Morbimortalidade e sobrevida após o primeiro evento de histoplasmose disseminada em pacientes com aids atendidos em unidades de referência de Fortaleza/Ceará

Abstract

Histoplasmosis is one of the most opportunistic systemic mycoses associated with AIDS today in Brazil and worldwide. Ceará is the state of Brazil with the largest case in the last decade this co-infection. The objective of this study was to characterize the survival and morbimortality of patients with co-infection HD/AIDS after the 1st HD event, served in in units of a reference for HIV/AIDS in Fortaleza/Ceará. Retrospective cohort study of patients with co-infection HD/AIDS, when the first HD episode occurred between 2002-2008. The data were collected from the diagnosis of HD until 12/31/2010. Statistical analysis was performed using STATA 9.0 program. The study included 145 patients. The majority were young adults with median age of 34.6 years (95%CI = 33.2-36.0), males (83.5%) and without risk activity associated with histoplasmosis (80%). The prevalence of co-infection was of 38 cases/year. HD was first defining opportunistic infection of AIDS in 59% of the patients. Amphotericin B was used in 97% of patients as induction drug and itraconazole in 92% on maintenance dose. The average clinical follow-up was 3.38 years (sd=2.2,95%CI= 3.01 to 3.75); 55.2% of patients needed for new admissions; 23.3% presented relapse of histoplasmosis; 31.4% discontinued the use of antifungal as medical advice. The average follow-up after the interruption was 2.85 years (95%CI= 2.24 to 3.46). Only one patient relapsed after stopping the antifungal. Risk factors related to relapse were not adhering to ART (p 0.000), irregular use of antifungal (e.g. 0.000), non-recovery of CD4 (p 0.000) and have AIDS before diagnosis of HD (0.025). Non-adherence to ART (OR 4.96; 95% CI = 1.26- 30.10; p = 0.026) was the only independent risk factor for relapse. To 60 months the likelihood of remission was 67% (95%IC = 55% -76%). Join the ART (94% vs. 51% - p = 0.000), regular use of antifungal (87vs. 48 - p = 0.000), recovery of CD4+ (83% vs. 45% – p =0.000) and not having AIDS before the HD (76% vs.55% - p = 0.035) were the main factors that contributed to maintenance of remission. Death occurred in 30.2% of patients; mortalityrelated factors were not adherence to treatment of aids (p = 0.000), irregular use of antifungal medication (p = 0.000), non-recovery of CD4+ (p = 0.000), have had a new episode of histoplasmosis (p = 0.000) and have AIDS before the HD (p = 0.009). Patients with adherence to ART (92% vs. 54% - p = 0,000) and without relapse episode (77% vs. 32% - p = 0,000), had better chances of survival. Regular use of secondary prophylaxis as a maintenance therapy in HD was a factor associated with lower probability of progression to death (p=0.000). The survival at 60 months was of 68% (95%CI = 57%-76%). Regular use of antifungal (84% vs. 50% - p = 0.000), have had CD4+ recovery (89% vs. 54% - p = 0.000)and not have had AIDS before the HD (75% vs. 57% - p = 0.021) also were factors associated with better survival. Therefore, it was found in this study, high prevalence of HD in patients with AIDS in this region of Brazil, with high rates of relapse and death. Join the ART was the only independent risk factor associated with outcomes, relapse and death. The best survival occurred in patients adhering to ART.