Cryptococcosis (CC) in the pediatric population in Gauteng, South Africa (SA): epidemiology and characteristics of 34 cases identified during population-based CC surveillance in SA, 2002-2004
Background: CC is rare among HIV-infected children, in contrast to HIV-infected adults, in developing countries. The reason for this is unclear. We present the largest case series of CC in children from a population with high HIV prevalence infection, and compare the clinical presentation and outcome with adults with CC. Methods: Active population-based surveillance for CC was conducted in Gauteng province, SA, during March 2002 to March 2004. Incident cases were defined by the first positive India ink, latex agglutination, or isolation of C. neoformans from any biologic specimen in a Gauteng resident. Medical records of cases were reviewed and demographic, clinical, HIV-related, laboratory and outcome data were collected. Characteristics of pediatric cases (8804; 16 years of age) were compared to adult cases by chi-square. Results: During the two years of surveillance, 3018 incident cases of CC were identified; 2898 had age recorded and 34 (1.2%) were pediatric cases (median 8.5 years, range 3 months to 16 years). Twenty (59%) cases were male and all but one case was black. HIV status was known on 24, three (12.5%) tested negative. Of the 21 HIV-infected pediatric cases, four had a CD4 count performed (all were 8804;100), and this infection was the AIDS defining illness for 65%. Overall, the 34 pediatric cases were less likely than adults to present with meningitis: 53% vs. 79% had headache, 47% vs. 70% had neck stiffness and 12% vs. 31% had altered mental status (pediatric vs. adult cases respectively, all comparisons p< 0.01). Respiratory symptoms such as cough (56% vs 34%), and shortness of breath (21% vs. 3%) were significantly more common among the pediatric vs. adult cases, respectively (p<0.01). Over 90% of pediatric and adults cases had lumbar punctures, but pediatric cases were significantly less likely to have a positive result on the India ink stain of the cerebral spinal fluid (87% and 97%, p<0.01). Pediatric cases were more likely than adults to have a blood culture obtained compared to adult cases (47% vs. 17%, respectively) but were as likely to have C. neoformans recovered. Most pediatric and adult cases received antifungal medication (89% and 93% respectively, p>0.05). Mortality during hospitalization for CC among pediatric and adults cases was similar: 24% of children died compared to 29% of adults (p>0.05). Among pediatric survivors, only 74% received fluconazole at the time of discharge from the hospital, compared to 98% of adult survivors (p<0.01). Conclusions: CC among children from Gauteng, SA, an area with high HIV-prevalence, is uncommon but associated with high mortality. We found the clinical presentation to be different from that seen in adults and from previous reports among children, with a predominance of respiratory symptoms. The diagnosis and institution of appropriate treatment for CC may be delayed because of the non-classic presentation of this infection among children. Further studies are needed to assess the reasons secondary prophylaxis is not given routinely, especially among children.
Full conference title:
15th Annual Focus on Fungal Infections