title: Role of quantitative CSF microscopy to predict culture status and outcome in HIV-associated cryptococcal meningitis in a Brazilian cohort.
abstract: This retrospective study aimed to evaluate the clinical, laboratory, and quantitative cerebrospinal fluid (CSF) cryptococcal cell counts for associations with in-hospital outcomes of HIV-infected patients with cryptococcal meningitis. Ninety-eight HIV-infected adult patients with CSF culture-proven cryptococcal meningitis were admitted between January 2006 and June 2008 at a referral center in Sao Paulo, Brazil. Cryptococcal meningitis was the first AIDS-defining illness in 69%, of whom 97% (95/98) had known prior HIV infection. The median CD4+ T-cell count was 39 cells/μL (interquartile range 17-87 cells/μL). Prior antiretroviral therapy was reported in 50%. Failure to sterilize the CSF by 7-14 days was associated with baseline fungal burden of ≥ 10 yeasts/μL by quantitative CSF microscopy (odds ratio [OR] = 15.3, 95% confidence interval [CI] 4.1-56.7; P < 0.001) and positive blood cultures (OR = 11.5, 95% CI 1.2-109; P = 0.034). At 7-14 days, ≥ 10 yeasts/μL CSF was associated with positive CSF cultures in 98% versus 36% with <10 yeasts/μL CSF (P < 0.001). In-hospital mortality was 30% and was associated with symptoms duration for >14 days, altered mental status (P < 0.001), CSF white blood cell counts <5 cells/μL (P = 0.027), intracranial hypertension (P = 0.011), viral loads >50,000 copies/mL (P = 0.036), ≥ 10 yeasts/μL CSF at 7-14 days (P = 0.038), and intracranial pressure >50 cmH(2)0 at 7-14 days (P = 0.007). In conclusion, most patients were aware of their HIV status. Fungal burden of ≥ 10 yeasts/μL by quantitative CSF microscopy predicted current CSF culture status and may be useful to customize the induction therapy. High uncontrolled intracranial pressure was associated with mortality.
authors.affiliation: Department of Infectious Diseases, Emilio Ribas Institute of Infectious Diseases, University of Sao Paulo School of Medicine, São Paulo, Brazil. josevibe@gmail.com
authors.forename: José E
authors.initials: JE
authors.lastname: Vidal
authors.forename: Juliana
authors.initials: J
authors.lastname: Gerhardt
authors.forename: Erique J
authors.initials: EJ
authors.lastname: Peixoto de Miranda
authors.forename: Rafi F
authors.initials: RF
authors.lastname: Dauar
authors.forename: Gilberto S
authors.initials: GS
authors.lastname: Oliveira Filho
authors.forename: Augusto C
authors.initials: AC
authors.lastname: Penalva de Oliveira
authors.forename: David R
authors.initials: DR
authors.lastname: Boulware
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy*; D000293:Adolescent; D000328:Adult; D001938:Brazil; D002555:Cerebrospinal Fluid / Q000382:microbiology*; D015331:Cohort Studies; D015169:Colony Count, Microbial / Q000379:methods; D016903:Drug Monitoring / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D016919:Meningitis, Cryptococcal / Q000175:diagnosis / Q000188:drug therapy*; D008853:Microscopy / Q000379:methods*; D008875:Middle Aged; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult