Relevance of intracranial hypertension control in the management of Cryptococcus neoformans meningitis related to AIDS

Vedia, Lautaro De; Arechavala, Alicia; Calderón, Marta; Maiolo, Elena; Rodríguez, Alberto Domínguez; Lista, Nicolás; Virgilio, Edoardo; Cisneros, Juan Carlos; Prieto, Raúl Vasallo

doi:10.1007/s15010-013-0538-4

Cited by 22 publications

(15 citation statements)

References 18 publications

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“…Several studies have reported that serial LPs to lower ICP during treatment of cryptococcal meningitis may improve outcomes [16], [17]. Although Malawian national guidelines suggest performing daily LPs during early therapy [9], there is neither adequate staffing nor the equipment for this to be possible.…”

Section: Discussionmentioning

confidence: 99%

A Prospective Study of Mortality from Cryptococcal Meningitis following Treatment Induction with 1200mg Oral Fluconazole in Blantyre, Malawi

et al. 2014

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ObjectiveWe have previously reported high ten-week mortality from cryptococcal meningitis in Malawian adults following treatment-induction with 800mg oral fluconazole (57% [33/58]). National guidelines in Malawi and other African countries now advocate an increased induction dose of 1200mg. We assessed whether this has improved outcomes.DesignThis was a prospective observational study of HIV-infected adults with cryptococcal meningitis confirmed by diagnostic lumbar puncture. Treatment was with fluconazole 1200mg/day for two weeks then 400mg/day for 8 weeks. Mortality within the first 10 weeks was the study end-point, and current results were compared with data from our prior patient cohort who started on fluconazole 800mg/day.Results47 participants received fluconazole monotherapy. Despite a treatment-induction dose of 1200mg, ten-week mortality remained 55% (26/47). This was no better than our previous study (Hazard Ratio [HR] of death on 1200mg vs. 800mg fluconazole: 1.29 (95% CI: 0.77–2.16, p = 0.332)). There was some evidence for improved survival in patients who had repeat lumbar punctures during early therapy to lower intracranial pressure (HR: 0.27 [95% CI: 0.07–1.03, p = 0.055]).ConclusionThere remains an urgent need to identify more effective, affordable and deliverable regimens for cryptococcal meningitis.

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Section: Discussionmentioning

confidence: 99%

A Prospective Study of Mortality from Cryptococcal Meningitis following Treatment Induction with 1200mg Oral Fluconazole in Blantyre, Malawi

et al. 2014

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“…10,11 A recent retrospective study suggests elevated ICP in patients with cryptococcal meningitis is associated with higher mortality and aggressive management of ICP during the initial 5 days was more important than initial antifungal management alone for survival. 12 Aspergillus Historically, disease from A fumigatus was limited to individuals with repetitive exposure to pathogens, producing a mild condition known as farmer's lung. Aspergillus subsp were also known to produce lung aspergillomas, characterized as an overgrowth of fungus in preexisting cavitary lung lesions.…”

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confidence: 99%

Evaluation and Treatment of Chronic Meningitis

Baldwin

Zunt

2014

The Neurohospitalist

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Chronic meningitis is defined as an inflammatory cerebrospinal fluid (CSF) profile that persists for at least 1 month. The presentation often includes headache, nausea, vomiting, cranial neuropathies, symptoms of elevated intracranial pressure, or focal neurologic deficits. The most common etiologies of chronic meningitis fall into 3 broad categories: infectious, autoimmune, and neoplastic. Evaluation of the patient with suspected chronic meningitis should include a detailed history and physical examination as well as repeated CSF diagnostics, serologic studies, and biopsy of the brain or other abnormal tissue (eg, lymph node or lung), when indicated. Early identification of the etiology and rapid treatment are crucial for improving morbidity and mortality, but potential infectious and neoplastic conditions should be excluded prior to empirically starting steroids or immunosuppressive medications.

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“…39 In another study, the incidence reported was higher among patients with severe bacterial meningitis (GCS score ≤ 8), wherein 93% of patients admitted to the neurointensive care unit developed intracranial hypertension. 21 Intracranial hypertension is not only limited to bacterial and viral infections, but also to parasitic and fungal pathogens, 4,8,29,49 e.g., Cryptococcus is particularly notorious for causing intractable ICP requiring CSF drainage. 8,23 Head CT is recommended in adults with suspected meningitis who present with focal neurological deficit or a decreased level of consciousness.…”

Section: Clinical Relevancementioning

confidence: 99%

The role of ICP monitoring in meningitis

Tariq

Aguilar‐Salinas

Hanel

et al. 2017

Neurosurgical Focus

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Intracranial pressure (ICP) monitoring has been widely accepted in the management of traumatic brain injury. However, its use in other pathologies that affect ICP has not been advocated as strongly, especially in CNS infections. Despite the most aggressive and novel antimicrobial therapies for meningitis, the mortality rate associated with this disease is far from satisfactory. Although intracranial hypertension and subsequent death have long been known to complicate meningitis, no specific guidelines targeting ICP monitoring are available. A review of the literature was performed to understand the pathophysiology of elevated ICP in meningitis, diagnostic challenges, and clinical outcomes in the use of ICP monitoring.

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Relevance of intracranial hypertension control in the management of Cryptococcus neoformans meningitis related to AIDS

Abstract: 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.

Cited by 22 publications

References 18 publications

A Prospective Study of Mortality from Cryptococcal Meningitis following Treatment Induction with 1200mg Oral Fluconazole in Blantyre, Malawi

A Prospective Study of Mortality from Cryptococcal Meningitis following Treatment Induction with 1200mg Oral Fluconazole in Blantyre, Malawi

Evaluation and Treatment of Chronic Meningitis

The role of ICP monitoring in meningitis

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