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High fungal burden predicted mortality in cryptococcal meningitis
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Among HIV patients who had cryptococcal meningitis, a high baseline fungal burden in the cerebrospinal fluid was one of the strongest risk factors associated with 2-week mortality, according to researchers from the London School of Hygiene & Tropical Medicine.
Other factors that were independently associated with mortality at 2 weeks included altered mental status, older age and high peripheral white cell count.
“Given the high proportion of patients presenting with cryptococcal meningitis who have already been diagnosed with HIV, screening for subclinical infection with point-of-care tests and pre-emptive antifungal treatment, along with early [antiretroviral therapy] initiation, could prevent a substantial proportion of clinical disease from developing,” the researchers wrote in Clinical Infectious Diseases.
The researchers evaluated a cohort of patients from nine trials that were conducted from 2002 to 2010 in Thailand, South Africa, Malawi and Uganda. The cohort included 501 ART-naive patients who had a first episode of cryptococcal meningitis, of whom 76% were known to have HIV at the time they presented. All-cause mortality was 17% at 2 weeks and 34% at 10 weeks.
Patients with altered mental status at presentation had a threefold increase in mortality at 2 weeks, and patients aged at least 50 years were four times more likely to die than those who were younger. In addition, there was a 1.4 odds increase in mortality with each log10 colony-forming units/mL increase in fungal burden in the cerebrospinal fluid (CSF).
At 10 weeks, additional risk factors that were independently associated with mortality included lower body weight, low CSF opening pressure and anemia. At 2 weeks and 10 weeks, treatment with amphotericin B deoxycholate was independently associated with lower mortality.
“These results emphasize the high acute mortality in patients with cryptococcal meningitis, even among patients primarily treated with amphotericin-based therapy in research settings,” the researchers wrote. “Such patients are likely to have better outcomes than those managed in routine care; hence, these results provide a minimum mortality estimate.”
Disclosure: The researchers report no relevant financial disclosures.
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