IMPACTO DA CRIPTOCOCOSE NA RECUPERAÇÃO IMUNOLÓGICA EM PACIENTES COM AIDS E IMUNOSSUPRESSÃO GRAVE

Abstract

Cryptococcosis is an opportunistic systemic mycosis in AIDS, it has high lethality and occurs in immunosuppressed conditions, including HIV/AIDS. The immune recovery obtained with highly active antiviral therapy (HAART) is the most effective way to control opportunistic infections in AIDS. Based on observation in clinical practice and considering some evidences that Cryptococcus spp accelerates the replication of the HIV in vitro, we hypothesized that cryptococcosis delays or prevents the immune recovery of AIDS patients with severe immunosuppression. The aim of this study was to analyze whether there is an association between the presence of cryptococcosis and the immune recovery of patients with AIDS and severe immunosuppression in a follow-up of up to 5 years. Participants were selected from a population of 230 consecutive AIDS patients with a CD4+ count ≤ 200 cells/mm3 who underwent systematic investigation of cryptococcosis. Those who were followed up for more than 100 days were eligible for this paired cohort study. Thus, the group exposed to cryptococcosis consisted of 21 patients, and an unexposed group was randomly selected and matched by CD4+ cell range, in a ratio of 3 unexposed to 1 exposed, with 67 participants. The immune recovery outcome was defined as a CD4+ count of 350 cells or more. The statistical analyzes used were the chi2 or Fisher's exact test to compare categorical variables and the Mann Whitney U test for continuous variables. Multivariate logistic regression analysis was used to assess variables independently associated with immune recovery. The Kaplan Meier curve, analyzed by Log Rank, was used for immune recovery time. A p value < 0.05 was considered significant and from 0.05 to 0.10 as trend. Both groups had similar baseline characteristics, except that those exposed to cryptococcosis had a lower proportion of neurotoxoplasmosis. A trend towards a lower immune recovery rate was observed in the cryptococcosis group (19.0% vs 38.8%, p=0.096). The other outcomes studied, such as final/initial CD4+ ratio, difference between final and initial CD4+ and time to achieve immune recovery did not differ between groups. In the multivariate analysis, it was possible to observe that age lower than 40 years, undetectable HIV viral load at follow-up and longer follow-up were variables independently associated with immune recovery. Patients with cryptococcosis had 3.61 (95% Confidence Interval 0.90-14.53; p=0.071) folds more chance of failure in immune recovery than patients without cryptococosis, still tending to statistical significance. The results found point to the possibility that cryptococcosis is a factor associated with lower rates of immune recovery in AIDS and severe immunosuppression, which can be elucidated with studies involving a greater number of patients.