Abstract
BackgroundCryptococcal meningitis is a leading cause of death among HIV-infected individuals in sub-Saharan Africa. Recent developments include the availability of intravenous fluconazole, cryptococcal antigen assays and new data to support fluconazole pre-emptive treatment. In this study, we describe the impact of screening HIV-positive adult inpatients with serum cryptococcal antigen (CRAG) at a Tanzanian referral hospital.MethodsAll adults admitted to the medical ward of Bugando Medical Centre are counseled and tested for HIV. In this prospective cohort study, we consecutively enrolled HIV-positive patients admitted between September 2009 and January 2010. All patients were interviewed, examined and screened with serum CRAG. Patients with positive serum CRAG or signs of meningitis underwent lumbar puncture. Patients were managed according to standard World Health Organization treatment guidelines. Discharge diagnoses and in-hospital mortality were recorded.ResultsOf 333 HIV-infected adults enrolled in our study, 15 (4.4%) had confirmed cryptococcal meningitis and 10 of these 15 (66%) died. All patients with cryptococcal meningitis had at least two of four classic symptoms and signs of meningitis: fever, headache, neck stiffness and altered mental status. Cryptococcal meningitis accounted for a quarter of all in-hospital deaths.ConclusionsDespite screening of all HIV-positive adult inpatients with the serum CRAG at the time of admission and prompt treatment with high-dose intravenous fluconazole in those with confirmed cryptococcal meningitis, the in-hospital mortality rate remained unacceptably high. Improved strategies for earlier diagnosis and treatment of HIV, implementation of fluconazole pre-emptive treatment for high-risk patients and acquisition of better resources for treatment of cryptococcal meningitis are needed.
Highlights
Cryptococcal meningitis is a leading cause of death among HIV-infected individuals in sub-Saharan Africa
Of the 333 HIV-infected adults consecutively admitted to our Tanzanian hospital during the antiretroviral therapy (ART) era and screened with the serum cryptococcal antigen, 15 (4.5%) had confirmed cryptococcal meningitis and 10 of 15 died in hospital despite high-dose intravenous fluconazole initiated within 24 hours of admission
Another study conducted at a referral hospital (Kilimanjaro Christian Medical Center) in central Tanzania reported a prevalence of cryptococcal meningitis of 40 out of 149 (26.8%) HIV-infected adults admitted with a chief complaint of either headache or altered mental status [19]
Summary
Cryptococcal meningitis is a leading cause of death among HIV-infected individuals in sub-Saharan Africa. The mortality rate from cryptococcal meningitis in sub-Saharan Africa has been estimated at 70% compared with 55% in other low- and middle-income countries and 20% in highincome countries [2]. This higher mortality is thought to be related to delayed diagnosis of both HIV and cryptococcal meningitis, as well as the inaccessibility of first-line treatment with combination amphotericin/flucytosine induction chemotherapy and intensive intracranial pressure management [8,9]. The serum cryptococcal antigen assay is a sensitive and specific screening tool that has been studied in several outpatient HIV-infected cohorts in subSaharan Africa, where the prevalence has been 7% to 8% [13,14]. The prevalence of cryptococcal antigenemia among HIV-positive inpatients in sub-Saharan Africa has not been reported
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