Abstract:

Background: Cryptococcal meningitis (CM) seems to be a rare disease in immunocompetent hosts but prevalent in HIV-infected patients making it a major cause of morbidity and mortality especially in sub Saharan Africa. This disease has been associated with unacceptably high mortality rate especially in the first two weeks of antimycotic treatment. The on-going high morbidity and mortality in these patients with Cryptococcal meningitis among other factors is contributed to raise intracranial pressure. However there have been little attempts in sub Saharan Africa to address the effect of reducing intracranial pressure in improving prognosis of these patients.

Objective: To determine how serial lumbar punctures affect morbidity and mortality among HIV-positive adults with Cryptococcal meningitis admitted at Bugando Medical Centre.

Material and Methods: All adults patients admitted at Bugando Medical Centre ward of our hospital and diagnosed to have HIV and CM as per operational definition between June 2011 and March 2012 were consecutively enrolled. Patients were interviewed, examined and underwent lumbar punctures to assess for Cryptococcal meningitis by both manometer and IV giving set. All patients were managed according to Tanzania standard guidelines and were followed for symptom improvement until discharge. Trend of change in ICP, symptom improvement, and in-hospital mortality were recorded.

Results: A total of 35 HIV-infected patients with Cryptococcal meningitis were enrolled into the study. The prevalence of increased ICP was 91% by manometer. Of these 35 HIV-infected adults with Cryptococcal meningitis, 33(94%) had severe headache and 22(63%) altered mental status on admission. There was a significant reduction in mortality in this cohort when compared to historical controls (HR = 2.1 [95%CI 1.1 – 3.8]; p-value = 0.018). Also trend towards symptom improvement after receiving high dose fluconazole and serial lumbar punctures was observed whereby by day 14, 18 (90%), 17 (85%) and 18 (90%) patients had no headache, fever or altered mental status respectively. Mean changes in opening pressure measured with standard deviation between baseline and day 3, 7 and 14 were compared. We found no statistically significant difference between measured CSF opening pressure using either manometer or improvised IV giving set.

Conclusion and Recommendations: There is high prevalence of increased intracranial pressure in HIV-infected patients with Cryptococcal meningitis admitted at Bugando Medical Centre despite high morbidity and mortality related to CM this study demonstrated that serial lumbar punctures with CSF opening pressure monitoring using either manometer of IV giving set improves mortality significantly compared to historical controls. It was also found that there was no significant difference in measurements between manometer and IV giving set when was used to monitor ICP. We therefore recommend that in all patients with Cryptococcal meningitis, repeat lumbar puncture should be performed on hospital days 3, 7 and 14 and IV giving set can be used to measure and monitor ICP in resource limited settings.