Determination of Cryptococcal Antigen in Newly Diagnosed HIV Infected Patients Attending Specialist Hospital Sokoto North- Western Nigeria

doi:10.21203/rs.3.rs-4536055/v1

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Determination of Cryptococcal Antigen in Newly Diagnosed HIV Infected Patients Attending Specialist Hospital Sokoto North- Western Nigeria

https://doi.org/10.21203/rs.3.rs-4536055/v1

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Cryptococcosis is a common infectious disease that contributes significantly to death in HIV/AIDS patients. The aim of this study was to determine the prevalence of cryptococcal antigen among newly diagnosed HIV infected patients with CD4 count below 200µL attending antiretroviral clinic in specialist hospital Sokoto.. A descriptive cross-sectional study was carried out in the HIV clinic of the Sokoto Specialist Hospital. The participants were newly diagnosed HIV positive patients recruited through thorough random sampling. The sociodemographic and clinical characteristics of the subjects were recorded. Blood was obtained from the subjects to determine their CD4 level and the presence of cryptococcosis. Their CD4 levels were measured using the Visitect CD4 Advanced Disease Kit, and the presence of cryptococcal antigen in the blood sample was discovered using the CrAg LFA. Statistical analysis was performed using SPSS version 25.0. Univariate, bivariate, and multivariate analyses were completed. Out of the 154 HIV-positive patients recruited, 55 had CD4 count below 200µL (prevalence of 35.7%), 21 were positive to cryptococcal antigen (prevalence of 38.2%), and cryptococcal antigen and HIV co-infection was high among married couples (prevalence of 61.9%) and the age group of 31–40 (prevalence of 47.6%). The socioeconomic distribution of the co-infection showed that it was high among Hausa/Fulani, business owners, and informally educated people. This study reveals that cryptococcosis is a burden among HIV patients in Sokoto, and its frequency is linked to lower CD4 levels.

cryptococcal antigen

human immunodeficiency virus

CD4 count

Sokoto North

Cryptococcal meningitis (CM) is an infection of the meninges, which are membranes that protect the brain and spinal cord, Meningitis could be caused by bacteria, fungi, or viruses [1]. Cryptococcal meningitis is caused by two species of fungi: Cryptococcus neoformans and Cryptococcus gattii [1].This condition is uncommon in healthy people but more common in people with weakened immune systems, such as those with AIDS [2]. Cryptococcosis is one of the most common opportunistic systemic fungal infections among HIV/AIDS patients and other immunocompromised individuals as a result of cancer chemotherapy, diabetes mellitus, sarcoidosis, steroid therapy, renal transplantation, or other genetically related diseases [1]. Cryptococcus neoformans and Cryptococcus gattii are the most common causes of cryptococcosis [3]. The fungus C. neoformans is often found in soil and is disseminated by bird droppings, which is how most cases of cryptococcal meningitis are caused [4]. People do not contract fungal meningitis from other people; rather, they contract cryptococcal meningitis via inhaling soil particles tainted with bird droppings [5].

Cryptococcal infection usually presented as meningitis which is swelling of the meninges, has been a major cause of morbidity and mortality among people with HIV, despite the increasing improvement in access to HIV testing and treatment services [1]. It is known to be the major cause of death among HIV patient with low CD4 count, with Sub-Sahara Africa being the most affected region in the world [2]. It is known to have caused more death among HIV patient than tuberculosis in this region of the world [6]. Thus, the advancement in technology has provided means of early screening of cryptococcal antigen (CrAg), with the aid of CrAg test strip in other to increase diagnosis, provide awareness and enlightenment in other to control and avoid mortality among HIV patient due to cryptococcal antigen [6]. For years cryptococcal antigen has been a major cause of death among HIV infected patient which has been ongoing due to lack attention, awareness and minimal diagnosis on the infection [3]. This study dwells on the determination of cryptococcal antigen among newly diagnosed HIV infected people attending Specialist hospital Sokoto with a view to increase the understanding, intervention planning and approach of HIV infected patients’ management and reduce the complications in treatment of newly HIV infected patients in Specialist hospital Sokoto.

2.1 Study design

This descriptive cross-sectional study was carried out among newly diagnosed HIV infected patient attending antiretroviral clinic in Specialist Hospital Sokoto North-Western Nigeria.

