A retrospective review of paediatric cryptococcosis in three academic hospitals in Johannesburg, 2002-2011

Mabena, Fikile Cynthia
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Aim: To describe the demographics, management and outcomes of children admitted with laboratory-confirmed cryptococcosis at three Johannesburg hospitals from 2002-2011. Method: Records of patients younger than 14 years of age who were diagnosed with cryptococcosis (as identified by review of the GERMS-SA surveillance) over the 10 year study period were reviewed using a structured data collection tool. The patients were managed in the Paediatric Departments at Chris Hani Baragwanath Academic Hospital (CHBAH), Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Rahima Moosa Mother and Child Hospital (RMMCH). Results: Forty-eight children under 14 years of age were included in this study. The median age was 9.6 years (Interquartile Range (IQR), 7.0 to 11.8 years), most of them (31/48, 64.6%) were boys and 27 (56.3%) were from CHBAH. Thirty-eight (79.2%) were HIV positive with very low CD4 counts (n=26; median 13 cells/mm3; IQR, 5 to 144 cells/mm3). Of the eight HIV negative patients, one had leukaemia, two were neonates and five had no known underlying predisposing condition. Children with cryptococcosis presented for care mainly with headache (60.5%), vomiting (59.5%) and fever (43.2%). Twenty-four (50.0%) had cryptococcal meningitis, 14 (29.2%) had meningitis with concomitant cryptococcaemia, and 10 (20.8%) had cryptococcaemia without meningitis. Children with cryptococcal meningitis were 7.5-fold (95% CI, 1.31 to 51.93) more likely to have been treated with amphotericin B compared to those who had fungaemia without meningitis, P=0.001. Nineteen (39.6%) patients were started on anti-tuberculosis treatment during the course of their hospitalisation with cryptococcosis. Five (41.7%) of the 12 children on fluconazole and concomitant TB treatment were on boosted fluconazole dosage regimens (i.e., >10 mg/kg/day). Twelve (31.6%) of the 38 HIV positive children with cryptococcosis were not sent home on fluconazole prophylaxis. Ten (20.8%) children died during the course of their hospital admission. Conclusion: Paediatric cryptococcosis is a rare condition. HIV infection is an important predisposing condition to cryptococcal disease. There appeared to be widespread deviation from published guidelines in terms of treating patients with fluconazole at public health facilities in Gauteng Province. Clinicians caring for children with cryptococcal disease should seek advice from infectious disease clinicians in order to optimise patient care.
A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Paediatrics Johannesburg, 2015