Abstract
BackgroundHIV-associated cryptococcal meningitis (CCM) and related mortality may be prevented by the effective implementation of a screen-and-treat intervention.AimThe aim of this study was to assess the effectiveness of the screen-and-treat intervention at a regional hospital in KwaZulu-Natal province, South Africa.MethodThis was a descriptive study in which the records of patients seen in 2015 and 2016 with a CD4 count ≤ 100 cell/mm3 were retrieved from National Health Laboratory Service (NHLS) records and matched against patients admitted for HIV-associated CCM.ResultsA total of 5.1% (190 out of 3702) patients with CD4 count ≤ 100 cell/mm3 were cryptococcal antigen positive (CrAg +ve), of whom 22.6% (43 out of 190) were admitted with CCM. Patients who were CrAg +ve had significantly lower CD4 counts (mean CD4 = 38.9 ± 28.5) when compared to CrAg –ve patients (mean CD4 = 49.9 ± 37.4) with p = 0.0001. Only 2.6% (5 out of 190) of patients were referred for a lumbar puncture (LP) as part of the screen-and-treat intervention, whilst 38 who were CrAg +ve self-presented with CCM. Eighty-eight patients were admitted for suspected CCM: eight because of the screen-and-treat-intervention (none of whom had meningitis based on cerebrospinal fluid results) and 80 of whom self-presented and had confirmed CCM. The overall mortality of patients admitted with CCM was 30% (24 out of 80).ConclusionThe current ad-hoc screen-and-treat intervention was ineffective in detecting patients at risk of developing CCM. Systems need to be put in place to ensure that all CrAg +ve patients have an LP to detect subclinical CCM to improve the outcome for those with HIV-associated CCM.
Highlights
Cryptococcus meningitis is caused by Cryptococcus neoformans, an encapsulated yeast-like organism ubiquitous in the environment.[1,2] exposed to C. neoformans pathogens, most people with a normal immune system do not acquire this infection
Screening for Cr antigenaemia is considered to be cost-effective, the benefits are currently not being realised. This may be because of the challenges associated with identifying patients with latent or early cryptococcal meningitis (CCM) as well as the challenges within the health care system that include large numbers of patients, overloaded staff and the failure of patients to return for follow-up
Based on the findings of this research, we recommend that a system be considered to ensure that all patients with Cr antigenaemia are offered an lumbar puncture (LP) to exclude CCM, and that the cut-off point for assessing Cr antigenaemia be increased to a CD4 count of 150 cells/mm[3]
Summary
Cryptococcus meningitis is caused by Cryptococcus neoformans, an encapsulated yeast-like organism ubiquitous in the environment.[1,2] exposed to C. neoformans pathogens, most people with a normal immune system do not acquire this infection Those with a lowered immune response are susceptible to cryptococcal infection, which has a particular tropism for the central nervous system, frequently causing fatal cryptococcal meningitis (CCM).[3] This is a common opportunistic infection in Southeast Asia and sub-Saharan Africa,[1] and is an Acquired Immune Deficiency Syndrome (AIDS)-defining illness in patients with late-stage HIV infection. HIV-associated cryptococcal meningitis (CCM) and related mortality may be prevented by the effective implementation of a screen-and-treat intervention
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