Impact of biological sex on cryptococcal meningitis mortality in Uganda and South Africa

Anna M. Stadelman, Kenneth Ssebambulidde, Lillian Tugume, Katelyn Pastick, Kathy Huppler Hullsiek, Sarah Lofgren, Edwin Nuwagira, Emily E. Evans, Darlisha A Williams, Conrad Muzoora, David B Meya, Radha Rajasingham, Joshua Rhein, David R. Boulware

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


The role of biological sex on clinical outcomes and the pathogenesis of AIDS-related opportunistic infections is unknown. We assessed baseline biomarkers and outcomes between 577 men and 400 women in HIV-related cryptococcal meningitis cohorts in Uganda and South Africa from 2010 to 2017. We compared 10-week mortality by sex via Cox proportional hazards models. The 10-week mortality for women was 50% (198/400) and 43% (247/577) for men. Women had higher risk of death in an unadjusted model (Hazard Ratio (HR) = 1.20; 95%CI, 1.00-1.45; P = .05). Women maintained a higher risk when adjusting for quantitative CSF culture, altered mental status, CSF pleocytosis, age, and antiretroviral status (HR = 1.31; 95%CI, 1.07-1.59; P < .01). However, after adjusting for hemoglobin, the risk of death did not differ between women and men (HR = 1.17; 95%CI, 0.94-1.45; P = .17). Moderate to severe anemia (hemoglobin < 8.5 g/dL) was present among 16% (55/355) of women and 10% (55/532) of men (P = .02). Of the 373 participants with CSF biomarkers, men had higher median pro- and anti-inflammatory, monocyte/macrophage differentiation, maturation, and migration, immune exhaustion, and cytotoxicity cytokines than women (P < .05). We identified biological sex as proxy for anemia, a potentially modifiable risk factor for cryptococcal meningitis mortality. Immune response may contribute to the multifaceted underlying mechanisms for the discrepancy in mortality based on sex.

LAY SUMMARY: We examined the role of biological sex in cryptococcal meningitis mortality in a large cohort. Our findings reveal significant differences in inflammatory markers by biological sex. Women have significantly higher mortality due to cryptococcal meningitis that is attributable to anemia at baseline.

Original languageEnglish (US)
Pages (from-to)712-719
Number of pages8
JournalMedical mycology
Issue number7
StatePublished - Jul 1 2021

Bibliographical note

Publisher Copyright:
© 2021 The Author(s) 2021. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology.


  • HIV
  • South Africa
  • Uganda
  • biological sex
  • cryptococcal meningitis
  • cytokines
  • immunology


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