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Mabovula NS, Enicker BC. A comparison of the surgical outcomes of ventriculoperitoneal versus lumbar peritoneal shunts in the management of intracranial hypertension secondary to cryptococcal meningitis in HIV infected adult patients. Clin Neurol Neurosurg 2024; 238:108184. [PMID: 38394855 DOI: 10.1016/j.clineuro.2024.108184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/16/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVE Cryptococcal meningitis (CM), an AIDS-defining illness, significantly impacts morbidity and mortality. This study aims to compare complications arising from ventriculoperitoneal shunt (VPS) and lumbar peritoneal shunt (LPS) procedures used to manage refractory intracranial hypertension (IH) secondary to CM in HIV-infected patients. METHODS Retrospective data were collected from January 2003 to January 2015 for HIV-infected adults diagnosed with refractory IH secondary to CM and subsequently shunted. Demographics, clinical characteristics, antiretroviral therapy, laboratory findings (including CD4 count and CSF results), CT brain scan results, shunt-related complications, and mortality were compared between VPS and LPS groups. RESULTS This study included 83 patients, with 60 (72%) undergoing VPS and 23 (28%) receiving LPS. Mean ages were comparable between VPS (32.5) and LPS (32.2) groups (p = 0.89). Median CD4+ counts were 76 cells/µl (IQR= 30-129) in VPS versus 54 cells/µl (IQR= 31-83) in LPS (p=0.45). VPS group showed a higher mean haemoglobin of 11.5 g/dl compared to 9.9 g/dl in the LPS group (p=0.001). CT brain scans showed hydrocephalus in 55 VPS and 13 LPS patients respectively. Shunt complications were observed in 17 (28%) VPS patients versus 10 (43.5%) LPS patients (p=0.5). Patients developing shunt sepsis in the VPS group exhibited a median CD4+ count of 117 cells/µl (IQR= 76-129) versus 48 cells/µl (IQR= 31- 66) in the LPS group (p=0.03). Early shunt malfunction occurred more frequently in the LPS group compared to VPS group (p=0.044). The mean hospital stay was 6.2 days for VPS versus 5.4 days for LPS patients (p=0.9). In-hospital mortality was 6%, occurring in three VPS and two LPS patients respectively. CONCLUSION Shunting procedures remain important surgical interventions for refractory IH secondary to HIV-related CM. However, cautious consideration is warranted for patients with CD4 counts below 200 cells/µL due to increased shunt complications. This study suggests a trend toward higher complication rates in patients undergoing LPS insertion.
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Affiliation(s)
- Ndyebo S Mabovula
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, KwaZulu Natal 4091, South Africa.
| | - Basil C Enicker
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, KwaZulu Natal 4091, South Africa.
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Zhao H, Lu Y, Li S, Qin J, Xu M, Ye H, Yang Z, Rao J, Chen G, Su F, Hu Z, Xu L. Voriconazole plus flucytosine is not superior to amphotericin B deoxycholate plus flucytosine as an induction regimen for cryptococcal meningitis treatment. Mycoses 2024; 67:e13674. [PMID: 37986630 DOI: 10.1111/myc.13674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The efficacy and side effects of voriconazole plus 5-flucytosine (Vori + 5-FC) versus amphotericin B deoxycholate plus 5-flucytosine (AmBd + 5-FC) as an induction treatment for cryptococcal meningitis are unknown. METHODS Forty-seven patients treated with Vori + 5-FC and 92 patients treated with AmBd + 5-FC were included in the current study after propensity score matching (PSM) at a ratio of 1:2. Two-week laboratory test results and 90-day mortality were compared between the two groups. RESULTS After 2 weeks of induction treatment, the CSF Cryptococcus sterile culture rate was 57.1% in the Vori + 5-FC group and 76.5% in the AmBd + 5-FC group (p = .026). No difference was found in the normalization of CSF indicators (glucose, total protein, intracranial pressure and India ink sterile rate) between the two groups. Both the Vori + 5FC regimen and AmBd + 5-FC regimen obviously decreased haemoglobin concentrations, platelet counts and serum potassium levels (all p ≤ .010). Notably, the Vori + 5FC regimen did not influence serum creatinine levels (p = .263), while AmBd + 5FC increased serum creatinine levels (p = .019) after 2-week induction treatment. The Vori + 5-FC group and AmBd + 5-FC group had similar 90-day cumulative survival rates (89.9% vs. 87.8%, p = .926). CONCLUSION The Vori + 5-FC regimen was associated with low 2-week CSF sterile culture and was not superior to AmBd + 5-FC as induction therapy in terms of the 90-day cumulative survival rate of CM patients.
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Affiliation(s)
- Handan Zhao
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yanqiu Lu
- Chongqing Public Health Medical Center, Southwest University Public Health Hospital, Chongqing, China
| | - Shan Li
- Department of Infectious Diseases, The Ninth Hospital of Nanchang, Nanchang, China
| | - Jiangying Qin
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Miaomiao Xu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Hui Ye
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
| | - Zongxing Yang
- Xixi Hospital of Hangzhou, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianfeng Rao
- Department of Infectious Diseases, The Ninth Hospital of Nanchang, Nanchang, China
| | - Guochun Chen
- Department of Infectious Diseases, The Third Peoples' Hospital of Changzhou, Changzhou, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Lijun Xu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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3
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Chai Z, Shou Y, Mungur R, Gong J, Zheng P, Zheng J. Analysis of the efficacy and related factors of ventriculoperitoneal shunt for AIDS with cryptococcal meningitis. Front Surg 2022; 9:942506. [PMID: 36117823 PMCID: PMC9479539 DOI: 10.3389/fsurg.2022.942506] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Zhaohui Chai
- Department of Neurosurgery, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Yikai Shou
- School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou, China
| | - Rajneesh Mungur
- Department of Neurosurgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jiangbiao Gong
- Department of Neurosurgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Peidong Zheng
- Department of Neurosurgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jiesheng Zheng
- Department of Neurosurgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Correspondence: Jiesheng Zheng
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Peláez N, Dunlop D, Negro E. Multiple cerebral infarctions as a complication of cryptococcal meningitis in a patient undergoing single lung transplantation. Neurologia 2022; 37:411-412. [PMID: 34521543 DOI: 10.1016/j.nrl.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 04/13/2021] [Accepted: 05/22/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- N Peláez
- Hospital Universitario Reina Sofía, Córdoba, España.
| | - D Dunlop
- Hospital Universitario Reina Sofía, Córdoba, España
| | - E Negro
- Hospital Universitario Reina Sofía, Córdoba, España
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Multiple cerebral infarctions as a complication of cryptococcal meningitis in a patient undergoing single lung transplantation. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:411-412. [DOI: 10.1016/j.nrleng.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/22/2021] [Indexed: 11/21/2022] Open
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Chang CC, Hall V, Cooper C, Grigoriadis G, Beardsley J, Sorrell TC, Heath CH. Consensus guidelines for the diagnosis and management of cryptococcosis and rare yeast infections in the haematology/oncology setting, 2021. Intern Med J 2021; 51 Suppl 7:118-142. [PMID: 34937137 DOI: 10.1111/imj.15590] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cryptococcosis caused by the Cryptococcus neoformans-Cryptococcus gattii complex is an important opportunistic infection in people with immunodeficiency, including in the haematology/oncology setting. This may manifest clinically as cryptococcal meningitis or pulmonary cryptococcosis, or be detected incidentally by cryptococcal antigenemia, a positive sputum culture or radiological imaging. Non-Candida, non-Cryptococcus spp. rare yeast fungaemia are increasingly common in this population. These consensus guidelines aim to provide clinicians working in the Australian and New Zealand haematology/oncology setting with clear guiding principles and practical recommendations for the management of cryptococcosis, while also highlighting important and emerging rare yeast infections and their recommended management.
