Ommaya reservoir in the treatment of cryptococcal meningitis

Cryptococcal meningitis in apparently immunocompetent patients

Cryptococcal meningitis (CM) is an invasive fungal disease that currently poses a threat to human health worldwide, with high morbidity and mortality, particularly in immunocompromised patients. Although CM mainly occurs in HIV-positive patients and other immunocompromised patients, it is also increasingly seen in seemingly immunocompetent hosts. The clinical characteristics of CM between immunocompromised and immunocompetent populations are different. However, few studies have focussed on CM in immunocompetent individuals. This review summarizes the clinical characteristics of apparently immunocompetent CM patients in terms of aetiology, immune pathogenesis, clinical presentation, laboratory data, imaging findings, treatment strategies and prognosis. It is of great significance to further understand the disease characteristics of CM, explore new treatment strategies and improve the prognosis of CM in immunocompetent individuals.

Analysis of the efficacy and related factors of ventriculoperitoneal shunt for AIDS with cryptococcal meningitis

Background

Cryptococcus neoformans is an opportunistic pathogen, which is more common in patients with AIDS. Increased intracranial pressure (ICP) is an important complication of cryptococcal meningitis (CM) and affects the therapeutic effect of CM.

Objective

To evaluate the effect and treatment for the management of ventriculoperitoneal shunt (VPS) in the treatment of AIDS complicated with CM and to analyze the factors associated with VPS and the indices affecting the outcome of CM patients.

Methods

A retrospective case study was conducted on patients with CM treated in the First Affiliated Hospital of Zhejiang University School of Medicine from 2011 to 2019. The Chi-square test was used for categorical variables and the Student’s t-test was used for continuous variables. Multivariable analysis of baseline factors related to VPS placement was performed with stepwise logistic regression analysis, factors associated with the outcome of these patients were studied by Cox regression analysis, and Kaplan–Meier survival curves were constructed to assess the outcome of patients.

Results

There were 96 patients with AIDS complicated with CM. VPS had a great effect on the patients, especially those with ICP > 350 mmH₂O. The outcome, including the mortality rate and modified Rankin scale (MRS) score of these patients, significantly improved after the placement of VPS. The karnofsky performance status (KPS) scores of patients whose ICP > 350 mmH₂O improved from 39.3 ± 21.3 at baseline to 88.7 ± 26.9 at 3 months after VPS, better than those without VPS. Multivariable analysis showed that visual impairment (OR, 0.026; 95% CI, 0.001, 0.567; P = 0.021) and ICP > 350 mmH₂O (OR, 0.026; 95% CI, 0.002, 0.293; P = 0.003) were related elements with the placement of shunt, and KPS score (HR, 0.968; 95% CI, 0.943, 0.993; P = 0.013) and ICP > 350 mmH₂O (HR, 2.801; 95% CI, 1.035, 7.580; P = 0.043) were indices of the outcome of AIDS patients with CM. For patients with ICP > 350 mmHg, Kaplan–Meier analysis showed that the 3-year outcome of patients with VPS was better than that of patients without VPS (P = 0.0067).

Conclusion

VPS was associated with better 3-year survival rates, and postshunt placement complications like infections were rare. The identification of factors related to VPS in the initial diagnosis of CM can contribute to more active management and improve the outcome.

Clinical characteristic of 15 cases of cryptococcal meningitis treated with Ommaya reservoir

Cryptococcal meningitis is a severe subacute fungal meningoencephalitis. Intracerebroventricular (ICV) injection of antifungal medication and aspiration of cerebrospinal fluid (CSF) through Ommaya reservoir were reported to be useful cryptococcal meningitis treatment method. We want to evaluate the role of Ommaya reservoir in the treatment of refractory cryptococcal meningitis. We retrospectively analyzed clinical records and data of 15 refractory cryptococcal meningitis patients who were treated with Ommaya reservoir in Sir Run Run Shaw hospital from June 2013 to June 2017. Fifteen patients who underwent Ommaya reservoir implanted surgery include eight women and seven men. Headache and fever were the common clinical symptoms. Underlying diseases mainly include diabetes mellitus and hypertension. Three patients occurred renal dysfunction and four patients experienced liver damage. Thirteen patients recovered completely, whereas two patients died. Implant Ommaya reservoir which can serial extract CSF and ICV injection of Amphotericin B is a valuable approach in the treatment of Cryptococcal meningitis, especially for patients with refractory intracranial hypertension.

Management of human immunodeficiency virus-associated cryptococcal meningitis: Current status and future directions

Cryptococcal meningitis (CM) is one of the most common opportunistic infections of acquired immunodeficiency syndrome (AIDS), as well as an important cause of hospitalisation and death. In recent years, the mortality of CM has remained high in HIV/AIDS population, with up to 30%, including within developed countries. The treatment usually encompasses controls of Cryptococcus, HIV, and increased intracranial pressure. Recent progress on the management of HIV-associated CM mainly centres in optimising induction regimens, looking for appropriate timing of initiating antiretroviral therapy and prevention of symptomatic onset and adverse consequences. This review compared several international guidelines combined with the results from some clinical researches to illustrate the similarities, differences and potential in CM treatment. The present practice is still far from satisfactory, and there remains much to explore due to our limited understanding of the pathogenesis of HIV-associated CM. Thus, screening and monitoring should be strengthened, and better therapies in line with the actual situation of each country should be discovered.

A Rare Presentation of Cryptococcal Meningitis and Cerebellitis in an Asplenic Patient, Seronegative for Human Immunodeficiency Virus (HIV)

BACKGROUND Cryptococcal meningitis in patients who are seronegative for the human immunodeficiency virus (HIV) and in patients who are splenectomized is rare. This report is an unusual case of meningeal and cerebellar infection due to the encapsulated yeast, Cryptococcus neoformans, which has not previously been associated with asplenia. CASE REPORT A 65-year-old HIV-negative patient with a previous splenectomy, presented with a three-day history of fever, vomiting, and headache. His symptoms progressed to generalized body aches, persistent fever, and neck stiffness. A lumbar puncture was performed, and cerebrospinal fluid (CSF) culture grew Cryptococcus neoformans. Treatment commenced with intravenous amphotericin B and flucytosine. The patient required serial lumbar punctures due to persistent raised intracranial pressure (ICP). Magnetic resonance imaging (MRI) of the brain showed acute meningitis and cerebellitis. Antimicrobial therapy and CSF drainage resulted in clinical improvement.  CONCLUSIONS The occurrence of meningeal and cerebellar cryptococcosis in an asplenic patient is rare, and few cases have been previously reported. This case report highlights the possibility of invasive cryptococcal infection, or cryptococcosis, in asplenic individuals in the absence of HIV infection.