Treatment of Hydrocephalus Secondary to Cryptococcal Meningitis by Use of Shunting

Park, Matthew K.; Hospenthal, Duane R.; Bennett, John E.

doi:10.1086/515161

Cited by 97 publications

(56 citation statements)

References 9 publications

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“…13,22 In HIV-negative patients, ventriculoperitoneal shunting is well described by multiple authors and has had excellent results. 6,10,11,15,19,25,27,28,33,[35][36][37] In HIV-positive patients, however, the use of shunting to treat intracranial hypertension has been surprisingly sparse. Rather, there has been a greater emphasis on the use of serial lumbar punctures and lumbar drains for therapeutic relief of CSF pressure.…”

Section: Discussionmentioning

confidence: 99%

“…As highlighted by previous authors, shunting during active fungal infection is not an issue if antifungal therapy has been started prior to implantation. 25,26 IRIS is a clinical diagnosis representing exuberant tissue inflammation in patients experiencing rapid improvement in cellular immunity after initiation of HAART. CSF cultures are generally negative.…”

Section: Shunt Placement In the Immunocompromisedmentioning

confidence: 99%

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Shunting in cryptococcal meningitis

Cherian¹,

Atmar

Gopinath³

2016

JNS

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obJective 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 H 2 O) in 33 cases and normal (≤ 25 cm H 2 O) 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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Section: Discussionmentioning

confidence: 99%

Section: Shunt Placement In the Immunocompromisedmentioning

confidence: 99%

Shunting in cryptococcal meningitis

Cherian¹,

Atmar

Gopinath³

2016

JNS

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“…Clinical manifestations, including severe headache, papilledema, loss of vision or hearing, other neurological deficits, and altered mental consciousness, are common, and death may result, presumably from cerebral ischemia (211,291,295). Cryptococcomas due to C. gattii have caused raised ICP or obstructive hydrocephalus via a mass effect (27,296) but are not necessarily associated with measurably raised ICP (130). Patients with elevated pressures are more likely to present with abnormal neurological signs (P Ͻ 0.05) (130).…”

Section: Clinical Complications Of Human Infection Neurological Complmentioning

confidence: 99%

“…Notably, 25% of patients presenting with hydrocephalus had "silent" or unexpected findings of meningitis upon CSF examination (27). In C. neoformans infection, most patients with hydrocephalus have indolent meningitis (296). Factors that predispose patients with C. gattii meningitis to developing hydrocephalus remain unclear.…”

Section: Clinical Complications Of Human Infection Neurological Complmentioning

confidence: 99%

Cryptococcus gattii Infections

2014

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SUMMARY Understanding of the taxonomy and phylogeny of Cryptococcus gattii has been advanced by modern molecular techniques. C. gattii probably diverged from Cryptococcus neoformans between 16 million and 160 million years ago, depending on the dating methods applied, and maintains diversity by recombining in nature. South America is the likely source of the virulent C. gattii VGII molecular types that have emerged in North America. C. gattii shares major virulence determinants with C. neoformans , although genomic and transcriptomic studies revealed that despite similar genomes, the VGIIa and VGIIb subtypes employ very different transcriptional circuits and manifest differences in virulence phenotypes. Preliminary evidence suggests that C. gattii VGII causes severe lung disease and death without dissemination, whereas C. neoformans disseminates readily to the central nervous system (CNS) and causes death from meningoencephalitis. Overall, currently available data indicate that the C. gattii VGI, VGII, and VGIII molecular types more commonly affect nonimmunocompromised hosts, in contrast to VGIV. New, rapid, cheap diagnostic tests and imaging modalities are assisting early diagnosis and enabling better outcomes of cerebral cryptococcosis. Complications of CNS infection include increased intracranial pressure, severe neurological sequelae, and development of immune reconstitution syndrome, although the mortality rate is low. C. gattii VGII isolates may exhibit higher fluconazole MICs than other genotypes. Optimal therapeutic regimens are yet to be determined; in most cases, initial therapy with amphotericin B and 5-flucytosine is recommended.

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“…New additions to the antifungal drug armament either have no demonstrated activity against C. neoformans (echinocandins) or have not been tested for their activities against human cryptococcal disease (voriconazole, an expanded-spectrum azole). Improvements in the treatment of cryptococcal meningitis have come primarily from the use of combination antifungal chemotherapy and attention to raised intracranial pressure (21,25,26). However, the frequent need to use toxic agents, particularly the combination of amphotericin B and flucytosine, and the recent emergence of fluconazole-resistant isolates of C. neoformans highlight the need for improved treatment regimens and the use of combination therapy to forestall the emergence of resistant organisms (1,2,5,13).…”

mentioning

confidence: 99%

Amphotericin B and Fluconazole, a Potent Combination Therapy for Cryptococcal Meningitis

Larsen

Bauer

Thomas

et al. 2004

Antimicrob Agents Chemother

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We evaluated the antifungal activities of amphotericin B, fluconazole, and flucytosine, alone and in combination, in a murine model of cryptococcal meningitis. The objectives were to determine the greatest antifungal effects achievable with these drugs alone or in combination. Meningitis was established in male BALB/c mice weighing 23 to 25 g by intracerebral injection of Cryptococcus neoformans. Treatment was started on day 2. Amphotericin B was tested at 0.3 to 1.3 mg/kg of body weight/day by slow intravenous injection. Fluconazole at 10 to 40 mg/kg/day and flucytosine at 20 to 105 mg/kg/day were administered in the sole source of drinking water. The mice were killed at 16 days, and the numbers of fungal colonies in the brain were quantified. The association between the response and the dose combination was evaluated by local nonparametric response surface methods; 99% confidence intervals were used to evaluate the antifungal effects. Ninety-five percent of the mice treated with amphotericin B at 0.5 mg/kg survived to the end of the experiment, regardless of the fluconazole or flucytosine dose used. The greatest activity was seen with amphotericin B plus fluconazole with or without flucytosine. However, the addition of flucytosine did not increase the antifungal activity. Given the widespread availability of amphotericin B and fluconazole and the relative safety profile of fluconazole compared to that of flucytosine, the full potential of this two-drug combination deserves further evaluation.

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Treatment of Hydrocephalus Secondary to Cryptococcal Meningitis by Use of Shunting

Cited by 97 publications

References 9 publications

Shunting in cryptococcal meningitis

Shunting in cryptococcal meningitis

Cryptococcus gattii Infections

Amphotericin B and Fluconazole, a Potent Combination Therapy for Cryptococcal Meningitis

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