Management of cryptococcal meningitis in HIV-infected patients: Experience from western India

Abstract

Introduction:Cryptococcal meningitis is one of the acquired immunodeficiency syndrome defining infections with high mortality. Amphotericin B is the preferred drug for induction therapy. Despite advances in human immunodeficiency virus (HIV) treatment, Antiretroviral Treatment (ART) roll-out programs and availability of amphotericin B, cryptococcal meningitis remains an important cause of mortality in the African and other developing countries.Materials and Methods:We carried out a prospective observational study to determine the treatment response rate, tolerability and outcome of patients with cryptococcal meningitis in HIV treated with amphotericin B. Descriptive statistic was used to analyze the data.Results:A total of 27 patients were diagnosed with cryptococcal meningitis during the study period. Headache (96.29%) was the single most common presenting symptom of cryptococcal meningitis in HIV-infected patients, followed by vomiting (77.77%) and fever (66.66%). Cerebrospinal fluid (CSF) routine and microscopic examination was within normal limits in six patients. CSF became sterile on the 12th day of Amphotericin B in 55.55% of the patients while 33.33% had positive CSF cultures. Patients were started with ART after achieving sterile CSF and tolerated at least 2 weeks of fluconazole consolidation treatment and were free from symptoms. Median time for antiretroviral treatment initiation was 35 (14–90) days after completion of Amphotericin B treatment. One patient developed immune reconstitution inflammatory syndrome (IRIS) after ART.Conclusions:We found that the recommended 2 weeks induction treatment with Amphotericin B monotherapy for HIV patients with cryptococcal meningitis in resource-limited settings may be suboptimal for at least one-third of the patients. Extending the therapy to 3 weeks is likely to result in sterilization of the CSF in a majority of these patients. This finding requires confirmation by a larger sample size in appropriately powered studies. Delaying ART initiation by at least 2 weeks after amphotericin B treatment may decrease the incidence of IRIS.

Changing paradigm of Cryptococcal meningitis: An eight-year experience from a tertiary hospital in South India

“…Usual symptoms are headache and altered mental status, including personality changes, confusion, lethargy, obtundation, and coma. In our study, headache was the most common presenting complaint followed by nausea and [8,9] Contrary to our fi ndings, other studies had shown that HIV-infected patients had lesser CSF pleocytosis, lower CSF protein response and a higher rate of isolation from non-neural sites. One of our patients had a CSF WBC count of 3500 cells/cu mm, probably the highest reported value for CM.…”

Hospital-based retrospective study of cryptococcal meningitis in a large cohort from India

“…Magnitude of CSF pleocytosis among patients without HIV infection was documented to be higher compared to patients with HIV infection. [ 15 ] Although we have a smaller HIV-negative group, similar findings were seen in our patients. An important observation in our patients was the lower degree of CSF pleocytosis and lower protein levels among the patients who succumbed probably reflecting the poor immunological status.…”

Management of cryptococcal meningitis in a district hospital in KwaZulu-Natal: A clinical audit

“…Deviations from the 14-day induction target were mainly a result of early mortality; clinicians’ decision to discontinue amphotericin B on account of improvement in the clinical status of the patient; and amphotericin B-related toxicity. Given the finding from a prospective study in India that even the standard 14-day amphotericin B monotherapy might be suboptimal for one third of patients, 26 clinicians’ decision to discontinue amphotericin B before 14 days on the premise of clinical improvement remains a concern. It is pertinent to mention that the South African National Department of Health (NDOH) conceded that completing the 14-day course of amphotericin B might not always be ‘feasible’ given the high demands for hospital beds and thus recommended that ‘… an earlier switch to oral fluconazole may be considered … [ by the clinician ] … if there has been a good clinical response’ 12 (p. 169).…”