2.2 Study population

Blood samples of 154 newly diagnosed HIV infected individuals were taken and investigated for detecting cryptococcal antigen and CD4 count. Prior to the study, written informed consent was obtained from the subjects.

2.3 Ethical Considerations

The ethical clearance and permission to conduct the study was obtained from Ethics Committee of Specialist Hospital, Sokoto, Sokoto State (SHS/ETC/08/23/721).

2.4 Inclusion Criteria

The Study includes newly diagnosed HIV infected patient both males and females, within the age bracket of 15 to 65 years who has consented to participate in the study attending the Antiretroviral clinic in Specialist hospital Sokoto, North-west Nigeria.

2.5 Exclusion Criteria

The study excludes HIV negative patients, newly diagnosed HIV positive patients outside the age bracket of 15 to 65, and those that did no consent to participate in the study.

2.6 Sample Collection

For the purpose of the study, 3 mL blood was drawn from each participant using a sterile needle and vacutainer in an EDTA vacutainer tube by a phlebotomist and labeled appropriately.

2.6.1 CD4 + T-cell count

The CD4 + T-cell count in whole blood was determined using VISITECT CD4 Advanced Disease Rapid Test according to the manufacturer’s written instructions.

2.6.2 Cryptococcal Antigen Detection using Lateral Flow Assay

Detection of cryptococcal antigen was accomplished using the lateral flow assay (CrAg LFA CR2122) test kit) Forty (40) microliters of LF Specimen Diluent (REF GLF025) was added to an appropriate labeled reservoir (test tubes). The strip was labeled prior to inserting of sample. Forty (40) microliters of specimen were added to the reservoir and mixed. The white end of the CrAg LF Test Strip (REF LFCR50) was submerged into the specimen. It was left to stand for 10 minutes. The result was read and recorded.

2.7 Statistics Analysis

The data collected was analyzed using statistical software package for social science (SPSS) version 25. 0 and the results obtained were presented in tables and figures, values were expressed as Mean ± standard deviation (SD). The age, gender and other socio-demographic details of all the participants were collected using questionnaire.

The results obtained from the statistical analysis of data collected from the questionnaire laboratory analysis of 154 newly diagnosed Human Immuno-Deficiency Virus patient in specialist hospital Sokoto, Sokoto Nigeria are presented in the tables below.

3.1 CD4 COUNT OF NEWLY DIAGNOSED HIV INFECTED PATIENTS

Out of 154 participants tested, CD4 > 200µL was detected in 99 patients and CD4 < 200µL was detected in 55 patients, having the prevalence of 64. 3% and 38. 7% respectively as shown in Fig. 1.

3.2 PREVALENCE OF CRYPTOCOCCAL ANTIGEN IN THE NEWLY DIAGNOSED HIV INFECTED PATIENTS WITH CD4 COUNT BELOW 200 CELLS/uL

CrAg lateral flow assay was carried out on patient with CD4 < 200µL, the 55 patients with CD4 < 200µL 21(38. 2%) were positive to CrAg and 34(61. 8%) were negative to CrAg as shown in Table 2. The distribution of newly infected HIV patient with CD4 < 200µL to CrAg shows there was a significant association of CD4 < 200µL in HIV patient with CrAg presence with p-value of 0. 000.

Table 2

Prevalence of cryptococcal antigen in the newly diagnosed HIV infected patients with CD4 count below 200 cells/uL
CrAg	Frequency (N)	Percentage (%)	X²	p-value
Positive	21	38. 20	154. 00	0. 000
Negative	34	61. 80
Total	55	100. 00

3.3 DISTRIBUTION OF CRYPTOCOCCAL INFECTION BETWEEN MARITAL STATUS AND AGE GROUP OF IN NEWLY DIAGNOSED HIV POSITIVE PATIENTS

The age distribution of 21 CrAg positive newly diagnosed HIV patients with CD4 < 200µL was as follow: 15–20 was 1(4. 8%) positive patient, 21–30 was 4(19. 0%), 31–40 was 10(47. 6%), 41–50 was 6(28. 6%), 51–60 was 0, 61–70 was 0. According to age distribution there is no significant association between HIV and CrAg co-infection with age having p-value of 0. 669. Furthermore, the marital status distribution of 21 CrAg positive newly diagnosed HIV patient with CD4 < 200µL was as follows; co-habiting was 1(4. 8%) positive patient, engaged was 0, married was 13(61,9%), single was 7(33. 3%). According to marital status distribution there was no significant association between HIV and CrAg co-infection to marital status with p-value of 0. 089 as shown in the table below.