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Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Therapeutic and Vaccine Research Programme, Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu Natal, South Africa
| | - Victoria Hall
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Transplant Infectious Diseases and Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Celia Cooper
- Department of Microbiology and Infectious Diseases, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - George Grigoriadis
- Monash Haematology, Monash Health, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Centre for Cancer Research, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Haematology, Alfred Hospital, Prahran, Victoria, Australia
| | - Justin Beardsley
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney, Sydney, New South Wales, Australia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Infectious Diseases, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney, Sydney, New South Wales, Australia.,Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Westmead, New South Wales, Australia.,Infectious Diseases and Sexual Health, Western Sydney Local Health District, Parramatta, New South Wales, Australia
| | - Christopher H Heath
- Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Department of Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Murdoch, Western Australia, Australia
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Zhao T, Xu XL, Nie JM, Chen XH, Jiang ZS, Liu SQ, Yang TT, Yang X, Sun F, Lu YQ, Harypursat V, Chen YK. Establishment of a novel scoring model for mortality risk prediction in HIV-infected patients with cryptococcal meningitis. BMC Infect Dis 2021; 21:786. [PMID: 34376147 PMCID: PMC8353436 DOI: 10.1186/s12879-021-06417-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/07/2021] [Indexed: 12/04/2022] Open
Abstract
Background Cryptococcal meningitis (CM) remains a leading cause of death in HIV-infected patients, despite advances in CM diagnostic and therapeutic strategies. This study was performed with the aim to develop and validate a novel scoring model to predict mortality risk in HIV-infected patients with CM (HIV/CM). Methods Data on HIV/CM inpatients were obtained from a Multicenter Cohort study in China. Independent risk factors associated with mortality were identified based on data from 2013 to 2017, and a novel scoring model for mortality risk prediction was established. The bootstrapping statistical method was used for internal validation. External validation was performed using data from 2018 to 2020. Results We found that six predictors, including age, stiff neck, impaired consciousness, intracranial pressure, CD4+ T-cell count, and urea levels, were associated with poor prognosis in HIV/CM patients. The novel scoring model could effectively identify HIV/CM patients at high risk of death on admission (area under curve 0.876; p<0.001). When the cut-off value of 5.5 points or more was applied, the sensitivity and specificity was 74.1 and 83.8%, respectively. Our scoring model showed a good discriminatory ability, with an area under the curve of 0.879 for internal validation via bootstrapping, and an area under the curve of 0.886 for external validation. Conclusions Our developed scoring model of six variables is simple, convenient, and accurate for screening high-risk patients with HIV/CM, which may be a useful tool for physicians to assess prognosis in HIV/CM inpatients.
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Affiliation(s)
- Ting Zhao
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Xiao-Lei Xu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Jing-Min Nie
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Xiao-Hong Chen
- Department of Infectious Diseases, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang province, China
| | - Zhong-Sheng Jiang
- Division of Infectious Diseases, Liuzhou People's Hospital, Liuzhou, Guangxi province, China
| | - Shui-Qing Liu
- Department of Infectious Diseases, Guiyang Public Health Clinical Center, Guiyang, Guizhou province, China
| | - Tong-Tong Yang
- Department of Infectious Disease, Public Health Clinical Center of Chengdu, Chengdu, Sichuan province, China
| | - Xuan Yang
- Department of Infectious Diseases, Sixth People's Hospital of Zhengzhou, Zhengzhou, Henan province, China
| | - Feng Sun
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Yan-Qiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Yao-Kai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China.
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Stead GA, Cresswell FV, Jjunju S, Oanh PK, Thwaites GE, Donovan J. The role of optic nerve sheath diameter ultrasound in brain infection. eNeurologicalSci 2021; 23:100330. [PMID: 33728383 PMCID: PMC7935708 DOI: 10.1016/j.ensci.2021.100330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
Abstract
Brain infections cause significant morbidity and mortality worldwide, especially in resource-limited settings with high HIV co-infection rates. Raised intracranial pressure [ICP] may complicate brain infection and worsen neurological injury, yet invasive ICP monitoring is often unavailable. Optic nerve sheath diameter [ONSD] ultrasound may allow detection of raised ICP at the bedside; however, pathology in brain infection is different to traumatic brain injury, in which most studies have been performed. The use of ONSD ultrasound has been described in tuberculous meningitis, cryptococcal meningitis and cerebral malaria; however correlation with invasive ICP measurement has not been performed. Normal optic nerve sheath values are not yet established for most populations, and thresholds for clinical intervention cannot be assumed to match those used in non-infective brain pathology. ONSD ultrasound may be suitable for use in resource-limited settings by clinicians with limited ultrasound training. Standardisation of scanning technique, consensus on normal ONSD values, and action on abnormal results, are areas for future research. This scoping review examines the role of ONSD ultrasound in brain infection. We discuss pathophysiology, and describe the rationale, practicalities, and challenges of utilising ONSD ultrasound for brain infection monitoring and management. We discuss the existing evidence base for this technique, and identify knowledge gaps and future research priorities.
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Key Words
- AIDS, Acquired immunodeficiency syndrome
- Brain infection
- CSF, Cerebrospinal fluid
- HIV, Human immunodeficiency virus
- ICP, Intracranial pressure
- IQR, Interquartile range
- IRIS, Immune reconstitution inflammatory syndrome
- LP, Lumbar puncture
- MAP, Mean arterial pressure
- Meningitis
- ONSD, Optic nerve sheath diameter
- Optic nerve sheath diameter
- ROC, Receiver-operator characteristic
- Raised intracranial pressure
- SD, Standard deviation
- TB meningitis, Tuberculous meningitis
- TBI, Traumatic brain injury
- Ultrasound
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Affiliation(s)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, Kampala, Uganda
- Clinical Research Department London School of Hygiene and Tropical Medicine, London, United Kingdom
- Medical Research Council – Uganda Virus Research Institute - London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Pham K.N. Oanh
- Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Guy E. Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
| | - Joseph Donovan
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
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Mansoor AER, Thompson J, Sarwari AR. Delays in lumbar puncture are independently associated with mortality in cryptococcal meningitis: a nationwide study. Infect Dis (Lond) 2021; 53:361-369. [PMID: 33661068 DOI: 10.1080/23744235.2021.1889656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is the most serious presentation of invasive cryptococcosis. Seen in patients with and without HIV infection, CM is associated with significant morbidity and mortality. Early lumbar puncture is a cornerstone of treatment in cryptococcal meningitis. We present findings from a nationwide analysis of patients admitted with CM in the United States between 2007 and 2016, with the aim of determining the impact of delays in lumbar puncture on inpatient outcomes. METHODS The national inpatient sample (NIS) database was queried for all inpatient visits for cryptococcal meningitis between January 2007 and December 2016. Logistic regression models were used to determine risk factors for inpatient mortality, prolonged admissions, and delays in obtaining an initial lumbar puncture. RESULTS The annual number of admissions for CM decreased during the study interval, from 3590 in 2007 to 2830 in 2016. Mortality did not change over this period (9.9%); however, length of stay and inpatient cost significantly increased. The proportion of patients with HIV declined from 70.7% to 54.0%. Delay in lumbar puncture beyond the first 24 h was independently associated with mortality (OR = 1.55, CI = 1.31-1.82, p-value <.001). Patients admitted on a weekend, those of African-American ethnicity, and those without a known history of HIV were more likely to have delays in obtaining an early LP. HIV patients had a lower risk of mortality (OR = 0.77, CI = 0.68-0.86, p-value <.001). CONCLUSION We found an independent association of delay in early lumbar puncture with worsened patient outcomes. Inpatient mortality for patients with CM continues to remain high, with an increasing proportion of patients without underlying HIV infection. There were significant deviations in management of CM from Infectious Diseases Society of America (IDSA) guidelines.
