title: Universal screening of Tanzanian HIV-infected adult inpatients with the serum cryptococcal antigen to improve diagnosis and reduce mortality: an operational study.
abstract: BACKGROUND
  Cryptococcal meningitis is a leading cause of death among HIV-infected individuals in sub-Saharan Africa. Recent developments include the availability of intravenous fluconazole, cryptococcal antigen assays and new data to support fluconazole pre-emptive treatment. In this study, we describe the impact of screening HIV-positive adult inpatients with serum cryptococcal antigen (CRAG) at a Tanzanian referral hospital.
  
  
  METHODS
  All adults admitted to the medical ward of Bugando Medical Centre are counseled and tested for HIV. In this prospective cohort study, we consecutively enrolled HIV-positive patients admitted between September 2009 and January 2010. All patients were interviewed, examined and screened with serum CRAG. Patients with positive serum CRAG or signs of meningitis underwent lumbar puncture. Patients were managed according to standard World Health Organization treatment guidelines. Discharge diagnoses and in-hospital mortality were recorded.
  
  
  RESULTS
  Of 333 HIV-infected adults enrolled in our study, 15 (4.4%) had confirmed cryptococcal meningitis and 10 of these 15 (66%) died. All patients with cryptococcal meningitis had at least two of four classic symptoms and signs of meningitis: fever, headache, neck stiffness and altered mental status. Cryptococcal meningitis accounted for a quarter of all in-hospital deaths.
  
  
  CONCLUSIONS
  Despite screening of all HIV-positive adult inpatients with the serum CRAG at the time of admission and prompt treatment with high-dose intravenous fluconazole in those with confirmed cryptococcal meningitis, the in-hospital mortality rate remained unacceptably high. Improved strategies for earlier diagnosis and treatment of HIV, implementation of fluconazole pre-emptive treatment for high-risk patients and acquisition of better resources for treatment of cryptococcal meningitis are needed.
authors: Department of Medicine, Bugando Medical Centre, Box 1370, Mwanza, Tanzania.
authors: Bahati Mk
authors: BM
authors: Wajanga
authors: Samuel
authors: S
authors: Kalluvya
authors: Jennifer A
authors: JA
authors: Downs
authors: Warren D
authors: WD
authors: Johnson
authors: Daniel W
authors: DW
authors: Fitzgerald
authors: Robert N
authors: RN
authors: Peck
mesh_terms: D000293:Adolescent; D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use; D000946:Antigens, Fungal / Q000097:blood*; D002555:Cerebrospinal Fluid / Q000737:chemistry; D015331:Cohort Studies; D003454:Cryptococcus / Q000302:isolation & purification*; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006761:Hospitals; D006801:Humans; D007297:Inpatients; D008297:Male; D008403:Mass Screening / Q000379:methods*; D016919:Meningitis, Cryptococcal / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D008828:Microbiological Techniques / Q000379:methods*; D008875:Middle Aged; D011446:Prospective Studies; D016019:Survival Analysis; D013636:Tanzania; D055815:Young Adult
chemical_list: D000935:Antifungal Agents; D000946:Antigens, Fungal