Table 3

Distribution of cryptococcal infection among the different age group and marital status of in specialist hospital Sokoto
Characteristics	Frequency (N)	Percentage (%)	X²	p-value
Age Range
15–20	1	4.8	7.590	0.669
21–30	4	19.0
31–40	10	47.6
41–50	6	28.6
51–60	0	0.0
61–70	0	0.0
Total	21	100.0
Marital Status
Co-habiting 1 4. 80	1	4.8	10.794	0.089
Engaged 0 0. 00	0	0.0
Married 13 61. 9	13	61.9
Single 7 33. 3	7	33.3
Total	21	100.0

3.4 SOCIOECONOMIC RISK FACTOR DISTRIBUTION ASSOCIATED WITH HIV AND CRYPTOCOCCAL DISEASES AMONG NEWLY HIV INFECTED PATIENTS

The distribution based on tribe was as follows Hausa/Fulani 18 patients, Igbo 1 patients, others 1 patients and Yoruba 1 patients with percentage distribution of 85. 7%, 4. 8%, 4. 8% and 4. 8% respectively. According to tribe distribution there’s no significant association between HIV and CrAg co-infection with tribe having a p value of 0. 724. Their distribution based on educational status was as follows; informal only 14 patients, No Formal and Informal 0 patients, primary school 0 patient, secondary school 5 patients and tertiary 2 patients with percentage distribution of 66. 7%, 0%, 0%, 23. 8% and 9. 5% respectively. According to tribe distribution there’s no significant association between HIV and CrAg co-infection with educational status having p value of 0. 525. Their distribution based on occupation was as follows; Business 9 patients, civil servant 3, house wife 4, others 1, students 0, unemployed 4patients with percentage distribution of 42. 9%, 14. 3%, 19. 0%, 4. 8%, 0%, and 19. 0% respectively. Hencebased on occupation status distribution there’s no significant association between HIV and CrAg co infection with occupations of the individuals having a p value of 0. 294.

Table 4

Socioeconomic risk factor associated with HIV and cryptococcal diseases among newly HIV Infected patient
Characteristics	Frequency (N)	Percentage (%)	X²	p-value
Tribe
Hausa/Fulani	18	85.7	3.647	0.724
Igbo	1	4.8
Yoruba	1	4.8
Others	1	4.8
Total	21	100.0
Educational status
Informal only	14	66.7	7.104	0.525
No formal and informal	0	0.0
Primary School	0	0.0
Secondary School	5	23.8
Tertiary Institution	2	9.5
Total	21	100.0
Occupation
Business	9	42.9	11.863	0.294
Civil servant	3	14.3
House wife	4	19.0
Student	0	0.0
Unemployed	4	19.0
Other	1	4.8
Total	21	100.0

Human Immuno-Deficiency Virus patients with CD4 count below 200uL have been reported to be associated with increase in risk factors responsible for them getting infected with cryptococcal antigen [7]. Based on the fact that HIV attacks the immune cell mostly the CD4 cells resulting in their destruction [8]. Destruction of CD4 cells by HIV has resulted in immuno deficiency hence making HIV patients with CD4 count below 200uL at higher risk of getting ill with cryptococcal antigen infection.

Findings from this study showed the distributionCD4 count among newly infected HIV patients, with those below 200uL having a prevalence of 64. 3%. This finding was supported by Yahaya et al., 2022 where prevalence of 55% was gotten from HIV patient. Similarly, a prevalence of 52. 4% was determined by Chukwuanukwu et al.[9], a study made at south eastern Nigeria even though their study populations were mainly pregnant women utilizing the prevention of mother to child transmission of HIV/AIDS at their center. Low CD4 + ve T cell level has been found to be the only factor significantly associated with positive serum cryptococcal antigenaemia, also the lower the CD4 + ve T cell count, the higher the occurrence of cryptococcal meningitis in HIV infected patients. Hence, the implication of this finding is that once HIV patient have a CD4 count below 200ul it becomes necessary to screen for cryptococcal antigen.