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Affiliation(s)
| | - Jesse Thompson
- Department of Internal Medicine, West Virginia University, Morgantown, WV, USA
| | - Arif R Sarwari
- Department of Internal Medicine, West Virginia University, Morgantown, WV, USA
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Li M, Liu J, Deng X, Gan Q, Wang Y, Xu X, Jiang Y, Peng F. Triple therapy combined with ventriculoperitoneal shunts can improve neurological function and shorten hospitalization time in non-HIV cryptococcal meningitis patients with increased intracranial pressure. BMC Infect Dis 2020; 20:844. [PMID: 33198666 PMCID: PMC7667777 DOI: 10.1186/s12879-020-05510-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Abstract
Background Raised intracranial pressure (ICP) and insufficient antifungal regimens are the two main factors result to unsatisfactory outcomes in non-HIV cryptococcal meningitis (CM) patients. In this study, we try to discuss that whether triple therapy of amphotericin B (AmB), fluconazole, 5-flucytosine (5-FC) plus ventriculoperitoneal shunts (VPS) is superior to AmB, 5-FC, fluconazole plus intermittent lumbar puncture in induction therapy in non-HIV CM patients with increased ICP. Methods We reviewed 66 clinical records from non-HIV CM patients with increased ICP. The demographic and clinical characteristics, BMRC staging, cerebrospinal fluid profiles (CSF), brain magnetic resonance imaging, treatment, and outcomes of these individuals were retrospectively analyzed. All non-HIV CM patients with increased ICP (≥ 25 cmH2O) were divided into two groups, including 27 patients treated with triple antifungal agents and 39 patients treated with the same triple therapy plus VPS. Results Triple therapy plus VPS group had more satisfactory outcomes, more CSF sterilization at 10 weeks follow-up, lower CSF opening pressure, lower BMRC staging scores one week after VPS, less CSF C. neoformans counts and CSF culture positive. Besides, these patients had shorter hospital stay than triple therapy group. Conclusions Triple antifungal agents combined with VPS could effectively reduce ICP, had faster rate of clearance of C. neoformans counts, more improved neurological function, shorten hospitalization time and better outcomes in non-HIV CM patients with increased ICP. Our study indicated that triple therapy plus early VPS may be an optimal treatment for non-HIV CM patients with increased ICP.
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Affiliation(s)
- Min Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Xuhui Deng
- Department of Neurology, Yuebei People' Hospital, Shaoguan, 5120264, Guangdong, China
| | - Qingzhou Gan
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Yijie Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Xiaofeng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
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Xu L, Yu J, Zheng B, Su F, Yang Z, Guo Y, Tao R, Dai X, Huang Y, Shi J, Zhang Z, Chen Y, Zhu B. HIV Infection Does Not Increase 10-Week Mortality of Chinese Cryptococcal Meningitis Patients. AIDS Res Hum Retroviruses 2020; 36:734-741. [PMID: 32539429 DOI: 10.1089/aid.2020.0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The role of HIV infection in precipitating different clinical features in cryptococcal meningitis (CM) patients remains controversial. One hundred twelve CM patients living with HIV/AIDS (CM+HIV+ patients) and 112 CM patients living without HIV/AIDS (CM+HIV- patients) were enrolled after propensity score matching. Demographic characteristics, symptoms, routine blood tests, and biochemical and cerebrospinal fluid (CSF) profiles were compared between the two groups. Kaplan-Meier analysis and Cox proportional hazards model was used to assess 10-week mortality. CM+HIV+ patients frequently occurred in young (mean age 40.3 ± 10.5) and male (89.3%) populations who also experienced leukopenia, neutropenia, lymphocytopenia, thrombocytopenia, and hypoalbuminemia, less headaches (66.9%), and higher cryptococcemia (23.2%) (all p < .050); they also had higher glucose (2.6 ± 1.1 mmol/L), increased smear positivity (78.8%), and decreased white blood cells [8.0 (2.0-28.0) × 106/L] in initial CSF assay (all p < .050). The 10-week cumulative survival rate was 84.6% for CM+HIV+ patients and 88.5% for CM+HIV- patients (p = .345). Age <35.0 years (hazard ratio (HR) 3.0 (1.0-8.9), p = .046), intracranial pressure (ICP) >250.0 mmH2O (HR: 4.8 (1.1-21.6), p = .041), and treatment lacking amphotericin B [HR: 6.5 (1.9-21.4), p = .003] were independent risk factors for 10-week mortality in CM+HIV+ patients. There are significant clinical differences in CM patients living with or without HIV/AIDS. However, the 10-week survival rate was similar between the two groups. Younger population, high ICP, and treatment lacking amphotericin B were independent risk factors for 10-week mortality of Chinese CM+HIV+ patients.
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Affiliation(s)
- Lijun Xu
- National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the Department of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianhua Yu
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou, China
| | - Bin Zheng
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
| | - Zongxing Yang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou, China
| | - Yongzheng Guo
- National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the Department of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ran Tao
- National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the Department of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiahong Dai
- Department of Infectious Diseases, Shulan Hospital, Hangzhou, China
| | - Ying Huang
- National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the Department of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jinchuan Shi
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou, China
| | - Zhongdong Zhang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou, China
| | - Yaokai Chen
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Biao Zhu
- National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the Department of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Loan JJM, Poon MTC, Tominey S, Mankahla N, Meintjes G, Fieggen AG. Ventriculoperitoneal shunt insertion in human immunodeficiency virus infected adults: a systematic review and meta-analysis. BMC Neurol 2020; 20:141. [PMID: 32303190 PMCID: PMC7164262 DOI: 10.1186/s12883-020-01713-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 03/31/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hydrocephalus is a common, life threatening complication of human immunodeficiency virus (HIV)-related central nervous system opportunistic infection which can be treated by insertion of a ventriculoperitoneal shunt (VPS). In HIV-infected patients there is concern that VPS might be associated with unacceptably high mortality. To identify prognostic indicators, we aimed to compare survival and clinical outcome following VPS placement between all studied causes of hydrocephalus in HIV infected patients. METHODS The following electronic databases were searched: The Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), EMBASE, CINAHL Plus, LILACS, Research Registry, the metaRegister of Controlled Trials, ClinicalTrials.gov, African Journals Online, and the OpenGrey database. We included observational studies of HIV-infected patients treated with VPS which reported of survival or clinical outcome. Data was extracted using standardised proformas. Risk of bias was assessed using validated domain-based tools. RESULTS Seven Hunderd twenty-three unique study records were screened. Nine observational studies were included. Three included a total of 75 patients with tuberculous meningitis (TBM) and six included a total of 49 patients with cryptococcal meningitis (CM). All of the CM and two of the TBM studies were of weak quality. One of the TBM studies was of moderate quality. One-month mortality ranged from 62.5-100% for CM and 33.3-61.9% for TBM. These pooled data were of low to very-low quality and was inadequate to support meta-analysis between aetiologies. Pooling of results from two studies with a total of 77 participants indicated that HIV-infected patients with TBM had higher risk of one-month mortality compared with HIV non-infected controls (odds ratio 3.03; 95% confidence-interval 1.13-8.12; p = 0.03). CONCLUSIONS The evidence base is currently inadequate to inform prognostication in VPS insertion in HIV-infected patients. A population-based prospective cohort study is required to address this, in the first instance.
