Intracranial hypertension and cryptococcal meningitis in a girl with AIDS

A retrospective study of contributing factors for prognosis and survival length of cryptococcal meningoencephalitis in Southern part of China (1998-2013)

BACKGROUND

Cryptococcal meningoencephalitis (CM) is the most common opportunistic infection of the central nervous system (CNS). Despite this observation, there have only been a few studies analyzing clinical characteristics as well as cerebrospinal fluid (CSF), electroencephalograph (EEG), and magnetic resonance imaging (MRI) features in CM patients of all ages.

METHODS

We reviewed the medical records of all patients diagnosed with cryptococcal meningoencephalitis from 1998 to 2013 in the Nanfang Hospital in China and gathered data on the underlying diseases, bird exposure history, and clinical features, including those from CSF, EEG and MRI.

RESULTS

CM is more likely to infect adults younger than 60 years old. 71.3% of CM patients were male. Unlike data from other countries, we found that chronic use of corticosteroids or other immunosuppressants (17.59%) was the most frequent risk factor in CM patients rather than HIV infection (1.85%). Clear exposure with bird/ bird droppings before CM onset is obvious in a previous study in CM children. However, our study found that 4.63% CM patients had such an exposure. More importantly, patients with brain tissue damage (p = 0.021) and decreased CSF/blood glucose ratio (p = 0.008) were significantly associated with death, but only the decreased CSF/blood glucose ratio was the contributing factor of prognosis (odds ratio, 0.047; p = 0.025). Decreased CSF/blood glucose ratio was significantly related to the survival length of CM (odds ratio, 0.134; p = 0.033).

CONCLUSIONS

Our study shows that CM has predilection for young male adults. The chronic use of corticosteroids or other immunosuppressants, rather than HIV infection or bird/bird droppings exposure, was the most frequent risk factor in CM patients in our study. Decreased CSF/blood glucose ratio was both an independent contributing factor to death and was significantly related to the survival length of CM patients. The more decreased the CSF/blood glucose ratio was, the worse prognosis and shorter survival length CM patients had.

Fluconazole induces teratogenic effects in the tunicate Phallusia mammillata

Fluconazole (FLUCO) is an azole derivative used to treat fungal and yeast infections. Embryotoxicity tests on the ascidian Phallusia mammillata were performed to evaluate the effects of this drug. FLUCO proved to have strong consequences on P. mammillata development. Incidence of malformations and of lethality increased in a dose dependent way. Probit analysis showed that FLUCO had a high TI value (Teratogenic Index, LC(50)/TC(50)), thus this substance could be classified as a teratogenic compound for ascidians. Larvae exposed to FLUCO showed a typical phenotype characterized by malformations restricted to the trunk region: the trunk appeared round in shape with flat palps, the sensory vesicle cavity was absent or reduced and the anterior central nervous system failed to correctly differentiate. These anomalies resulted similar to those induced by retinoic acid (RA) treatment. Thus, it could be hypothesized that FLUCO and RA may act with a similar pathogenic mechanism in ascidian larvae, as it has been proposed for mammals.

A randomized, double-blind, placebo-controlled trial of acetazolamide for the treatment of elevated intracranial pressure in cryptococcal meningitis

We conducted a trial of oral acetazolamide for the treatment of cryptococcal meningitis in 22 Thai adults with headache and an opening cerebrospinal fluid pressure of >/=200 mm H(2)0. The trial was terminated prematurely because patients who received acetazolamide developed significantly lower venous bicarbonate levels and higher chloride levels and had more-frequent serious adverse events than did subjects who received placebo.

Use of ventriculoperitoneal shunts to treat uncontrollable intracranial hypertension in patients who have cryptococcal meningitis without hydrocephalus

Between 1997 and 2000, 4 human immunodeficiency virus-negative patients in our institution had cryptococcal meningitis with uncontrollable intracranial hypertension. All 4 patients were treated with antifungal drugs as well as ventriculoperitoneal (VP) shunts for intracranial hypertension. Neurological deficits that were unresponsive to pharmacologic treatment were resolved by use of the VP shunt. Uncontrollable elevation of intracranial pressure associated with cryptococcal meningitis can be resolved by use of a VP shunt, even when imaging studies do not reveal hydrocephalus.