The result of this study also shows that there is increase in the prevalence of cryptococcal antigen among HIV/AIDS patients with CD4 count below 200ul from specialist hospital Sokoto with a prevalence of 38. 2%, and a p-value of 0. 000 indicating that there’s significant association between HIV/AIDS patient with CD4 count below 200uL and cryptococcal antigen infection. This is consistent with the findings of a previous study made at Usmanu Dan Fodiyo University Teaching Hospital Sokoto by Yahaya et al[10], where a prevalence of 11%, chi value of 128. 7 and p-value 0. 00 was determined. Similarly, a prevalence of 13% was determined by Chukwuanukwu et al.[9], a study made at southeastern Nigeria even though their study population were mainly pregnant women utilizing the prevention of mother to child transmission of HIV/AIDS at their center. Similarly, a prevalence of 12. 7% was found by Favour et al.[6] in a study conducted in Benin city, Nigeria. The finding of this study concurs with the 12. 2% in Congo, 12. 9% in Bangkok and 13. 5% in Kampala, Uganda. However, it is in contrary with the study on the prevalence of cryptococcal antigenaemia and its relation to CD4 + ve T cell counts and WHO clinical staging among treatment naive HIV positive Nigerian adults [11]. In which cryptococcal antigenaemia rate of 1. 6% was observed, which was similar with previous reports from Shika in Nigeria 2. 2%, Tanzania 3% and USA 2. 9%. However, this overall prevalence value in this study is lower than some reports from Nnewi 13. 1%, South east, and Benin 12. 7%, South-south part of Nigeria as well as Kenya 11%, Uganda 5. 7%, Indonesia 7. 1% and Thailand 9. 2%. This relatively high prevalence from the research is comparable across different regions in Nigeria and around Africa, this is based on the fact that HIV targets and destroys the immune cells thereby resulting in immunodeficiency hence making the patients to be at higher risk of getting ill with cryptococcal antigen infection. Thereby indicating needs for the institution of national screening program for HIV patients for Cryptococcal antigen, alsothe detection of cryptococcal antigen in the serum (CrAg) is clinically relevant and precedes the onset of overt disease. Early diagnosis of CM would translate into a reduction in CM-related deaths. Considering the substantial mortality and morbidity associated with CM, preventive interventions should be prioritized.

Findings from this study showed that majority of the study population were between the age group of 31–40 years (47. 6%), chi square value of 7. 590 and p-value of 0. 669 indicating no significant association between age and co-infection with HIV and CrAg. This is similar to 2022 study on prevalence and factors associated with cryptococcosis among HIV infected patient of a tertiary hospital in North western Nigeria by Yahaya et al.[10], with high prevalence among age group of 30–39 years (40. 2%) and p-value of 0. 6660. However, it is in contrast with to a study done in central Nigeria on patient’s satisfaction with ART services by Osungbade et al. [12], which showed that majority with 27. 1% chi square value of 3. 629 and p-value of 0. 30 and the entire client assessing ART services were young people aged 15–24 years old. Also in contrast with the study by Balogun et al.[11], where most of the patients in our study were in age group 29–39 years and this observation is similar to findings in a previous research with 24–40 years.

Findings from this study also showed that majority of the study population was among married individuals with the prevalence of 61. 9%, chi square value of 10. 974 and p-value of 0. 089 showing there’s no significant relationship between marital status and co-infection of HIV and CrAg. This is similar to prevalence of 49. 3%, chi square value of 6. 865 and p-value of 0. 076 gotten by Osungbade et al. [12]. This is due to the fact that married couples share higher level of intimacy and spend time together closely hence they can transmit it to one another through contaminated air droppings from either of them.