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Affiliation(s)
- James J. M. Loan
- Centre for Clinical Brain Sciences and Centre for Discovery Brain Sciences, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
- Edinburgh Medical School, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
- Division of Neurosurgery, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925 South Africa
| | - Michael T. C. Poon
- Centre for Clinical Brain Sciences and Centre for Discovery Brain Sciences, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
- Edinburgh Medical School, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
| | - Steven Tominey
- Edinburgh Medical School, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
| | - Ncedile Mankahla
- Division of Neurosurgery, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925 South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - A. Graham Fieggen
- Division of Neurosurgery, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925 South Africa
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13
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Beardsley J, Sorrell TC, Chen SCA. Central Nervous System Cryptococcal Infections in Non-HIV Infected Patients. J Fungi (Basel) 2019; 5:jof5030071. [PMID: 31382367 PMCID: PMC6787755 DOI: 10.3390/jof5030071] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/22/2019] [Accepted: 07/29/2019] [Indexed: 12/27/2022] Open
Abstract
Central nervous system (CNS) cryptococcosis in non-HIV infected patients affects solid organ transplant (SOT) recipients, patients with malignancy, rheumatic disorders, other immunosuppressive conditions and immunocompetent hosts. More recently described risks include the use of newer biologicals and recreational intravenous drug use. Disease is caused by Cryptococcus neoformans and Cryptococcus gattii species complex; C. gattii is endemic in several geographic regions and has caused outbreaks in North America. Major virulence determinants are the polysaccharide capsule, melanin and several ‘invasins’. Cryptococcal plb1, laccase and urease are essential for dissemination from lung to CNS and crossing the blood–brain barrier. Meningo-encephalitis is common but intracerebral infection or hydrocephalus also occur, and are relatively frequent in C. gattii infection. Complications include neurologic deficits, raised intracranial pressure (ICP) and disseminated disease. Diagnosis relies on culture, phenotypic identification methods, and cryptococcal antigen detection. Molecular methods can assist. Preferred induction antifungal therapy is a lipid amphotericin B formulation (amphotericin B deoxycholate may be used in non-transplant patients) plus 5-flucytosine for 2–6 weeks depending on host type followed by consolidation/maintenance therapy with fluconazole for 12 months or longer. Control of raised ICP is essential. Clinicians should be vigilant for immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Justin Beardsley
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia
- Westmead Institute for Medical Research, Westmead, Sydney 2145, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital and the Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia.
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14
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Baddley JW, Thompson GR, Riley KO, Moore MK, Moser SA, Pappas PG. Factors Associated With Ventriculoperitoneal Shunt Placement in Patients With Cryptococcal Meningitis. Open Forum Infect Dis 2019; 6:ofz241. [PMID: 31214629 PMCID: PMC6565380 DOI: 10.1093/ofid/ofz241] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/19/2019] [Indexed: 11/14/2022] Open
Abstract
Objective Increased intracranial pressure (ICP) is an important complication of cryptococcal meningitis (CM) and impacts morbidity and mortality. Factors associated with permanent ventriculoperitoneal (VP) shunt placement are poorly characterized. Method We conducted a retrospective cohort study of patients with CM at the University of Alabama at Birmingham from 1996 through 2015. Characteristics of patients at time of CM diagnosis who did and did not receive a VP shunt were compared with use of the 2-group chi-square test or Fisher exact test for categorical variables and the 2-group t test for continuous variables. Stepwise logistic regression analysis was used to determine predictors of shunt placement. Results Of 422 patients with cryptococcosis, 257 (60.9%) had CM. Mean age was 47.7 years, 71.6% were male, and 44.4% were African American. The most common underlying conditions were HIV (42.4%), solid organ transplantation (29.6%), and corticosteroid use (34.2%). Forty-four (17.1%) received a VP shunt a median of 17 days (range, 1-320 days) post-diagnosis. By multivariable analysis, baseline opening pressure >30 cm H2O (OR, 9.4; 95% CI, 3.0, 28.8; P < .0001), being a normal host (OR, 6.3; 95% CI, 1.5, 26.1; P = .011) and hydrocephalus (OR, 4.9, 95% CI, 1.3, 17.9); P = .017) were associated with increased odds of shunting (Table 2). In contrast, age (OR, 0.96; 95% CI, 0.92, 0.99; P = .037) and male gender (OR, 0.18; 95% CI, 0.06, 0.55; P = .023) were associated with decreased odds of shunting. Conclusions Identification of factors at time of CM diagnosis associated with need for permanent VP shunt placement may allow for earlier, more aggressive treatment and potentially improve outcomes associated with increased ICP from cryptococcal meningitis.
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Affiliation(s)
- John W Baddley
- Department of Internal Medicine, Division of Infectious Diseases, University of Alabama at Birmingham.,Medical Service, Birmingham VA Medical Center, Alabama
| | - George R Thompson
- Department of Medical Microbiology and Immunology.,Department of Internal Medicine, Division of Infectious Diseases, University of California-Davis Medical Center
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham
| | - Mary K Moore
- Department of Internal Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | - Stephen A Moser
- Department of Pathology, University of Alabama at Birmingham
| | - Peter G Pappas
- Department of Internal Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
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15
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Seelig S, Ryus CR, Harrison RF, Wilson MP, Wong AH. Cryptococcal Meningoencephalitis Presenting as a Psychiatric Emergency. J Emerg Med 2019; 57:203-206. [PMID: 31014972 DOI: 10.1016/j.jemermed.2019.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Organic conditions can often mimic neuropsychiatric disorders, leading to delays in diagnosis and treatment for the most vulnerable populations presenting to the emergency department (ED). CASE REPORT Here we discuss a case of cryptococcal meningoencephalitis seemingly consistent with psychosis on initial evaluation, and present strategies to recognize and treat this condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to the indolent time course of this disease, initial symptoms of altered mental status and personality changes may be attributed to drug use or psychiatric illness before more overt evidence for increased intracranial pressure and neurologic infection develops. It is important for emergency clinicians to maintain a high level of suspicion for this condition in at-risk patients and reassess them frequently during their ED visit.
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Affiliation(s)
- Sandra Seelig
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut
| | - Caitlin R Ryus
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut
| | - Raquel F Harrison
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael P Wilson
- Department of Emergency Medicine, Behavioral Emergencies Research (DEMBER) Lab, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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16
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Khan N, Hiesgen J. Computerised tomography findings in HIV-associated cryptococcal meningoencephalitis at a tertiary hospital in Pretoria. SA J Radiol 2017; 21:1215. [PMID: 31754477 PMCID: PMC6837803 DOI: 10.4102/sajr.v21i2.1215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/24/2017] [Indexed: 12/03/2022] Open
Abstract
Objective Computerised tomography (CT) scans of 30 patients, admitted with HIV-associated cryptococcal meningoencephalitis (CM), were retrospectively reviewed and the different neuroradiological findings categorised. In addition to the characterisation of the cohort, we looked at whether positive CT scans can indicate negative outcomes when compared with normal imaging. Methods We identified all patients admitted with CM to Kalafong Hospital in Pretoria, South Africa, over a 2-year period and selected those who underwent brain CT. Abnormal findings were divided into cryptococcal-related lesions and other pathological findings. Clinical data, as well as laboratory data and information about the outcomes were collected. Results Thirty-nine (44.8%) out of 87 patients had a CT done during the hospital admission, of which 30 were reviewed and independently reported by the authors. The majority of CT scans were non-contrasted (n = 21). Four patients (13.3%) had normal imaging. Amongst the 26 patients with abnormal CTs, we found 16 brain scans (53.3%) with changes most likely attributed to CM. Dilated Virchow–Robin (VR) spaces, found on eight scans (26.7%), were the most common CT finding related to neurocryptococcosis. Global cerebral atrophy, present in 17 patients (56.7%), was the prevailing generalised abnormality. The mortality of all patients who underwent imaging was similar (33.3%) to the mortality in the total cohort of patients with cryptococcal meningitis (31%). In the group with cryptococcal-related changes on imaging, the mortality was higher (53.3%) than in both groups and a subgroup of five patients with hydrocephalus showed 100% mortality. Conclusion Computerised tomography brain imaging was performed in 44.8% of all patients admitted with CM into our hospital. More than half of the images showed cryptococcal-related pathological findings, of which dilated VR spaces were the most common. Only 13.3% of scans were normal. Mortality was higher in the patients with cryptococcal-related pathology (53.3% vs. 31%), with hydrocephalus being associated with a 100% mortality. No scan in our cohort showed any pathology requiring neurosurgical intervention or contraindicating the procedure of a lumbar puncture.
