title: Different presentations and outcomes between HIV-infected and HIV-uninfected patients with Cryptococcal meningitis.
abstract: OBJECTIVE
  Cryptococcus species are the most common causative agents of fungal meningitis. Different populations may show different clinical manifestations and outcomes. In this retrospective study, we investigated these differences in patients with and without HIV infection.
  
  
  METHODS
  From 1995 to 2009, we collected data from HIV-infected or HIV-uninfected patients aged 18 years or over who had cryptococcal meningitis (CM) in a medical center in Taiwan. We reviewed and analyzed their demographic data, clinical manifestations, therapeutic strategies and outcomes.
  
  
  RESULTS
  Among the 72 patients with CM, 19 HIV-infected patients were predominantly younger males, and all of them had AIDS status when CM was diagnosed. In contrast, the 53 HIV-uninfected patients were mostly older males with underlying diseases. The time from initial symptoms to diagnosis was shorter in HIV-infected patients (median 10 vs. 18 days, p = 0.048). The HIV-infected patients presented with less pleocytosis (p = 0.003) and lower protein levels in the cerebrospinal fluid (CSF), but a higher proportion had positive results for cryptococci in the CSF (90% vs. 60%, p = 0.02) and blood (53% vs. 21%, p = 0.009) cultures. Surgical drains and repeated lumbar punctures for the management of increased intracranial pressure were performed in 47% of the HIV-infected patients and 38% of the HIV-uninfected patients. A lower mortality rate was observed in the HIV-infected patients (p = 0.038). On multivariate analysis, initial CD4 count ≤20/mm(3) was an indicator of death or relapse in HIV-infected patients. In the HIV-uninfected group, the initial high cryptococcal antigen titer in the CSF (≥1:512) and hydrocephalus were related to unsatisfactory outcomes.
  
  
  CONCLUSIONS
  In addition to well-known differences, we found a lower mortality in HIV-infected patients than in HIV-uninfected patients. Cryptococci and inflammation in the central nervous system may play important roles in the pathogenesis of CM. Low intensity of inflammation and effective surgical CSF drains for increased intracranial pressure and cryptococci removal may contribute to lower mortality in HIV-infected patients.
authors.affiliation: Section of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan.
authors.forename: Chia-Hung
authors.initials: CH
authors.lastname: Liao
authors.forename: Chih-Yu
authors.initials: CY
authors.lastname: Chi
authors.forename: Yi-Jen
authors.initials: YJ
authors.lastname: Wang
authors.forename: Shu-Wen
authors.initials: SW
authors.lastname: Tseng
authors.forename: Chia-Huei
authors.initials: CH
authors.lastname: Chou
authors.forename: Cheng-Mao
authors.initials: CM
authors.lastname: Ho
authors.forename: Po-Chang
authors.initials: PC
authors.lastname: Lin
authors.forename: Mao-Wang
authors.initials: MW
authors.lastname: Ho
authors.forename: Jen-Hsian
authors.initials: JH
authors.lastname: Wang
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D000328:Adult; D000368:Aged; D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D000946:Antigens, Fungal / Q000097:blood / Q000134:cerebrospinal fluid / Q000276:immunology; D018791:CD4 Lymphocyte Count; D003454:Cryptococcus / Q000187:drug effects / Q000472:pathogenicity; D005260:Female; D005437:Flucytosine / Q000627:therapeutic use; D005500:Follow-Up Studies; D006678:HIV / Q000187:drug effects / Q000472:pathogenicity; D015658:HIV Infections / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D006801:Humans; D006849:Hydrocephalus / Q000188:drug therapy; D019586:Intracranial Hypertension / Q000188:drug therapy; D008297:Male; D016919:Meningitis, Cryptococcal / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D012189:Retrospective Studies; D013129:Spinal Puncture; D013624:Taiwan; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D000946:Antigens, Fungal; D000666:Amphotericin B; D005437:Flucytosine