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Volume 45, Number 4, August 2012

Different presentations and outcomes between HIV-infected and HIV-uninfected patients with Cryptococcal meningitis


Chia-Hung Liao, Chih-Yu Chi, Yi-Jen Wang, Shu-Wen Tseng, Chia-Huei Chou, Cheng-Mao Ho, Po-Chang Lin, Mao-Wang Ho, Jen-Hsian Wang


Received: April 15, 2011    Revised: July 13, 2011    Accepted: August 22, 2011   

 

Corresponding author:

 Mao-Wang Ho, Section of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Number 2 Yuh-Der Road, North District, Taichung City 40447, Taiwan.

E-mail address: Liaoch0809@gmail.com (M.-W. Ho).


 

Background and purpose: 

 Cryptococcus species are the most common causative agents of fungal meningitis. Different populations may show different clinical manifestations and outcomes. In this retrospective study, we investigated these differences in patients with and without HIV infection.



 

Methods:

 From 1995 to 2009, we collected data from HIV-infected or HIV-uninfected patients aged 18 years or over who had cryptococcal meningitis (CM) in a medical center in Taiwan. We reviewed and analyzed their demographic data, clinical manifestations, therapeutic strategies and outcomes.



 

Results:

 Among the 72 patients with CM, 19 HIV-infected patients were predominantly younger males, and all of them had AIDS status when CM was diagnosed. In contrast, the 53 HIVuninfected patients were mostly older males with underlying diseases. The time from initial symptoms to diagnosis was shorter in HIV-infected patients (median 10 vs. 18 days, p Z 0.048). The HIV-infected patients presented with less pleocytosis (p Z 0.003) and lower protein levels in the cerebrospinal fluid (CSF), but a higher proportion had positive results for cryptococci in the CSF (90% vs. 60%, p Z 0.02) and blood (53% vs. 21%, p Z 0.009) cultures. Surgical drains and repeated lumbar punctures for the management of increased intracranial pressure were performed in 47% of the HIV-infected patients and 38% of the HIV-uninfected

patients. A lower mortality rate was observed in the HIV-infected patients (p Z 0.038). On multivariate analysis, initial CD4 count 20/mm3 was an indicator of death or relapse in HIVinfected patients. In the HIV-uninfected group, the initial high cryptococcal antigen titer in the CSF (1:512) and hydrocephalus were related to unsatisfactory outcomes. 


 

Conclusion:

 In addition to well-known differences, we found a lower mortality in HIV-infected patients than in HIV-uninfected patients. Cryptococci and inflammation in the central nervous system may play important roles in the pathogenesis of CM. Low intensity of inflammation and effective surgical CSF drains for increased intracranial pressure and cryptococci removal may contribute to lower mortality in HIV-infected patients. 



 

Key words:

 Cryptococcus; HIV; Meningitis; Surgery; Taiwan