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Affiliation(s)
- Nausheen Khan
- Kalafong Hospital, University of Pretoria, South Africa
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17
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Loan JJM, Mankahla N, Meintjes G, Fieggen AG. Ventriculoperitoneal shunt insertion for hydrocephalus in human immunodeficiency virus-infected adults: a systematic review and meta-analysis protocol. Syst Rev 2017; 6:201. [PMID: 29037257 PMCID: PMC5644263 DOI: 10.1186/s13643-017-0603-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 10/04/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hydrocephalus is a recognised complication of human immunodeficiency virus (HIV)-related opportunistic infections. Symptomatic raised cerebrospinal fluid pressure can be treated with ventriculoperitoneal shunt insertion (VPS). In HIV-infected patients however, there is a concern that VPS might be associated with unacceptably high rates of mortality. We aim to systematically review and appraise published literature to determine reported outcomes and identify predictors of outcome following VPS in relevant subgroups of HIV-infected adults. METHODS The following electronic databases will be searched: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE, CINAHL (EBSCOhost), LILACS (BIREME), Research Registry ( www.researchregistry.com ), the metaRegister of Controlled Trials (mRCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and OpenSIGLE database. Any randomised studies, cohort studies, case-control studies, interrupted time series or sequential case series reporting survival following VPS in HIV-infected individuals will be included. If high-quality homogenous studies exist, meta-analysis will be conducted to determine 1-, 6- and 12-month mortality with comparison made between underlying aetiologies of hydrocephalus. DISCUSSION AND CONCLUSION This study will generate a comprehensive review of VPS in HIV-infected patients for publication. The primary outcome of meta-analysis is 12-month survival. If only low-quality, heterogeneous studies are available, this study will demonstrate this deficiency and will be of value in justifying and aiding the design of future studies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016052239.
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Affiliation(s)
- James J M Loan
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK. .,Institute of Neurosciences, 1345 Govan Road, Glasgow, G51 4TF, UK. .,Groote Schuur Hospital, Observatory, Cape Town, South Africa.
| | - Ncedile Mankahla
- Groote Schuur Hospital, Observatory, Cape Town, South Africa.,University of Cape Town, Rondebosch, Cape Town, South Africa.,Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
| | - Graeme Meintjes
- Groote Schuur Hospital, Observatory, Cape Town, South Africa.,University of Cape Town, Rondebosch, Cape Town, South Africa
| | - A Graham Fieggen
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.,Groote Schuur Hospital, Observatory, Cape Town, South Africa.,University of Cape Town, Rondebosch, Cape Town, South Africa.,Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
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18
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Rigi M, Khan K, Smith SV, Suleiman AO, Lee AG. Evaluation and management of the swollen optic disk in cryptococcal meningitis. Surv Ophthalmol 2017; 62:150-160. [DOI: 10.1016/j.survophthal.2016.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 10/02/2016] [Accepted: 10/10/2016] [Indexed: 12/20/2022]
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Hu Z, Yang Y, Cheng J, Cheng C, Chi Y, Wei H. The use of mannitol in HIV-infected patients with symptomatic cryptococcal meningitis. Drug Discov Ther 2016; 10:329-333. [PMID: 27725572 DOI: 10.5582/ddt.2016.01054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cryptococcal meningitis (CM) is a common opportunistic infection with a high mortality rate in human immunodeficiency virus (HIV)-infected patients. It is unclear whether mannitol could be used to manage neurological symptoms in HIV-associated CM. Here, we retrospectively analyzed the clinical data of 33 patients with HIV-associated symptomatic CM at our hospital where mannitol was used to relieve neurologic symptoms. With the empirical mannitol therapy, patients had a median of 2 episodes (range, 1-6 episodes) of headaches the day at the starting of anti-cryptococcal therapy. The median score of pain intensity assessed by numerical rating scales was 7-point (range, 4-8 points). After the administration of mannitol, the score of pain intensity was reduced to 3-point or less. Three weeks after anti-cryptococcal therapy, 75.8% (25/33) of the patients did not report headaches. During the initial 3 weeks of anti-cryptococcal therapy, 13 patients had a total of 42 episodes of seizures. 97.6% (41/42) of the episodes of seizures were controlled after the administration of mannitol. Overall, 87.9% (29/33) of the patients survived more than 10 weeks without the need of therapeutic cerebrospinal fluid drainage. Mannitol was used for median of 26 days (range, 1-85 days) in these 29 patients. One patient had permanent vision loss. This study indicates that mannitol may possibly relieve neurologic symptoms in HIV-associated CM. It is worth re-revaluating the role of mannitol administration as a symptom control strategy in mild cases of HIV-associated CM.
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Affiliation(s)
- Zhiliang Hu
- Department of Infectious Diseases, the Second Affiliated Hospital of Medical School of the Southeast University
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20
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Abstract
OBJECT Patients with cryptococcal meningitis often develop symptomatic intracranial hypertension. The need for permanent CSF diversion in these cases remains unclear. METHODS Cases of cryptococcal meningitis over a 5-year period were reviewed from a single, large teaching hospital. Sources of identification included ICD-9 codes, operative logs, and microscopy laboratory records. RESULTS Fifty cases of cryptococcal meningitis were identified. Ninety-eight percent (49/50) of patients were HIV positive. Opening pressure on initial lumbar puncture diagnosing cryptococcal meningitis was elevated (> 25 cm H2O) in 33 cases and normal (≤ 25 cm H2O) in 17 cases. Thirty-eight patients ultimately developed elevated opening pressure over a follow-up period ranging from weeks to years. Serial lumbar punctures for relief of intracranial hypertension were performed in 29 cases. Thirteen of these patients ultimately had shunting procedures performed after failing to improve clinically. Two factors were significantly associated with the need for shunting: patients undergoing shunt placement were more likely to be women (5/13 vs 0/16; p = 0.01) and to have a pattern of increasing CSF cryptococcal antigen (10/13 vs 3/16 cases; p = 0.003). All patients re-presenting with mycological relapse either underwent or were offered shunt placement. CONCLUSIONS Neurosurgeons are often asked to consider CSF diversion in cases of cryptococcal meningitis complicated by intracranial hypertension. Most patients do well with serial lumbar punctures combined with antifungal therapy. When required, shunting generally provided sustained relief from intracranial hypertension symptoms. Ventriculoperitoneal shunts are the favored method of diversion. To the authors' knowledge, the present study is the largest series on diversionary shunts in primarily HIV-positive patients with this problem.
