifestation of disseminated cryptococcosis or isolated urinary tract infection.

Use of the membrane filtration technique and Staib agar for the detection of Cryptococcus neoformans in the urine of AIDS patients--a contribution to diagnosis, therapy and pathogenesis of cryptococcosis.

For the cultural control of Cryptococcus neoformans (Cr.n.), among the routinely examined standard specimens like CSF, sputum, blood, etc., urine earns special attention. The combination of membrane filtration technique (MFT) and Staib agar for the detection of Cr.n. from body fluids as described by Staib in 1963 was used for the cultural isolation of Cr.n. from urine of AIDS patients. In 3 examplary cases the diagnostic significance of this method could be demonstrated: The brown colour effect (BCE) of Cr.n. of a single CFU, as well as in colonies growing with a high density, was produced on average within 3-5 d/26 degrees C. The method was found to be useful for the evaluation of antimycotic therapy. One example of the survival of a few CFUs of Cr.n. under treatment with fluconazole as compared to the efficacy of therapy with amphotericin B + flucytosine, and one example of a re-emergence of Cr.n. in the urogenital tract after a too short duration of treatment with amphotericin B + flucytosine are shown. For the exclusion of the survival of single CFUs of Cr.n. in the urogenital tract of males, quantities up to 1 l of urine for the combination of MFT and Staib agar are proposed. As a secondary observation, it was found that this diagnostic combination in addition to its primary purpose, can serve to detect the metabolic end products of the human body present in urine which may influence capsule formation of Cr.n. neoformans.

Criptococosis: diagnostico por el laboratorio / Cryptococosis: laboratory diagnosis

Se informan 29 casos de criptococosis diagnosticados en el laboratorio de Micologia del Instituto Nacional de Salud, durante un periodo de 6 anos (1981-1986), lo que corresponde a 4.8 casos por ano. La entidad fue mas frecuente en hombre y en edades comprendidas entre 20 y 40 anos. En 12 pacientes se disponia de historia clinica y en todos ellos se demostro la presencia de una enfermedad o condicion de base. El cryptococcus neoformans fue observado en el examen directo en el 79% de los casos y en el 93% de los cultivos. En 14 apcientes en los cuales se practico la prueba de aglutinacion de latex, ella fue positiva en todos los liquidos cefalorraquideos, asi como en 60% de los sueros y en el 50% de las orinas. La clasificacion por serotipos de 16 aislamientos fue lograda empleando el medio CGB y ella dio como resultado 14 cepas de C. neoformansvar. neoformans y 2 cepas de C. neoformans var, gattii.

Criptococúria: relato de caso / Criptococcosis: report of a case

Um caso de criptococose disseminada, com urocultivo positivo, é relatado. Revisäo da literatura indica que o envolvimento renal é comum. A importância do exame de urina e cultivo para o Cryptococus neoformans é enfatizado

Crystalluria during flucytosine therapy.

A case of urinary crystalluria occurring in a patient during treatment with flucytosine (5-fluorocytosine) is presented. A reduction in the dosage of the 5-fluorocytosine resulted in a marked decrease in the excretion of urinary gravel which was shown to be a coprecipitate of 5-fluorocytosine and uric acid.