Cargando…

Therapeutic Lumbar Punctures in Human Immunodeficiency Virus–Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management?

BACKGROUND: Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs. METHODS: We prospectively enrolled huma...

Descripción completa

Detalles Bibliográficos
Autores principales: Kagimu, Enock, Engen, Nicole, Ssebambulidde, Kenneth, Kasibante, John, Kiiza, Tadeo K, Mpoza, Edward, Tugume, Lillian, Nuwagira, Edwin, Nsangi, Laura, Williams, Darlisha A, Hullsiek, Kathy Huppler, Boulware, David R, Meya, David B, Rhein, Joshua, Abassi, Mahsa, Musubire, Abdu K
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9454029/
https://www.ncbi.nlm.nih.gov/pubmed/36092828
http://dx.doi.org/10.1093/ofid/ofac416
Descripción
Sumario:BACKGROUND: Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs. METHODS: We prospectively enrolled human immunodeficiency virus (HIV)–seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within 7 days. RESULTS: Our analysis included 533 participants. Participants with baseline ICP >350 mm H(2)O were more likely to have Glasgow Coma Scale (GCS) score <15 (P < .001), seizures (P < .01), and higher quantitative cryptococcal cultures (P < .001), whereas participants with ICP <200 mm H(2)O were more likely to have baseline sterile CSF cultures (P < .001) and CSF white blood cell count ≥5 cells/µL (P = .02). Thirty-day mortality was higher in participants with baseline ICP >350 mm H(2)O and ICP <200 mm H(2)O as compared with baseline ICP 200–350 mm H(2)O (hazard ratio, 1.55 [95% confidence interval, 1.10–2.19]; P = .02). Among survivors at least 7 days, the 30-day relative mortality was 50% higher among participants who did not receive any additional therapeutic LPs compared to those with ≥1 additional follow-up LP (33% vs 22%; P = .04), irrespective of baseline ICP. CONCLUSIONS: Management of increased ICP remains crucial in improving clinical outcomes in cryptococcal meningitis. Guidelines should consider an approach to therapeutic LPs that is not dictated by baseline ICP.