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Affiliation(s)
| | - Robert L Atmar
- Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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21
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Beardsley J, Thanh LT, Day J. A Model CNS Fungal Infection: Cryptococcal Meningitis. CURRENT CLINICAL MICROBIOLOGY REPORTS 2015. [DOI: 10.1007/s40588-015-0016-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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22
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Corti M, Priarone M, Negroni R, Gilardi L, Castrelo J, Arechayala AI, Messina F, Franze O. Ventriculoperitoneal shunts for treating increased intracranial pressure in cryptococcal meningitis with or without ventriculomegaly. Rev Soc Bras Med Trop 2015; 47:524-7. [PMID: 25229298 DOI: 10.1590/0037-8682-0176-2013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Cryptococcosis is an opportunistic mycosis, especially in patients that are human immunodeficiency virus (HIV)-positive, and frequently involves the central nervous system. METHODS We assessed the potential of ventriculoperitoneal shunting (VPS) in preventing mortality due to uncontrollable intracranial hypertension (ICH) in 15 patients with acquired immunodeficiency syndrome (AIDS)-related cryptococcal meningitis. RESULTS After 2 weeks of antifungal therapy consisting of amphotericin B deoxycholate with or without fluconazole, patients with persistent ICH underwent VPS, despite having persistent Cryptococcus neoformans infection. In 12 patients, the uncontrollable ICH was resolved by VPS. CONCLUSIONS Patients with cryptococcal meningoencephalitis who have ICH must be considered for VPS even with positive cerebrospinal fluid cultures.
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Affiliation(s)
- Marcelo Corti
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Maria Priarone
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Ricardo Negroni
- Mycology Unit, Francisco Javier Muñiz Hospital, Buenos Aires, Argentina
| | - Leonardo Gilardi
- Sociedad Iberoamericana de Información Cientifica, Buenos Aires, Argentina
| | - Jimena Castrelo
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Fernando Messina
- Mycology Unit, Francisco Javier Muñiz Hospital, Buenos Aires, Argentina
| | - Osvaldo Franze
- Neurosurgery Department, Francisco Javier Muñiz Hospital, Buenos Aires, Argentina
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de Vedia L, Arechavala A, Calderón MI, Maiolo E, Rodríguez A, Lista N, Di Virgilio E, Cisneros JC, Prieto R. Relevance of intracranial hypertension control in the management of Cryptococcus neoformans meningitis related to AIDS. Infection 2014; 41:1073-7. [PMID: 24122543 DOI: 10.1007/s15010-013-0538-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 09/23/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the relationship between intracranial hyperpressure (HICP) and mortality in patients with cryptococcal meningitis related to AIDS (CMRA). METHODS This was an observational retrospective study. Patients were treated according to the Infectious Diseases Society of America recommendations during the evaluation period (days 0, 3, 5 and after hospitalization). High intracranial pressure (HICP) was defined as ICP values of C250 mm H20. The correlation between HICP and mortality at each of the three time points considered was investigated. Statistical analysis on the descriptive parameters and on the probability of a "death" event (odds ratio, OR) at each of those three time points was performed using the statistical software program Epidata. RESULTS Eighty patients were included in this study, of whom 53 (66.25 %) were male. The average age of the patients was 37.5 ± 8.1 (range 22–55) years. The median CD4?lymphocyte cell count was 35 (range 0–367) cells/ml. Among the entire patient cohort, 53 patients had a favorable outcome, and the mortality rate was 33.75 %. At baseline (day 0), 57 subjects (71.5 %) presented HICP, and these patients had a higher mortality rate than those with a normal ICP, but the difference did not reach statistical significance[OR 1.65, 95 % confidence interval (CI) 0.56–4.84]. On day 3, 41 of the patients presented HICP, and HICP at this timepoint was significantly associated with an increased risk of mortality (OR 4.35, 95 % CI 1.56–12.09). On day 5, 35(43.5 %) patients presented HICP, and HCIP at this time point was also significantly associated with higher mortality (OR 7.23, 95 % CI 2.53–20.14). CONCLUSION The results of this study confirm an association between HICP and mortality in patients with CMRA and indicate that the control of ICP during the first 5 days of hospitalization is more important than managing HICP only at baseline.
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Abstract
Cryptococcal meningitis causes morbidity and mortality worldwide. The burden of disease is greatest in middle- and low-income countries with a high incidence of human immunodeficiency virus (HIV) infection. Patients taking immunosuppressive drugs and some immunocompetent hosts are also at risk. Treatment of cryptococcal meningitis consists of three phases: induction, consolidation, and maintenance. Effective induction therapy requires potent fungicidal drugs (amphotericin B and flucytosine), which are often unavailable in low-resource, high-endemicity settings. As a consequence, mortality is unacceptably high. Wider access to effective treatment is urgently required to improve outcomes. For human immunodeficiency virus-infected patients, judicious management of asymptomatic cryptococcal antigenemia and appropriately timed introduction of antiretroviral therapy are important.
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Affiliation(s)
- Derek J Sloan
- Tropical and infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Victoria Parris
- Tropical and infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
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La Hoz RM, Pappas PG. Cryptococcal infections: changing epidemiology and implications for therapy. Drugs 2014; 73:495-504. [PMID: 23575940 DOI: 10.1007/s40265-013-0037-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although the incidence of HIV-associated cryptococcosis has decreased in developed countries since the introduction of antiretroviral therapy, this disease continues to cause significant morbidity and mortality in sub-Saharan Africa among patients with AIDS. Important strides have been made in an attempt to decrease the burden of disease, particularly the development of the lateral flow assay cryptococcal antigen (LFA CrAg) as a diagnostic tool in resource-limited settings, coupled with the introduction of pre-emptive treatment with fluconazole for HIV-positive patients at risk for cryptococcosis with a positive LFA CrAg. Among solid organ transplant recipients, recent prospective studies have identified cryptococcosis as the third most common invasive fungal infection, and progress is being made toward earlier diagnosis and more effective therapy. Finally, the Cryptococcus gattii outbreak in British Columbia, Canada and the US Pacific Northwest is providing important new insights into the emergence of this pathogen in geographic areas previously considered low risk for acquisition of infection. Understanding the similarities and differences among C. gattii and C. neoformans infections will provide critical insights into the behavior of these organisms in the human host. Both pathogens affect immunocompetent and immunosuppressed hosts, causing pulmonary, central nervous system and widely disseminated infections. Treatment recommendations in the future will necessarily take into account the site of infection, clinical severity of the infection, Cryptococcus species, host immune status and economic resources.
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Affiliation(s)
- Ricardo M La Hoz
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd, THT 229, Birmingham, AL 35294-0006, USA
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Abstract
The field of HIV medicine has changed rapidly in the last two decades since effective and tolerable antiretroviral treatment became available. As a result, although classical opportunistic infections of the brain have become less common, clinicians need to be aware of a wider range of acute and chronic complications of HIV and its treatment. In this article, we summarise major opportunistic infections, immune reconstitution inflammatory syndrome, HIV-associated neurocognitive disorders, and cerebrovascular disease in HIV positive patients. We also emphasise the preventability and reversibility of most of the central nervous system complications of HIV, and hence the importance of early diagnosis of HIV and involvement of clinicians with special expertise in HIV medicine.
