Clinical Characteristics, Mortality, and Evaluation of Two Quantitative Severity Scores in People Living With Hiv and Progressive Disseminated Histoplasmosis: Retrospective Cohort Study in a Tertiary Center in São Paulo

Progressive disseminated histoplasmosis (PDH) is an opportunistic infection (OI) with high mortality in people with advanced AIDS. The World Health Organization classifies PDH as severe to moderately severe or mild to moderate. The objective of this study was to describe the main characteristics of this population, identify factors associated with in-hospital death, and evaluate the performance of two quantitative severity scores. Observational retrospective cohort study conducted in a tertiary hospital in São Paulo. Patients hospitalized with HIV infection and confirmed diagnosis of PDH over an 11-year period were included. Descriptive statistics and univariate analysis of variables associated with in-hospital mortality were performed. The prognostic performance for mortality of two severity scores at admission was evaluated using the area under the receiver operating characteristic curve (AUC): (i) SOFA (Sequential Organ Failure Assessment); and (ii) HFS (Histoplasmosis Case Fatality Score) (Françoise et al., 2023). Ninety patients were included, 69 (77%) male, with a median (interquartile range – IQR) age of 39 (32–47) years. The majority (89%, n = 80) had a previous diagnosis of HIV infection; 71 (79%) had at least one concomitant opportunistic infection (OI), and 60 (66%) had PDH as an AIDS-defining illness. The median (IQR) CD4+ count was 25 (11–59) cells/µL. In-hospital mortality was 37% (n = 33). Septic shock (P < 0.001), multiorgan failure (P < 0.001), ICU admission (P < 0.001), use of amphotericin deoxycholate (P < 0.001), elevated LDH (P = 0.02), SOFA ≥ 6 points (P = 0.003), and HFS ≥ 5 (P < 0.001) were associated with in-hospital mortality. HFS (AUC 0.80, 95% CI 0.71–0.90) performed better than SOFA (AUC 0.75, 95% CI 0.64–0.86) in predicting in-hospital mortality. SOFA ≥ 6 showed low sensitivity (30%) and low negative predictive value (72%), whereas HFS ≥ 5 showed high sensitivity (97%) and high negative predictive value (97%). PLHIV with PDH had severe immunosuppression, frequent concomitant OIs, and high in-hospital mortality. SOFA and HFS were associated with in-hospital mortality, as were other factors already recognized in the literature. HFS showed excellent prognostic discriminatory ability in a Brazilian population, suggesting potential usefulness in initial clinical evaluation and guidance of patient care.