Pressure In Cryptococcal Meningitis Research Articles

A case report of a brain herniation secondary to cryptococcal meningitis with elevated intracranial pressure in a patient with Human Immunodeficiency Virus/Acquired immunodeficiency syndrome (HIV/AIDS)

BackgroundCryptococcal meningitis is a major opportunistic infection in individuals with HIV. The worldwide annual incidence is estimated to be approximately one million cases per year, with the most significant burden in sub-Saharan Africa. HIV-associated cryptococcal meningitis continues to have a high mortality rate despite widespread availability and use of HAART.Case36-year-old male with a past medical history of AIDS and a CD4 count of 35 cells/mm3 presented with altered mental status initially thought to be related to using crystalline methamphetamine as reported by EMS. However, a lumbar puncture performed in the emergency department showed elevated CSF opening pressure of 29 cmH2O and positive CSF and serum cryptococcal antigen. The patient was admitted and commenced treatment according to the current IDSA guideline but continued to have waxing and waning mental status. On the fourth day of admission, he complained of headache, had a witnessed seizure, and was taken emergently for a CT scan of the brain, which was negative for any acute intracranial process, but suffered a cardiac arrest before it could be done. He was intubated and transferred to the intensive care unit. CT brain follow-up showed anoxic encephalopathy, development of marked cerebral edema, and complete effacement of the basilar cisterns, suggestive of downward transtentorial herniation; he continued to deteriorate and expired on the seventh day of admission.Objectives1.Describe a case of brain death secondary to increased intracranial pressure due to cryptococcal meningitis in a patient with HIV/AIDS.2.Explain the mechanisms of elevation in intracranial pressure in patients with cryptococcal meningitis.3.Discuss the options for managing elevated intracranial pressure in patients with cryptococcal meningitis.4.Create awareness in the medical community about the importance of prompt and efficient management of increased intracranial pressure in patients with cryptococcal meningitis.ConclusionThis case highlights the importance of aggressive management of elevated intracranial pressure in cryptococcal meningitis. It reiterates the need for more data regarding the optimal timing and frequency of therapeutic lumbar puncture and the use of temporary lumbar drainage catheters and ventriculostomy to manage this potentially fatal complication.

Brief Report: Flow Rate of Cerebrospinal Fluid Through a Spinal Needle Can Accurately Predict Intracranial Pressure in Cryptococcal Meningitis

Background: Patients with HIV-associated cryptococcal meningitis (CM) commonly present with raised intracranial pressure (ICP). Aggressive management of raised ICP reduces mortality but requires manometers, which are unavailable in most resource-limited settings. The law of Poiseuille states that the rate of flow of liquid through a tube is directly proportional to the difference in pressure between each end, and it may be possible to indirectly determine ICP by measuring flow of CSF through a spinal needle rather than using a manometer. Methods: A convenience sample of CM patients requiring lumbar puncture (LP) (with 22-G spinal needle) for ICP measurement and control were enrolled. ICP was first measured using a narrow bore manometer. After removing the manometer, the number of drops of CSF flowing from the spinal needle in 15 seconds was counted. Results: Thirty-two patients had 89 LPs performed (range, 1–23). Fifty-four had high opening pressure with a CSF flow rate of 16–200 drops/min, and 35 had normal pressure with a CSF flow rate of 8–140 drops/min. Area under the fitted receiver operator character curve was 0.89. A flow rate cutoff to define high pressure of ≥40 drops/min correctly classified 75 of 89 LPs (accuracy 84%). Conclusions: It is technically feasible to indirectly estimate CSF pressure to an accuracy that is clinically useful by counting drops of CSF flowing from a spinal needle. The optimal cutoff value for defining high pressure using a standard 22-G spinal needle is ≥40 drops/min. These findings have the potential to improve CM management in resource-limited settings.

Accuracy of noninvasive intraocular pressure or optic nerve sheath diameter measurements for predicting elevated intracranial pressure in cryptococcal meningitis.

Cryptococcal meningitis is associated with increased intracranial pressure (ICP). Therapeutic lumbar puncture (LP) is recommended when the initial ICP is >250 mm H2O, yet the availability of manometers in Africa is limited and not always used where available. We assessed whether intraocular pressure could be a noninvasive surrogate predictor to determine when additional therapeutic LPs are necessary. Ninety-eight human immunodeficiency virus-infected Ugandans with suspected meningitis (81% Cryptococcus) had intraocular pressure measured using a handheld tonometer (n = 78) or optic nerve sheath diameter (ONSD) measured by ultrasound (n = 81). We determined the diagnostic performance of these methods for predicting ICP vs a standard manometer. The median ICP was 225 mm H2O (interquartile range [IQR], 135-405 mm H2O). The median intraocular pressure was 28 mm Hg (IQR, 22-37 mm Hg), and median ultrasound ONSD was 5.4 mm (IQR, 4.95-6.1 mm). ICP moderately correlated with intraocular pressure (ρ = 0.45, P < .001) and with ultrasound ONSD (ρ = 0.44, P < .001). There were not discrete threshold cutoff values for either tonometry or ultrasound ONSD that provided a suitable cutoff diagnostic value to predict elevated ICP (>200 mm H2O). However, risk of elevated ICP >200 mm H2O was increased with an average intraocular pressure >28 mm Hg (relative risk [RR] = 3.03; 95% confidence interval [CI], 1.55-5.92; P < .001) or an average of ONSD >5 mm (RR = 2.39; 95% CI, 1.42-4.03; P = .003). As either intraocular pressure or ONSD increased, probability of elevated ICP increased (ie, positive predictive value increased). Noninvasive intraocular pressure measurements by tonometry or ultrasound correlate with cerebrospinal fluid opening pressure, but both are a suboptimal replacement for actual ICP measurement with a manometer.

