Page 342 - HIVMED_v21_i1.indb

Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 5 Original Research

Intracranial pressure management in patients with

human immunodeficiency virus-associated cryptococcal

meningitis in a resource-constrained setting

Authors: Background: Cryptococcal meningitis (CCM) is the leading cause of meningitis in people
Philasande Mkoko living with HIV (PLWH) in sub-Saharan Africa (SSA). The mortality and morbidity associated
1,2
Jessica Du Preez
2
Senlika Naidoo with CCM remain high. Combination of antifungal therapy, diligent management of
2,3
intracranial pressure (IP) and the correct timing of the introduction of antiretroviral therapy
Affiliations: (ART) minimise the risk of mortality and morbidity. The absence of spinal manometers in
1 Department of Medicine,
Division of Cardiology, Faculty many healthcare centres in SSA challenges the accurate measurement of cerebrospinal fluid
of Health Sciences, University (CSF) pressure and its control.
of Cape Town, Cape Town,
South Africa Objectives: We hypothesised that four lumbar punctures (LPs) in the first week of the
diagnosis and treatment of CCM would reduce IP such that in-hospital mortality and morbidity
2 Department of Medicine, of HIV-associated CCM (HIV/CCM) would be significantly reduced.
Dora Nginza Hospital, Port
Elizabeth, South Africa Methods: We conducted a retrospective study to assess whether receipt of four or more
LPs in the first week of the diagnosis and treatment with combination antifungal therapy
3 Department of Medicine,
Livingstone Hospital, Port of HIV/CCM would be associated with the reduction of in-hospital mortality in adult
Elizabeth, South Africa PLWH.

Corresponding author: Results: From 01 January 2016 to 31 December 2016, 116 adult patients were admitted to the
Philasande Mkoko, Dora Nginza District Hospital in Zwide, Port Elizabeth, South Africa. After exclusion of
[email protected] 11 (two were younger than 18 years, two had missing hospital records and seven demised or

Dates: left the hospital before 7 days of hospitalisation), 105 patients were included in the analysis.
Received: 25 Sept. 2020 The mean age was 39.4 (standard deviation [s.d.] ± 9.7) years, 64.8% were male. All were
Accepted: 20 Oct. 2020 PLWH. A total of 52.4% had defaulted ART and 25.7% were ART naïve. Forty-three patients
Published: 18 Dec. 2020
received four or more LPs (mean = 4.58 [± 0.96]) in the first week of hospitalisation with an
How to cite this article: associated in-hospital mortality of 11.6% (n = 5/43) compared with 62 patients who received
Mkoko P, Du Preez J, Naidoo less than four LPs (mean = 2.18 [± 0.80]) with an in-hospital mortality of 29% (n = 18/62) and
S. Intracranial pressure a relative risk of 0.80 (95% CI, 0.66–0.97), p = 0.034.
management in patients with
human immunodeficiency Conclusion: In the current study of adult PLWH presenting to hospital with HIV/CCM, four
virus-associated cryptococcal
meningitis in a resource- or more LPs in the first 7 days following admission and the initiation of treatment were
constrained setting. S Afr J associated with a 17.4% reduction in absolute risk of in-hospital mortality and a 20% reduction
HIV Med. 2020;21(1), a1171. in relative risk of in-hospital mortality. This mortality difference was noted in patients who
https://doi.org/10.4102/ survived and were in hospital at the time of the 7-day study census and persisted until the
sajhivmed.v21i1.1171
time of hospital discharge.
Copyright:
© 2020. The Authors. Keywords: cryptococcal meningitis; HIV; antifungal therapy; antiretroviral therapy; in-hospital
Licensee: AOSIS. This work mortality; adult PLWH.
is licensed under the
Creative Commons
Attribution License. Background

Cryptococcal meningitis (CCM) accounts for up to 60% of meningitis in adult persons living
with HIV (PLWH) in many African countries including South Africa (SA). Those with CD4
1,2
cell counts < 100 cells/µL are particularly at risk. Mortality is high – reaching levels of 70%
3
in sub-Saharan Africa (SSA). Altered mental state at presentation, older age, high
3
cerebrospinal fluid (CSF) fungal burden and high peripheral white cell count predict mortality
Read online: in antiretroviral therapy (ART) naïve patients. Although the availability of ART has led to a
4
Read online:
Scan this QR
5
Scan this QR decrease in HIV-associated CCM (HIV/CCM) in high-income countries, the condition
code with your
code with your 6
smart phone or remains responsible for 10% – 20% of HIV-related deaths in SSA. Notwithstanding improved
smart phone or
mobile device
mobile device access to ART, many remain outside of care or on failing treatment and at risk of opportunistic
to read online.
to read online.
disease. 7
http://www.sajhivmed.org.za 334 Open Access