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Affiliation(s)
- Lewis J Haddow
- Research Department of Infection and Population Health, University College London, UK
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Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis. PLoS Med 2012; 9:e1001316. [PMID: 23055838 PMCID: PMC3463510 DOI: 10.1371/journal.pmed.1001316] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 08/16/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is the most common form of meningitis in Africa. World Health Organization guidelines recommend 14-d amphotericin-based induction therapy; however, this is impractical for many resource-limited settings due to cost and intensive monitoring needs. A cost-effectiveness analysis was performed to guide stakeholders with respect to optimal CM treatment within resource limitations. METHODS AND FINDINGS We conducted a decision analysis to estimate the incremental cost-effectiveness ratio (ICER) of six CM induction regimens: fluconazole (800-1,200 mg/d) monotherapy, fluconazole + flucytosine (5FC), short-course amphotericin (7-d) + fluconazole, 14-d of amphotericin alone, amphotericin + fluconazole, and amphotericin + 5FC. We computed actual 2012 healthcare costs in Uganda for medications, supplies, and personnel, and average laboratory costs for three African countries. A systematic review of cryptococcal treatment trials in resource-limited areas summarized 10-wk survival outcomes. We modeled one-year survival based on South African, Ugandan, and Thai CM outcome data, and survival beyond one-year on Ugandan and Thai data. Quality-adjusted life years (QALYs) were determined and used to calculate the cost-effectiveness ratio and ICER. The cost of hospital care ranged from $154 for fluconazole monotherapy to $467 for 14 d of amphotericin + 5FC. Based on 18 studies investigating outcomes for HIV-infected individuals with CM in resource-limited settings, the estimated mean one-year survival was lowest for fluconazole monotherapy, at 40%. The cost-effectiveness ratio ranged from $20 to $44 per QALY. Overall, amphotericin-based regimens had higher costs but better survival. Short-course amphotericin (1 mg/kg/d for 7 d) with fluconazole (1,200 mg/d for14 d) had the best one-year survival (66%) and the most favorable cost-effectiveness ratio, at $20.24/QALY, with an ICER of $15.11 per additional QALY over fluconazole monotherapy. The main limitation of this study is the pooled nature of a systematic review, with a paucity of outcome data with direct comparisons between regimens. CONCLUSIONS Short-course (7-d) amphotericin induction therapy coupled with high-dose (1,200 mg/d) fluconazole is "very cost effective" per World Health Organization criteria and may be a worthy investment for policy-makers seeking cost-effective clinical outcomes. More head-to-head clinical trials are needed on treatments for this neglected tropical disease. Please see later in the article for the Editors' Summary.
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Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, Harrison TS, Larsen RA, Lortholary O, Nguyen MH, Pappas PG, Powderly WG, Singh N, Sobel JD, Sorrell TC. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis 2010; 50:291-322. [PMID: 20047480 PMCID: PMC5826644 DOI: 10.1086/649858] [Citation(s) in RCA: 1725] [Impact Index Per Article: 123.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. These guidelines for its management have been built on the previous Infectious Diseases Society of America guidelines from 2000 and include new sections. There is a discussion of the management of cryptococcal meningoencephalitis in 3 risk groups: (1) human immunodeficiency virus (HIV)-infected individuals, (2) organ transplant recipients, and (3) non-HIV-infected and nontransplant hosts. There are specific recommendations for other unique risk populations, such as children, pregnant women, persons in resource-limited environments, and those with Cryptococcus gattii infection. Recommendations for management also include other sites of infection, including strategies for pulmonary cryptococcosis. Emphasis has been placed on potential complications in management of cryptococcal infection, including increased intracranial pressure, immune reconstitution inflammatory syndrome (IRIS), drug resistance, and cryptococcomas. Three key management principles have been articulated: (1) induction therapy for meningoencephalitis using fungicidal regimens, such as a polyene and flucytosine, followed by suppressive regimens using fluconazole; (2) importance of early recognition and treatment of increased intracranial pressure and/or IRIS; and (3) the use of lipid formulations of amphotericin B regimens in patients with renal impairment. Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies. However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients.
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Affiliation(s)
- John R Perfect
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Blanch JJ, Rodríguez M, Escribano E, Atienzar M. [Cryptococcal meningitis with a fatal outcome in an immunocompetent adult]. Enferm Infecc Microbiol Clin 2009; 28:256-7. [PMID: 19683836 DOI: 10.1016/j.eimc.2009.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 03/16/2009] [Accepted: 03/20/2009] [Indexed: 11/29/2022]
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Moretti ML, Resende MR, Lazéra MDS, Colombo AL, Shikanai-Yasuda MA. [Guidelines in cryptococcosis--2008]. Rev Soc Bras Med Trop 2009; 41:524-44. [PMID: 19009203 DOI: 10.1590/s0037-86822008000500022] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Sloan D, Dlamini S, Paul N, Dedicoat M. Treatment of acute cryptococcal meningitis in HIV infected adults, with an emphasis on resource-limited settings. Cochrane Database Syst Rev 2008:CD005647. [PMID: 18843697 DOI: 10.1002/14651858.cd005647.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite the advent and increasingly wide availability of antiretroviral therapy, cryptococcal meningitis (CM) remains a significant cause of mortality and morbidity amongst individuals with HIV infection in resource-limited settings. The ideal management of CM remains unclear. The aim of this review is to assess the evidence for deciding on which antifungal regimen to use as well as other modalities of management to utilise especially resource poor settings in order to achieve the best possible outcome and enable an individual with CM to survive their acute illness and benefit from antiretroviral therapy. OBJECTIVES To determine the most effective initial and consolidation treatment strategy for CM in HIV infected adults. SEARCH STRATEGY The Cochrane HIV/AIDS group search strategy was used. Key words in the search included, meningitis, cryptococcus neoformans, treatment, trial, human immunodeficiency virus, acquired immunodeficiency syndrome, antifungal agents, amphotericin, flucytosine, fluconazole, azole, lumbar puncture, cerebrospinal fluid (CSF) pressure and acetazolamide. SELECTION CRITERIA Randomised of HIV-infected adults with a first episode of CM diagnosed on CSF examination, by India ink staining, CSF culture or cryptococcal antigen testing. DATA COLLECTION AND ANALYSIS Data were extracted using standardised forms and analysed using Rev Man 4.2.7 software. MAIN RESULTS Six studies are included in the review. Five of the studies compared antifungal treatments and one study addressed lowering intracranial pressure. This study was stopped early due to excess adverse effects. The results of the other five studies as summarised as follows.Mayanja-Kizza 1998 compared fluconazole to fluconazole with 5 flucytosine. The dose of fluconazole used 200mg initially is lower than the recommended initial dose of 400mg. No survival advantage was found with the use of 5 flucytosine in addition to fluconazole.Two studies Brouwer 2004 and van der Horst 1997 compared Amphotericin (AmB) to AmB with 5 flucytosine. Both drugs were given at currently recommended doses for 2 weeks. No survival difference was found at 14 days or at 10 weeks (only recorded in Brouwer 2004). There were significantly more patients with sterile CSF cultures at 14 days in the group that received AmB with flucytosine.Brouwer 2004 compared AmB given alone to AmB given with flucytosine and fluconazole alone or in combination. This was a small study and no differences in mortality were noted between the groups.Bicanic 2008 compared high to standard dose AmB both with flucytosine. There was no difference in mortality between the two groups or adverse events.Leenders 1997 compared standard AmB to liposomal AmB. There was no difference in death rates between the two groups. But there were significantly fewer side effects in the group treated with liposomal AmB. AUTHORS' CONCLUSIONS The main aim of this review was to determine the best treatment for cryptococcal meningitis in resource-limited settings. In these settings usually only AmB and fluconazole are available. No studies suitable for inclusion in the review were found that compared these two drugs. Therefore we are unable to recommend either treatment as superior to the other. The recommended treatment for CM is a combination of AmB and flucytosine. The optimal dosing of AmB remains unclear. Liposomal AmB is associated with less adverse events than AmB and may be useful in selected patients where resources allow.Future research into the management of cryptococcal meningitis in resource-limited settings should focus on the most effective use of medications that are available in these settings.Flucytosine in combination with AmB leads to faster and increased sterilisation of CSF compared to using AmB alone. As Flucytosine is often not available in developing countries, policy makers and national departments of heath should consider procuring this drug for HIV treatment programmes.
