PULMONARY CRYPTOCOCCOSIS ASSOCIATED WITH HIV-1 INFECTION IN RWANDA - A RETROSPECTIVE STUDY OF 37 CASES

Objectives: To study the demographic, clinical, radiographic and diagn ostic features, the clinical course and therapeutic response of pulmon ary cryptococcosis in HIV-1-infected patients. Design: Retrospective r eview. Setting: The Department of Medicine of an urban reference hospi tal in Central Africa. Methods: All the records of HIV-1-infected pati ents with pulmonary cryptoccosis were reviewed retrospectively with re gard to the parameters described above.Results: Over a 3-year period, pulmonary cryptococcosis was diagnosed in 37 HIV-1-infected Rwandan pa tients (21 men, 16 women; mean age, 35 years; range, 26-55 years). Twe nty-nine patients (78%) had primary pulmonary cryptococcosis. Cough (9 4%), weight loss (65%), fever (51%), dyspnoea (46%), thoracic pain (30 %), headache (13%) and haemoptysis (8%) were the predominant clinical findings. A diffuse interstitial infiltrate on chest radiograph was ob served in 76% of the patients, an alveolar pattern in 19%, mediastinal and/or hilar adenopathy in 11%, nodules and pleural effusion each in 5%. Bronchoalveolar lavage, with a yield of 82%, was found to be the m ost sensitive diagnostic procedure. Screening of cryptococcal antigen in the serum failed to detect cases of primary pulmonary cryptococcosi s. Twelve patients with primary pulmonary cryptococcosis treated with itraconazole as acute and maintenance therapy were all protected again st disseminated cryptococcal disease; seven out of 10 (70%) of those w ho did not receive a specific anticryptococcal drug developed dissemin ated cryptococcal disease. Conclusion: Pulmonary cryptococcosis is not a rare complication of HIV-1 infection in Rwanda. Its clinical and ra diographic patterns are non-specific and bronchoalveolar lavage is the procedure of choice for its diagnosis. The natural history of untreat ed primary pulmonary cryptococcosis is disseminated cryptococcal disea se. Itraconazole is highly effective in the prevention of disseminated cryptococcal disease in patients with primary pulmonary cryptococcosi s.