Mortality Predictors for Disseminated Histoplasmosis in Colombian HIV-infected Patients

Background:  In Central and South American countries mortality rates in HIV-infected patients for progressive disseminated histoplasmosis (PDH) vary from 18% to 48%. Our aim was to identify clinical and laboratory factors associated with mortality in patients with HIV and PDH. 

Methods:  Retrospective descriptive study in patients with HIV and PDH from 2002 to 2013 in a hospital in Medellin, Colombia. The diagnosis of histoplasmosis was made based on the recommendations of the EORTC/MSG. Demographic, laboratory, and clinical information was collected to identify factors associated with mortality using logistic regression.

Results: 125 HIV-infected patients with PDH were identified. 84% were males. The median age was 37 years (standard deviation [SD] 11 years) and the median CD4 count was 56 CD4 cells/µl (SD 87). 73 patients (58%) had other co-infections; of these 73% had an additional opportunistic infection and 27% had 2 or more. The most frequent co-infections were: tuberculosis (44%), cytomegalovirus (14%), candidiasis (14%), Pneumocystis (12%), cryptococosis and Herpes simplexvirus (10% each). Symptoms included fever (90%), weight loss (87%), anorexia (85%), pulmonary and gastrointestinal manifestations (82% each) and hematological abnormalities (95%). The mortality for the entire cohort was 24%. Non-survivors were more likely to have thrombocytopenia (OR 2.75), rales (OR 3.04) and vomiting (OR 3.96). Antifungal treatment (96% vs. 79%, OR 0.16, p <0.01) and highly active antiretroviral therapy (HAART) (77% vs. 17%, OR 0.06, p <0.01) were more frequent in patients that survived. On multivariable analysis, rales (OR 15.27, CI 95% 1.63-143.0, p=0.017) and vomiting (OR 12.58, CI 95% 1.28-123.3, p=0.030) were associated with an increased mortality risk, whereas treatment with itraconazole (OR 0.008, CI 95% 0.00-0.27, p=0.008) and HAART (OR 0.043, CI 95% 0.00-0.30, p=0.002) were associated with a decreased mortality risk.

Conclusion: Mortality for PDH in HIV-infected patients remains high in Colombia. Prompt antifungal and antiretroviral treatment, especially in acutely ill patients, should help mitigate this risk. Our data suggest the risk of death due to delays in treatment could supersede the risk of IRIS-associated death with early treatment.