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Utility of clinical assessment, imaging, and cryptococcal antigen titer to predict AIDS-related complicated forms of
Edward R Cachay1, Joseph Caperna, Amy M Sitapati
1Department of Medicine, University of California San Diego, 200 W, Arbor Drive, San Diego, California 92103, USA. ecachay@ucsd.edu.
Background:
This study aimed to evaluate the prevalence and predictors of AIDS-related complicated cryptococcal meningitis. The outcome was complicated cryptococcal meningitis: prolonged (>/= 14 days) altered mental status, persistent (>/= 14 days) focal neurologic findings, cerebrospinal fluid (CSF) shunt placement or death. Predictor variable operating characteristics were estimated using receiver operating characteristic curve (ROC) analysis. Multivariate analysis identified independent predictors of the outcome.
Results:
From 1990-2009, 82 patients with first episode of cryptococcal meningitis were identified. Of these, 14 (17%) met criteria for complicated forms of cryptococcal meningitis (prolonged altered mental status 6, persistent focal neurologic findings 7, CSF surgical shunt placement 8, and death 5). Patients with complicated cryptococcal meningitis had higher frequency of baseline focal neurological findings, head computed tomography (CT) abnormalities, mean CSF opening pressure, and cryptococcal antigen (CRAG) titers in serum and CSF. ROC area of log2 serum and CSF CRAG titers to predict complicated forms of cryptococcal meningitis were comparable, 0.78 (95%CI: 0.66 to 0.90) vs. 0.78 (95% CI: 0.67 to 0.89), respectively (chi2, p = 0.95). The ROC areas to predict the outcomes were similar for CSF pressure and CSF CRAG titers. In a multiple logistic regression model, the following were significant predictors of the outcome: baseline focal neurologic findings, head CT abnormalities and log2 CSF CRAG titer.
Conclusions:
During initial clinical evaluation, a focal neurologic exam, abnormal head CT and large cryptococcal burden measured by CRAG titer are associated with the outcome of complicated cryptococcal meningitis following 2 weeks from antifungal therapy initiation.
Insights
Focal neurologic exam, abnormal head CT, and high cryptococcal antigen (CRAG) titers predict complicated cryptococcal meningitis. These factors help identify patients needing closer monitoring and management for better outcomes.
Area of Science:
- Infectious Diseases
- Neurology
- Medical Diagnostics
Background:
- Cryptococcal meningitis is a significant opportunistic infection, particularly in individuals with Acquired Immunodeficiency Syndrome (AIDS).
- Complicated cryptococcal meningitis presents with severe outcomes including prolonged altered mental status, persistent focal neurologic deficits, need for cerebrospinal fluid (CSF) shunt placement, or death.
Purpose of the Study:
- To determine the prevalence of complicated cryptococcal meningitis in an AIDS-related context.
- To identify independent predictors of complicated cryptococcal meningitis to aid in early diagnosis and management.
Main Methods:
- Retrospective analysis of 82 patients with a first episode of cryptococcal meningitis between 1990-2009.
- Receiver operating characteristic (ROC) curve analysis to assess predictor variable operating characteristics.
- Multivariate logistic regression to identify independent predictors of complicated cryptococcal meningitis.
Main Results:
- 17% of patients (14 out of 82) met criteria for complicated cryptococcal meningitis.
- Patients with complicated forms exhibited higher frequencies of baseline focal neurological findings, head CT abnormalities, elevated CSF opening pressure, and higher serum and CSF cryptococcal antigen (CRAG) titers.
- ROC analysis showed comparable predictive values for serum and CSF CRAG titers, as well as CSF pressure.
- Focal neurologic findings, head CT abnormalities, and CSF CRAG titer were significant independent predictors in multivariate analysis.
Conclusions:
- Focal neurologic examination findings, abnormal head CT scans, and high cryptococcal burden (indicated by CRAG titers) are associated with complicated cryptococcal meningitis.
- These clinical and diagnostic indicators are valuable during initial evaluation for predicting outcomes after initiating antifungal therapy.
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