Findings from this study also showed the distribution of HIV and CrAg based on socio-economical risk factors such as tribe, educational status and occupation. Based on tribe it was high among the Hausa/Fulani having a prevalence of 85. 7%. This was supported by Yahaya et al. [10], where the prevalence of 82. 3% was obtained. Based on educational status it was high among people with only informal education having a prevalence of 66. 7%. This was in contrary to Yahaya et al. [10], where prevalence was high among formally educated individuals with prevalence of 33. 1%. Based on occupational status it was high among Business owners with prevalence of 42. 9%. This was in contrary to Yahaya et al. [10] where prevalence was high among unemployed individuals with prevalence of 37. 1%. This high prevalence among Hausa/Fulani is as a result of the region in which the research was carried out having high population of Hausa/Fulani in general, high prevalence seen among people with only informal education is due to lack of formal knowledge on the disease, it preventions and how to stay healthy, also high prevalence seen among people whose occupation are business owner is due to the fact that they come in contact with so many people and the unhealthy life style and practices common to business owners, due to lack of organization nor rules governing most of their activities.

Based on this study it is concluded that in specialist hospital Sokoto cryptococcosis is associated with the decreasing levels of CD4 count, However, age, marital status and socio-economical risk factors such as educational status, employment status and occupations are not associated with higher incidence of cryptococcal antigen infection in the newly diagnosed HIV/AIDS patients.

Conflicts of interest

The authors declare no conflicts of interest.

Financial disclosure

There were no funding sources that supported this work.

Author Contribution

ABU, handle the study design, AMI, KMH review the manuscript, ABU perform data analysis, YMY and SZF conducted the field work to administer questionnaire, and performed sample collection, YMY, SZF, ABU conducted the laboratory sample analysis and drafted the Methodology, HA drafted the tables and chats and review the statistical data analysis.

Data Availability

All data generated or analysed during this study are included in this published article as a references.

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Han S, Holm G. Cryptococcal Meningitis. 2018;1–4. DOI: 321031.
Jemal M, Deress T, Belachew T, Adem Y. Prevalence of Cryptococcal Antigenemia and Associated Factors among HIV/AIDS Patients at Felege-Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia. Int J Microbiol. 2021;1–18. 10.1155/2021/8839238.
Vijay S, Ngole NN, Njare SS, Mehta P. Prevalence of Cryptococcaemia in HIV Seropositive Patients in an Indian Setting. J Clin Diagn Res. 2019;13(6):1–5. 10.7860/JCDR/2019/40763.12904.
Fletcher J. Cryptococcal meningitis: Symptoms, risk factors, and complications. 2018;1–10. DOI: 321031.
Osazuwa F, Dirisu JO, Okuonghae PE, Ugbebor O. Screening for Cryptococcal Antigenemia in Anti-Retroviral Naïve AIDS Patients in Benin City, Nigeria. Oman Med J. 2012;27(3):228–31. 10.5001/omj.2012.51.
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Chukwuanukwu R, Manafa P, Iloghalu E, Onyenekwe C, Ifeanyichukwu M, Mbamalu C. Cryptococcus neoformans antigenemia in HIV positive pregnant women attending a PMTCT clinic in South-East Nigeria. J Biol Agric Healthc. 2013;1(3):15–20.
Yahaya M, Adebayo T, Fatima J, Aisha A. Prevalence and Factors Associated with Cryptococcosis among Human Immunodeficiency Virus-Infected patients of a tertiary Hospital in Northwestern Nigeria. Ann Trop Pathol. 2022;10:52–8.
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No competing interests reported.

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You are reading this latest preprint version

Determination of Cryptococcal Antigen in Newly Diagnosed HIV Infected Patients Attending Specialist Hospital Sokoto North- Western Nigeria

Status:

Version 1

Abstract

Figures

1.0 INTRODUCTION

2.0 MATERIALS AND METHODS

2.1 Study design

2.2 Study population

2.3 Ethical Considerations

2.4 Inclusion Criteria

2.5 Exclusion Criteria

2.6 Sample Collection

2.6.1 CD4 + T-cell count

2.6.2 Cryptococcal Antigen Detection using Lateral Flow Assay

2.7 Statistics Analysis

3.0 RESULTS

3.1 CD4 COUNT OF NEWLY DIAGNOSED HIV INFECTED PATIENTS

3.4 SOCIOECONOMIC RISK FACTOR DISTRIBUTION ASSOCIATED WITH HIV AND CRYPTOCOCCAL DISEASES AMONG NEWLY HIV INFECTED PATIENTS

4.0 DISCUSSION

5.0 CONCLUSION

Declarations

Conflicts of interest

Financial disclosure

Author Contribution

Data Availability

References

Additional Declarations

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