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Predictors of outcome in Cryptococcus neoformans var. gattii meningitis
R A Seaton1, S Naraqi, J P Wembri
1Nuffield Department of Medicine, University of Oxford, UK.
Abstract:
In Papua New Guinea, Cryptococcus neoformans var. gattii meningitis has a high fatality rate even in immunocompetent patients. Our retrospective study attempted to identify marker of poor prognosis. Of 88 immunocompetent patients, 30 (34.1%) died, usually soon after admission, and mortality was higher in men (p = 0.025) and older patients (p = 0.039). Death was associated with altered consciousness (p < 0.001), a history of convulsions prior to treatment (p = 0.002) and a maximum systolic blood pressure of > 150 mmHg (p = 0.017). These data suggest that death results from raised intracranial pressure and subsequent tentorial herniation. However, CSF opening pressure measured on admission was raised in 29/36 (81%) patients and did not predict outcome. In survivors, relapse was uncommon and was not predicted by discharge serum cryptococcal antigen titres, which were frequently raised on completion of therapy in asymptomatic patients. Mortality may be reduced if efforts are made to lower intracranial pressure in those patients who present with markers of poor prognosis.
Insights
Cryptococcus neoformans var. gattii meningitis is deadly in Papua New Guinea. Identifying poor prognosis markers like altered consciousness and high blood pressure could improve outcomes for immunocompetent patients.
Area of Science:
- Infectious Diseases
- Neurology
- Public Health
Background:
- Cryptococcus neoformans var. gattii meningitis presents a high fatality rate in Papua New Guinea, even among immunocompetent individuals.
- Previous studies have not fully elucidated prognostic markers for this specific patient population.
Purpose of the Study:
- To identify clinical and demographic markers associated with poor prognosis in immunocompetent patients with Cryptococcus neoformans var. gattii meningitis.
- To explore potential interventions for reducing mortality in this severe fungal meningitis.
Main Methods:
- Retrospective analysis of 88 immunocompetent patients diagnosed with Cryptococcus neoformans var. gattii meningitis.
- Statistical analysis to determine associations between patient characteristics, clinical findings, and mortality.
Main Results:
- Mortality rate was 34.1% (30/88), with deaths often occurring shortly after admission.
- Higher mortality was observed in men and older patients.
- Poor prognostic indicators included altered consciousness, prior convulsions, and systolic blood pressure > 150 mmHg.
- Cerebrospinal fluid opening pressure did not predict outcomes, despite being elevated in most patients.
Conclusions:
- Altered consciousness, prior convulsions, and elevated systolic blood pressure are significant markers of poor prognosis in this meningitis.
- Raised intracranial pressure is likely the cause of death, suggesting potential benefit from interventions targeting this.
- Relapse was uncommon in survivors, and discharge cryptococcal antigen levels did not predict outcomes.