Abstract TP258: Clinical and Radiographic Features of Stroke in Cryptococcal Meningoencephalitis in a US Cohort Study

Abstract

Background: Cryptococcal meningitis can present with small vessel vasculitis and ischemic stroke. Acute and chronic infection carry a high mortality in both immunocompetent and immunocompromised patients. Among the survivors, multiple neurological deficit cause marked disability. Predictors of poor outcome and stroke recurrence remain unrecognized. Methods: We aim to describe clinical and radiographic features of stroke in a prospectively collected cohort of patients with Cryptococcal meningitis. A retrospective analysis of neuroimaging studies, cerebrospinal fluid(CSF) and clinical presentation was performed at the University of Colorado Hospital between 2000-2018. A multivariable logistic regression model was constructed to explore associations between dichotomous variables and informed as risk ratios. A T-Test and Wilcoxon test were applied to means of continuous variables. Fisher's exact test and contingency tables were used. Results: A total of 42 patients had cryptococcal meningitis, of which 31 had available imaging. Ischemic stroke was present in 8 patients (26%). Most strokes were acute (75%), lacunar (100%), multiple (88%), bilateral (63%) and localized in the basal ganglia (75%). Hyponatremia carried a RR: 5.7 (95% CI, 1.7-34.1) p=0.005. Other variables such malignancy, basal exudates, cryptococcoma, meningeal enhancement, hydrocephalus and CSF WBC did not seem to increase or reduce the risk of stroke. Anemia and hyponatremia were associated with presence of stroke, p=0.02 and p=0.03, respectively. Every unit decrease in hemoglobin is associated with 0.26 times the risk of ischemic stroke, (95% CI, 1.7-34.1) p=0.0312. Cryptococcal meningitis lead to death in 13 patients (30%) and 3 (14%) in patients with pulmonary manifestations only. Conclusion: Cryptococcal meningitis carries a high risk of neurologic complications, including lacunar stroke, particularly in the basal ganglia. Predisposing risk factors include anemia and hyponatremia regardless of the immune status of the patients. We report a mortality comparable to developing countries in the setting of a center of reference. The most common radiographic features of cryptococcal vasculitic infection may play a role in the high mortality of the population.