Ventriculoperitoneal shunts for treating increased intracranial pressure in cryptococcal meningitis with or without ventriculomegaly.

Cryptococcosis is an opportunistic mycosis, especially in patients that are human immunodeficiency virus (HIV)-positive, and frequently involves the central nervous system. We assessed the potential of ventriculoperitoneal shunting (VPS) in preventing mortality due to uncontrollable intracranial hypertension (ICH) in 15 patients with acquired immunodeficiency syndrome (AIDS)-related cryptococcal meningitis. After 2 weeks of antifungal therapy consisting of amphotericin B deoxycholate with or without fluconazole, patients with persistent ICH underwent VPS, despite having persistent Cryptococcus neoformans infection. In 12 patients, the uncontrollable ICH was resolved by VPS. Patients with cryptococcal meningoencephalitis who have ICH must be considered for VPS even with positive cerebrospinal fluid cultures.

EDTA Inhibits Biofilm Formation, Extracellular Vesicular Secretion, and Shedding of the Capsular Polysaccharide Glucuronoxylomannan by Cryptococcus neoformans

The fungal pathogen Cryptococcus neoformans can grow as a biofilm on a range of synthetic and prosthetic materials. Cryptococcal biofilm formation can complicate the placement of shunts used to relieve increased intracranial pressure in cryptococcal meningitis and can serve as a nidus for chronic infection. Biofilms are generally advantageous to pathogens in vivo, as they can confer resistance to antimicrobial compounds, including fluconazole and voriconazole in the case of C. neoformans. EDTA can inhibit biofilm formation by several microbes and enhances the susceptibility of biofilms to antifungal drugs. In this study, we evaluated the effect of sublethal concentrations of EDTA on the growth of cryptococcal biofilms. EDTA inhibited biofilm growth by C. neoformans, and the inhibition could be reversed by the addition of magnesium or calcium, implying that the inhibitory effect was by divalent cation starvation. EDTA also reduced the amount of the capsular polysaccharide glucuronoxylomannan shed into the biofilm matrix and decreased vesicular secretion from the cell, thus providing a potential mechanism for the inhibitory effect of this cation-chelating compound. Our data imply that the growth of C. neoformans biofilms requires the presence of divalent metals in the growth medium and suggest that cations are required for the export of materials needed for biofilm formation, possibly including extracellular vesicles.

Serial Spinal Taps Prevent Complications from Elevated CSF Pressure in Cryptococcal Meningitis

Serial Spinal Taps Prevent Complications from Elevated CSF Pressure in Cryptococcal Meningitis

Epidemiology and management of cryptococcal meningitis: developments and challenges

The significance of cryptococcal infection as a cause of human disease has dramatically evolved in recent years. The objective of this study was to outline the worldwide significance of cryptococcosis and review developments in the management of cryptococcal meningitis. Cryptococcus neoformans var. grubii remains an important cause of disease, particularly in hosts with acquired immunosuppression. Cryptococcus gattii, on the other hand, infects hosts with seemingly normal immune systems and a recent dramatic outbreak in a new ecologic environment highlights the emerging clinical significance of this fungal pathogen. The introduction of new antifungal agents and the adoption of strategies for controlling elevated intracranial pressure in cryptococcal meningitis have added to our therapeutic options. However, the mortality from this infection remains unacceptably high and we are faced with the specific challenges in the management of this disease.

Lumbar drainage for control of raised cerebrospinal fluid pressure in cryptococcal meningitis: case report and review

Raised intracranial pressure in the absence of ventricular dilatation is common in cryptococcal meningitis and associated with increased mortality. We report the case of a patient with HIV-associated cryptococcal meningitis, who developed increasing CSF pressure and visual impairment on therapy despite serial lumbar punctures. Insertion of a temporary lumbar drain controlled the opening pressure and resulted in full visual recovery. The advantages and necessary precautions with this approach are reviewed, and alternative protocols for the use of lumbar drains discussed.

Management of Increased Intracranial Pressure in Cryptococcal Meningitis.

Therapy of cryptococcal meningitis has been focused primarily on optimizing the antifungal regimen to improve the previously high treatment failure rates. Until recently, relatively little attention has been paid to the impact of increased intracranial pressure, which is a frequent problem that complicates management of patients with cryptococcal meningitis. Patients with elevated baseline opening pressures have higher titers of cerebrospinal fluid cryptococcal capsular polysaccharide antigen, more frequent headaches, meningismus, papilledema, hearing loss, and pathologic reflexes, as well as increased morbidity and mortality compared with those patients with normal opening pressures. Optimal therapy has not yet been firmly established, but the diagnostic evaluation and available treatment options are reviewed here, including frequent high volume lumbar punctures, lumbar drains, ventriculoperitoneal shunting, and corticosteroids.