Editorial commentary: An expanded role for therapeutic lumbar punctures in newly diagnosed AIDS-associated cryptococcal meningitis?

Abstract

For decades, clinicians have debated the role of repeated lumbar punctures (LPs) in the management of increased intracranial pressure (ICP) among patients with cryptococcal meningitis. After the initial diagnosis of cryptococcal meningitis, most experts agree that repeated LPs are appropriate for the following reasons: first, in the management of increased ICP through the removal of cerebrospinal fluid (CSF); second, to follow the mycologic and inflammatory response to antifungal therapy; and third, to look for evidence for persistent or relapsing disease and the development of immune reactivation in inflammatory syndrome. Among these indications, management of increased ICP is the most common reason for performing repeated LPs among patients with newly diagnosed cryptococcal meningitis. These so-called “therapeutic LPs” have been endorsed by several groups, including the Infectious Diseases Society of America (IDSA), the South African Medical Society and the World Health Organization (WHO), and are performed in lieu of more invasive procedures, such as the placement of a lumbar drain or temporary ventriculostomy [1–3]. Indeed, the IDSA guidelines for the management of cryptococcal meningitis go so far as to recommend daily LPs in situations that dictate a more aggressive approach to controlling persistently elevated ICP (>250 mm of CSF), in an effort to improve overall survival, prevent neurologic consequences, such as sudden blindness, deafness, and/or other cranial nerve abnormalities, and improve symptom control [1]. To our knowledge, no randomized controlled trials have explored the optimal frequency of therapeutic LP, the amount of CSF to be removed at each interval, or important parameters that inform the clinician if and when to place a permanent ventricular shunt. There are even fewer data on such temporary interventions as lumbar drains and external ventriculostomy drains. Thus, our current recommendations are based on large data sets, smaller observational studies, and anecdotal experience. It is undeniable that outcomes are worse among human immunodeficiency virus– infected patients with newly diagnosed cryptococcosis in the developing world than among those in the industrialized world [4–7]. Factors contributing to these poorer outcomes are complicated, but certainly they include limited access to care and resources, including antifungal and antiretroviral therapy, and logistical challenges [5–8]. Much effort has been expended to help improve access to antifungal therapy for patients in greatest need [9, 10]; less attention has been given to the importance of therapeutic LPs in the management of cryptococcal meningitis. Why is this important? Because many investigators have demonstrated that poorer outcomes in these patients are due not only to limited access to rapidly fungicidal drugs, such as amphotericin B and flucytosine, but also to inadequate management of increased ICP [11]. The relative influences of these 2 factors on the poor outcomes among these patients are difficult to determine, but most investigators agree that they are inextricably linked. In this issue of Clinical Infectious Diseases, Rolfes and colleagues [12] provide more observational data supporting the use of therapeutic LPs among patients Received 15 July 2014; accepted 17 July 2014; electronically published 6 August 2014. Correspondence: Peter G. Pappas, MD, Division of Infectious Diseases, University of Alabama at Birmingham, 1900 University Blvd, 229 THT, Birmingham, AL 35294-0006 (pappas@uab.edu). Clinical Infectious Diseases 2014;59(11):1615–17 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/cid/ciu600