Determinants of prognosis in Talaromyces marneffei infections with respiratory system lesions

Abstract

Background: Little study has investigated the differences between Talatomyces marneffei (T. marneffei) respiratory infection and tuberculosis and the prognostic factors of such infection. This study investigated the characteristics and prognostic factors of T. marneffei infections with respiratory lesions and the causes of misdiagnosis.

Methods: Clinical characteristics and prognoses of patients with T. marneffei infections with respiratory system lesion were investigated. T. marneffei diagnosis followed isolation from clinical specimens using standard culture, cytology, and histopathology. Survival curves were estimated by using Kaplan-Meier analysis, with log-rank test to compare differences in survival rates between groups. Univariate and multivariate Cox regression analyses were also performed to assess significant differences in clinical characteristics of overall survival.

Results: Of 126 patients diagnosed with T. marneffei infections, 63 (50.0%) had T. marneffei respiratory system infections; 38.1% (24/63) were misdiagnosed as having tuberculosis. Human immunodeficiency virus (HIV) infection, CD4/CD8 < 0.5, percentage of CD4 T cells <42.8%, and length of time from onset to confirmation of diagnosis >105 days were potential risk factors for poor prognoses. Length of time from onset to confirmation of diagnosis persisted as an independent predictor of all-cause mortality in multivariate analysis (odds ratio: 0.083, 95.0% confidence interval: 0.021-0.326, P < 0.001). However, the size of the lung lesions, dyspnea, thoracalgia, mediastinal lymphadenopathy, and pleural effusion did not significantly predict overall survival. There was no significant difference in prognosis according to the type of treatment.

Conclusions: T. marneffei infections involving the respiratory system are common. The critical determinants of prognosis are HIV infection, CD4/CD8, percentage of CD4 T cells, type of treatment, and the time range from onset to confirmation of diagnosis. Rapid and accurate diagnosis is crucial for improving prognosis.

Figure 1

Enrollment, human immunodeficiency virus (HIV) infection status, and respiratory infection classification of the study.

Figure 2

High-resolution computed tomography revealed pulmonary involvement in human immunodeficiency virus (HIV)-positive patients. (A) Patchy exudates, (B) nodular infiltrates, (C) pleural effusion, (D) cavitary lesions, and (E) miliary lesions. High-resolution computed tomography revealed pulmonary involvement in HIV-negative patients. (F) Patchy exudates, (G) fibrous cords, (H) pleural effusion, (I) cavitary lesions, and (J) tracheobronchial stenosis.

Figure 3

Electronic nasopharyngoscopy revealed nasopharyngeal lumps (A and C) and throat obstruction (B). Fiberoptic bronchoscopy revealed pulmonary involvement. Inflammatory changes at the trachea (D), tracheobronchial stenosis (E), and an irregular tracheal wall with numerous protrusions in the main trachea and the left and right principal bronchi (F). Arrow: abnormal findings.

Figure 4

Survival curves. (A) Overall survival among human immunodeficiency virus (HIV)-positive and HIV-negative patients (log-rank test: P = 0.006). (B) Overall survival among patients aged >60 or <12 years, and ≥12 and ≤60 years (log-rank test: P = 0.069). (C) Overall survival among patients with underlying diseases and without underlying diseases except HIV infection (log-rank test: P = 0.694).

Figure 5

Survival curves. (A) Overall survival among bilateral lung lesions and unilateral lung lesions (log-rank test: P = 0.068). (B) Pleural effusion, (C) mediastina lymphadenopathy, and (D) dyspnea were not significantly associated with overall survival.

Figure 6

Overall survival among patients according to the duration of time from onset to confirmation of diagnosis (cut-off: 105 days; log-rank test: P < 0.001; A). Recurrence is not significantly associated with overall survival (B). Overall survival among patients according to a CD4⁺ T-cell percentage cut-off of 42.8% (log-rank test: P = 0.032; C). Overall survival among patients according to a CD4/CD8 ratio cut-off of <0.5 (log-rank test: P = 0.004; D).