Cryptococcal Meningitis Management in Tanzania With Strict Schedule of Serial Lumber Punctures Using Intravenous Tubing Sets

Meda, John R.; Kalluvya, Samuel; Downs, Jennifer A.; Chofle, Awilly A; Seni, Jeremiah; Kidenya, Benson R.; Fitzgerald, Daniel W.; Peck, Robert

doi:10.1097/qai.0000000000000147

Cited by 42 publications

(45 citation statements)

References 19 publications

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“…10 With these results, in both the general population and the population of inpatients with advanced HIV disease, and knowing that the cost of ceftriaxone 2 g (US$2) is the same as the cryptococcal antigen lateral flow assay (CrAg LFA, $2 Immy, Inc.), one might consider an algorithm for those HIV-infected patients initially presenting with meningitis, involving an initial cryptococcal antigen point-of-care test in the blood. If the CrAg LFA were positive, the physician would then measure CSF opening pressure, 31 or perform a large volume lumbar puncture to reduce intracranial pressure. If cryptococcal antigen negative, one could do the lumbar puncture and perform gram stain, culture, and consider empiric ceftriaxone.…”

Section: Discussionmentioning

confidence: 99%

Epidemiology of Meningitis in an HIV-Infected Ugandan Cohort

Rajasingham¹,

Rhein²,

Klammer³

et al. 2015

The American Society of Tropical Medicine and Hygiene

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Abstract. There is limited understanding of the epidemiology of meningitis among human immunodeficiency virus (HIV)-infected populations in sub-Saharan Africa. We conducted a prospective cohort study of HIV-infected adults with suspected meningitis in Uganda, to comprehensively evaluate the etiologies of meningitis. Intensive cerebrospiral fluid (CSF) testing was performed to evaluate for bacterial, viral, fungal, and mycobacterial etiologies, including neurosyphilis,16s ribosomal DNA (rDNA) polymerase chain reaction (PCR) for bacteria, Plex-ID broad viral assay, quantitative-PCR for HSV-1/2, cytomegalovirus (CMV), Epstein-Barr virus (EBV), and Toxoplasma gondii; reverse transcription-PCR (RT-PCR) for Enteroviruses and arboviruses, and Xpert MTB/RIF assay. Cryptococcal meningitis accounted for 60% (188 of 314) of all causes of meningitis. Of 117 samples sent for viral PCR, 36% were EBV positive. Among cryptococcal antigen negative patients, the yield of Xpert MTB/RIF assay was 22% (8 of 36). After exclusion of cryptococcosis and bacterial meningitis, 61% (43 of 71) with an abnormal CSF profile had no definitive diagnosis. Exploration of new TB diagnostics and diagnostic algorithms for evaluation of meningitis in resource-limited settings remains needed, and implementation of cryptococcal diagnostics is critical.

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Section: Discussionmentioning

confidence: 99%

Epidemiology of Meningitis in an HIV-Infected Ugandan Cohort

Rajasingham¹,

Rhein²,

Klammer³

et al. 2015

The American Society of Tropical Medicine and Hygiene

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“…Lumbar puncture drainage is an effective strategy to reduce the ICP and it also helps to remove fungal elements (7). There are accumulated evidences that therapeutic lumbar puncture in HIV associated CM is associated with improvement in survival, and non-adherence to this strategy may in part lead to neurological injury (14,17,18). Despite of survival benefit, therapeutic lumbar puncture is not performed in some patients, which may be due to limited awareness of the importance of ICP management (7,17,18).…”

Section: Discussionmentioning

confidence: 97%

“…For the patients that need massive mannitol administration, they would better receive therapeutic lumbar puncture drainage or perhaps ventriculoperitoneal shunting (25), although this was not performed in our patients. Of note, adult human produces 500-600 mL CSF every day (26), while usually less than 30 mL CSF is removed by a lumbar puncture drainage (14). If one lumbar puncture is performed each day, 94-95% of the CSF still needs to be reabsorbed by meninge.…”

Section: Discussionmentioning

confidence: 99%

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The use of mannitol in HIV-infected patients with symptomatic cryptococcal meningitis

Yang

Cheng

et al. 2016

DD&T

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“…After adjustment for potential confounding, a 69% relative survival benefit was observed after receiving a therapeutic LP. Raised intracranial pressure is common in cryptococcal meningitis, occurring in >60% of patients in sub-Saharan Africa [5,15,17]; thus, these findings may have a large impact on recovery from cryptococcal meningitis. Prior data suggest ICP can build up over time, and any rise may initially be asymptomatic [11,15].…”

Section: Discussionmentioning

confidence: 99%

The Effect of Therapeutic Lumbar Punctures on Acute Mortality from Cryptococcal Meningitis

2015

Clinical Infectious Diseases

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Introduction. Cryptococcal meningitis is the most common cause of adult meningitis in sub-Saharan Africa. Raised intracranial pressure (ICP) is common in cryptococcosis. Prior studies suggest elevated ICP is associated with mortality, and guidelines recommend frequent lumbar punctures (LPs) to control ICP. However, the magnitude of the impact of LPs on cryptococcal-related mortality is unknown.Methods. In sum, 248 individuals with human immunodeficiency virus (HIV)-associated cryptococcal meningitis, screened for the Cryptococcal Optimal ART Timing (COAT) trial in Uganda and South Africa, were observed. Individuals received an LP to diagnose meningitis, and subsequent therapeutic LPs were recommended for elevated ICP (>250 mmH 2 O) or new symptoms. We compared survival, through 11 days, between individuals receiving at least 1 therapeutic LP with individuals not receiving therapeutic LPs. The COAT trial randomized subjects at 7-11 days; thus, follow-up stopped at time of death, randomization, or 11 days.Results. Seventy-five (30%) individuals had at least 1 therapeutic LP. Individuals receiving therapeutic LPs had higher cerebrospinal fluid (CSF) opening pressures, higher CSF fungal burdens, and were more likely to have altered mental status at baseline than those with no therapeutic LPs. Thirty-one deaths (18%) occurred among 173 individuals without a therapeutic LP and 5 deaths (7%) among 75 with at least 1 therapeutic LP. The adjusted relative risk of mortality was 0.31 (95% confidence interval: .12-.82). The association was observed regardless of opening pressure at baseline.Conclusions. Therapeutic LPs were associated with a 69% relative improvement in survival, regardless of initial intracranial pressure. The role of therapeutic LPs should be reevaluated.

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Cryptococcal Meningitis Management in Tanzania With Strict Schedule of Serial Lumber Punctures Using Intravenous Tubing Sets

Cited by 42 publications

References 19 publications

Epidemiology of Meningitis in an HIV-Infected Ugandan Cohort

Epidemiology of Meningitis in an HIV-Infected Ugandan Cohort

The use of mannitol in HIV-infected patients with symptomatic cryptococcal meningitis

The Effect of Therapeutic Lumbar Punctures on Acute Mortality from Cryptococcal Meningitis

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