Cryptococcal meningitis in a tertiary hospital in Pretoria, mortality and risk factors – A retrospective cohort study

Abstract

Aim: This retrospective cohort study analyzes the impact of possible risk factors on the survival chance of patients with Cryptococcal meningitis (CM). These factors include the patient's socioeconomic background, age, gender, presenting symptoms, comorbidities, laboratory findings and, in particular, non-adherence versus adherence to therapy.Methods: Data was collected from all adult patients admitted to Kalafong Hospital with laboratory confirmed CM over a period of 24 months. We analyzed the data by the presentation of descriptive summary statistics, logistic regression was used to assess factors which showed association between outcome of measure and factor. Furthermore, multivariable logistic regression analysis using all the factors that showed significant association in the cross tabulation was applied to determine which factors had an impact on the patients' mortality risk. 2Results: 87 patients were identified. All except one were HIV positive, of which 55.2% were Antiretroviral Therapy (ART) naïve. A history of previous Tuberculosis (TB) was given by 25 patients (28.7%) and 49 (56.3%) were on TB treatment at admission or started during their hospital stay. In-hospital mortality was 31 %. Statistical analysis showed that ART naïve patients had 9.9 (CI 95% 1.2-81.2, p<0.0032) times greater odds of dying compared to those on ART, with 17 from 48 patients (35.4%) dying compared with 1 out of 21 patients (4.8%) on treatment.Defaulters had 14.7 (CI 95% 1.6-131.6, p<0.016) times greater odds of dying, with 9 from 18 patients dying (50%), compared to the non-defaulters. In addition, patients who presented with nausea and vomiting had a 6.3 (95% CI 1.7-23.1, p<0.005) times greater odds of dying (18/47, 38.3%); this remained significant when adjusted for ART naïve patients and defaulters.Conclusion: CM is still a common opportunistic infection in people living with HIV/AIDS resulting in hospitalization and a high mortality. Defaulting ART and presentation with nausea and vomiting were associated with a significantly increased mortality risk.

Mortality from HIV‐associated meningitis in sub‐Saharan Africa: a systematic review and meta‐analysis

“…In 10% (4/41) of included studies, the period of observation began prior to 2000. Seventeen countries were represented, with greatest representation from South Africa (14 studies) [34,[37][38][39][40][41][42][43][44][45][46][47][48][49], Ethiopia (three studies) [50][51][52] and Uganda (three studies) [53][54][55]; other countries had two or fewer studies [11,35,36,[56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74]. Amphotericin B-based induction therapy (with or without fluconazole) was the predominant induction regimen in 16 studies, fluconazole in 13 studies, and a mix of treatments (45% fluconazole and 43% amphotericin B) in one study [44], with antifungal regimens not specified in 11 studies.…”

Computerised tomography findings in HIV-associated cryptococcal meningoencephalitis at a tertiary hospital in Pretoria

“…There is sound data that raised intracranial pressure correlates with higher mortality and international and national guidelines support aggressive management if the baseline opening CSF pressure is raised. 20 Our own data showed an increased mortality in those patients that were admitted with features consistent with high CSF pressures 7 and the five patients with communicating hydrocephalus are probably part of this subgroup with poor prognosis. Unfortunately, as this was a retrospective study, opening pressures were mostly not documented and, therefore, we cannot compare and correlate the pressures with the imaging.…”

“…The overall mortality in the patients that underwent CT brain imaging was 33.3%, hence, very similar to the in-patient mortality in the total cohort of patients with cryptococcal meningitis (31%). 7 In the group with cryptococcal-related changes on imaging, the mortality was higher (50%) and a small subgroup of patients with hydrocephalus showed a 100% mortality ( n = 5). The patients with normal cerebral imaging and the group of patients that had cerebral atrophy and no other pathological findings, had lower mortalities at 25% and 16.7%, respectively.…”

“…In a previous study from Kalafong Hospital, Pretoria, we looked at the clinical presentation and outcomes of all patients admitted with cryptococcal meningitis over a 2-year period. 7 However, because of the high burden of patients and the limited resources, only a relatively small number of admitted patients with cryptococcal meningitis underwent cerebral imaging so that we did not analyse the radiological data.…”

Diagnostic and mortality outcomes in a cohort of adult meningitis suspects in KwaZulu-Natal

“…[1][2][3][4] In sub-Saharan Africa, the human immunodeficiency virus (HIV) pandemic increased the risk of meningitis in seropositive adults, with Cryptococcus neoformans and Mycobacterium tuberculosis emerging as prominent pathogens. [5][6][7][8] Symptoms of meningitis include headache, fever, altered mental status and neck stiffness, but are non-specific. 9 Clinicians working in high HIV prevalence settings need to maintain a high level of suspicion for meningitis, and investigate when the presenting symptoms suggest the diagnosis.…”