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Affiliation(s)
- Derek Sloan
- Hlabisa hospital, Private Bag x5001, Hlabisa, KwaZulu / Natal, South Africa, 3937.
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Kambugu A, Meya DB, Rhein J, O'Brien M, Janoff EN, Ronald AR, Kamya MR, Mayanja-Kizza H, Sande MA, Bohjanen PR, Boulware DR. Outcomes of cryptococcal meningitis in Uganda before and after the availability of highly active antiretroviral therapy. Clin Infect Dis 2008; 46:1694-701. [PMID: 18433339 DOI: 10.1086/587667] [Citation(s) in RCA: 226] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is the proximate cause of death in 20%-30% of persons with acquired immunodeficiency syndrome in Africa. METHODS Two prospective, observational cohorts enrolled human immunodeficiency virus (HIV)-infected, antiretroviral-naive persons with CM in Kampala, Uganda. The first cohort was enrolled in 2001-2002 (n = 92), prior to the availability of highly active antiretroviral therapy (HAART), and the second was enrolled in 2006-2007 (n = 44), when HAART was available. RESULTS Ugandans presented with prolonged CM symptoms (median duration, 14 days; interquartile range, 7-21 days). The 14-day survival rates were 49% in 2001-2002 and 80% in 2006 (P < .001). HAART was started 35 +/- 13 days after CM diagnosis and does not explain the improved 14-day survival rate in 2006. In 2006-2007, the survival rate continued to decrease after hospitalization, with only 55% surviving to initiate HAART as an outpatient. Probable cryptococcal-related immune reconstitution inflammatory syndrome occurred in 42% of patients, with 4 deaths. At 6 months after CM diagnosis, 18 persons (41%) were alive and receiving HAART in 2007. The median cerebral spinal fluid (CSF) opening pressure was 330 mm H(2)O; 81% of patients had elevated pressure (>200 mm H(2)O). Only 5 patients consented to therapeutic lumbar puncture. There was a trend for higher mortality for pressures >250 mm H(2)O (odds ratio [OR], 2.1; 95% confidence interval [CI], 0.9-5.2; P = .09). Initial CSF WBC counts of <5 cells/mL were associated with failure of CSF sterilization (OR, 17.3; 95% CI, 3.1-94.3; P < .001), and protein levels <35 mg/dL were associated with higher mortality (OR, 2.0; 95% CI, 1.2-3.3; P = .007). CONCLUSIONS Significant CM-associated mortality persists, despite the administration of amphotericin B and HIV therapy, because of the high mortality rate before receipt of HAART and because of immune reconstitution inflammatory syndrome-related complications after HAART initiation. Approaches to increase acceptance of therapeutic lumbar punctures are needed.
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Affiliation(s)
- Andrew Kambugu
- Infectious Disease Institute, Makerere University, Kampala Uganda
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Lin X, Litvintseva AP, Nielsen K, Patel S, Floyd A, Mitchell TG, Heitman J. alpha AD alpha hybrids of Cryptococcus neoformans: evidence of same-sex mating in nature and hybrid fitness. PLoS Genet 2007; 3:1975-90. [PMID: 17953489 PMCID: PMC2042000 DOI: 10.1371/journal.pgen.0030186] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2007] [Accepted: 09/10/2007] [Indexed: 11/19/2022] Open
Abstract
Cryptococcus neoformans is a ubiquitous human fungal pathogen that causes meningoencephalitis in predominantly immunocompromised hosts. The fungus is typically haploid, and sexual reproduction involves two individuals with opposite mating types/sexes, alpha and a. However, the overwhelming predominance of mating type (MAT) alpha over a in C. neoformans populations limits alpha-a mating in nature. Recently it was discovered that C. neoformans can undergo same-sex mating under laboratory conditions, especially between alpha isolates. Whether same-sex mating occurs in nature and contributes to the current population structure was unknown. In this study, natural alpha AD alpha hybrids that arose by fusion between two alpha cells of different serotypes (A and D) were identified and characterized, providing definitive evidence that same-sex mating occurs naturally. A novel truncated allele of the mating-type-specific cell identity determinant SXI1 alpha was also identified as a genetic factor likely involved in this process. In addition, laboratory-constructed alpha AD alpha strains exhibited hybrid vigor both in vitro and in vivo, providing a plausible explanation for their relative abundance in nature despite the fact that AD hybrids are inefficient in meiosis/sporulation and are trapped in the diploid state. These findings provide insights on the origins, genetic mechanisms, and fitness impact of unisexual hybridization in the Cryptococcus population.
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Affiliation(s)
- Xiaorong Lin
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Anastasia P Litvintseva
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Kirsten Nielsen
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Sweta Patel
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Anna Floyd
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Thomas G Mitchell
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joseph Heitman
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, United States of America
- * To whom correspondence should be addressed. E-mail:
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Hu G, Steen BR, Lian T, Sham AP, Tam N, Tangen KL, Kronstad JW. Transcriptional regulation by protein kinase A in Cryptococcus neoformans. PLoS Pathog 2007; 3:e42. [PMID: 17367210 PMCID: PMC1828699 DOI: 10.1371/journal.ppat.0030042] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Accepted: 02/06/2007] [Indexed: 11/26/2022] Open
Abstract
A defect in the PKA1 gene encoding the catalytic subunit of cyclic adenosine 5'-monophosphate (cAMP)-dependent protein kinase A (PKA) is known to reduce capsule size and attenuate virulence in the fungal pathogen Cryptococcus neoformans. Conversely, loss of the PKA regulatory subunit encoded by pkr1 results in overproduction of capsule and hypervirulence. We compared the transcriptomes between the pka1 and pkr1 mutants and a wild-type strain, and found that PKA influences transcript levels for genes involved in cell wall synthesis, transport functions such as iron uptake, the tricarboxylic acid cycle, and glycolysis. Among the myriad of transcriptional changes in the mutants, we also identified differential expression of ribosomal protein genes, genes encoding stress and chaperone functions, and genes for secretory pathway components and phospholipid synthesis. The transcriptional influence of PKA on these functions was reminiscent of the linkage between transcription, endoplasmic reticulum stress, and the unfolded protein response in Saccharomyces cerevisiae. Functional analyses confirmed that the PKA mutants have a differential response to temperature stress, caffeine, and lithium, and that secretion inhibitors block capsule production. Importantly, we also found that lithium treatment limits capsule size, thus reinforcing potential connections between this virulence trait and inositol and phospholipid metabolism. In addition, deletion of a PKA-regulated gene, OVA1, revealed an epistatic relationship with pka1 in the control of capsule size and melanin formation. OVA1 encodes a putative phosphatidylethanolamine-binding protein that appears to negatively influence capsule production and melanin accumulation. Overall, these findings support a role for PKA in regulating the delivery of virulence factors such as the capsular polysaccharide to the cell surface and serve to highlight the importance of secretion and phospholipid metabolism as potential targets for anti-cryptococcal therapy.
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Affiliation(s)
- Guanggan Hu
- The Michael Smith Laboratories, The University of British Columbia, Vancouver, British Columbia, Canada
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Clancy CJ, Nguyen MH. Reply to Antinori. Clin Infect Dis 2006. [DOI: 10.1086/507553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Pappas PG. Managing Cryptococcal Meningitis Is about Handling the Pressure. Clin Infect Dis 2005; 40:480-2. [PMID: 15668875 DOI: 10.1086/427222] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Accepted: 10/19/2004] [Indexed: 11/03/2022] Open
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