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Therapeutic Lumbar Punctures in Human Immunodeficiency Virus–Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management?
Abstract Background Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs. Methods We prospectively enroll...
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| Published in: | Open forum infectious diseases 2022-09, Vol.9 (9), p.ofac416-ofac416 |
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| creator | Kagimu, Enock Engen, Nicole Ssebambulidde, Kenneth Kasibante, John Kiiza, Tadeo K Mpoza, Edward Tugume, Lillian Nuwagira, Edwin Nsangi, Laura Williams, Darlisha A Hullsiek, Kathy Huppler Boulware, David R Meya, David B Rhein, Joshua Abassi, Mahsa Musubire, Abdu K |
| description | Abstract
Background
Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs.
Methods
We prospectively enrolled human immunodeficiency virus (HIV)–seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within 7 days.
Results
Our analysis included 533 participants. Participants with baseline ICP >350 mm H2O were more likely to have Glasgow Coma Scale (GCS) score |
| doi_str_mv | 10.1093/ofid/ofac416 |
| format | article |
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Background
Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs.
Methods
We prospectively enrolled human immunodeficiency virus (HIV)–seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within 7 days.
Results
Our analysis included 533 participants. Participants with baseline ICP >350 mm H2O were more likely to have Glasgow Coma Scale (GCS) score <15 (P < .001), seizures (P < .01), and higher quantitative cryptococcal cultures (P < .001), whereas participants with ICP <200 mm H2O were more likely to have baseline sterile CSF cultures (P < .001) and CSF white blood cell count ≥5 cells/µL (P = .02). Thirty-day mortality was higher in participants with baseline ICP >350 mm H2O and ICP <200 mm H2O as compared with baseline ICP 200–350 mm H2O (hazard ratio, 1.55 [95% confidence interval, 1.10–2.19]; P = .02). Among survivors at least 7 days, the 30-day relative mortality was 50% higher among participants who did not receive any additional therapeutic LPs compared to those with ≥1 additional follow-up LP (33% vs 22%; P = .04), irrespective of baseline ICP.
Conclusions
Management of increased ICP remains crucial in improving clinical outcomes in cryptococcal meningitis. Guidelines should consider an approach to therapeutic LPs that is not dictated by baseline ICP.
Baseline opening pressure was associated with mortality in cryptococcal meningitis; 2 therapeutic lumbar punctures had survival benefit irrespective of baseline opening pressure.]]></description><identifier>ISSN: 2328-8957</identifier><identifier>EISSN: 2328-8957</identifier><identifier>DOI: 10.1093/ofid/ofac416</identifier><identifier>PMID: 36092828</identifier><language>eng</language><publisher>United States: Oxford University Press</publisher><subject>Analysis ; Blood cell count ; Cryptococcal meningitis ; Editor's Choice ; Health aspects ; HIV (Viruses) ; Major ; Mortality ; Penetrating wounds ; Seizures (Medicine) ; Uganda</subject><ispartof>Open forum infectious diseases, 2022-09, Vol.9 (9), p.ofac416-ofac416</ispartof><rights>The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. 2022</rights><rights>The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.</rights><rights>COPYRIGHT 2022 Oxford University Press</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c483t-1fdb2ca97e4572fcb137c8cdf015d3254d814b13c2defddfd8fec7a56b266a0e3</citedby><cites>FETCH-LOGICAL-c483t-1fdb2ca97e4572fcb137c8cdf015d3254d814b13c2defddfd8fec7a56b266a0e3</cites><orcidid>0000-0002-2754-3473 ; 0000-0002-4715-0060 ; 0000-0002-0480-9646 ; 0000-0001-9601-3006 ; 0000-0002-0291-651X ; 0000-0003-1118-4194</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC9454029/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC9454029/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,315,733,786,790,891,1591,27957,27958,53827,53829</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/36092828$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Kagimu, Enock</creatorcontrib><creatorcontrib>Engen, Nicole</creatorcontrib><creatorcontrib>Ssebambulidde, Kenneth</creatorcontrib><creatorcontrib>Kasibante, John</creatorcontrib><creatorcontrib>Kiiza, Tadeo K</creatorcontrib><creatorcontrib>Mpoza, Edward</creatorcontrib><creatorcontrib>Tugume, Lillian</creatorcontrib><creatorcontrib>Nuwagira, Edwin</creatorcontrib><creatorcontrib>Nsangi, Laura</creatorcontrib><creatorcontrib>Williams, Darlisha A</creatorcontrib><creatorcontrib>Hullsiek, Kathy Huppler</creatorcontrib><creatorcontrib>Boulware, David R</creatorcontrib><creatorcontrib>Meya, David B</creatorcontrib><creatorcontrib>Rhein, Joshua</creatorcontrib><creatorcontrib>Abassi, Mahsa</creatorcontrib><creatorcontrib>Musubire, Abdu K</creatorcontrib><title>Therapeutic Lumbar Punctures in Human Immunodeficiency Virus–Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management?</title><title>Open forum infectious diseases</title><addtitle>Open Forum Infect Dis</addtitle><description><![CDATA[Abstract
Background
Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs.
Methods
We prospectively enrolled human immunodeficiency virus (HIV)–seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within 7 days.
Results
Our analysis included 533 participants. Participants with baseline ICP >350 mm H2O were more likely to have Glasgow Coma Scale (GCS) score <15 (P < .001), seizures (P < .01), and higher quantitative cryptococcal cultures (P < .001), whereas participants with ICP <200 mm H2O were more likely to have baseline sterile CSF cultures (P < .001) and CSF white blood cell count ≥5 cells/µL (P = .02). Thirty-day mortality was higher in participants with baseline ICP >350 mm H2O and ICP <200 mm H2O as compared with baseline ICP 200–350 mm H2O (hazard ratio, 1.55 [95% confidence interval, 1.10–2.19]; P = .02). Among survivors at least 7 days, the 30-day relative mortality was 50% higher among participants who did not receive any additional therapeutic LPs compared to those with ≥1 additional follow-up LP (33% vs 22%; P = .04), irrespective of baseline ICP.
Conclusions
Management of increased ICP remains crucial in improving clinical outcomes in cryptococcal meningitis. Guidelines should consider an approach to therapeutic LPs that is not dictated by baseline ICP.
Baseline opening pressure was associated with mortality in cryptococcal meningitis; 2 therapeutic lumbar punctures had survival benefit irrespective of baseline opening pressure.]]></description><subject>Analysis</subject><subject>Blood cell count</subject><subject>Cryptococcal meningitis</subject><subject>Editor's Choice</subject><subject>Health aspects</subject><subject>HIV (Viruses)</subject><subject>Major</subject><subject>Mortality</subject><subject>Penetrating wounds</subject><subject>Seizures (Medicine)</subject><subject>Uganda</subject><issn>2328-8957</issn><issn>2328-8957</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2022</creationdate><recordtype>article</recordtype><recordid>eNp9kk9rFDEYxgdRbKm9eZaABz24Ncn8y3hQlq3awpYWrF5D5s07u5GZZEwmwt76BTz5Df0kZt21tCASSMKT3_vkTXiy7CmjJ4w2-WvXGZ0mBQWrHmSHPOdiJpqyfnhnf5Adh_CVUsoYLWndPM4O8oo2XHBxmP24XqNXI8bJAFnGoVWeXEULU_QYiLHkLA7KkvNhiNZp7AwYtLAhX4yP4dfNz3kIDoyaUJOF34yTAwegenKB1tiVmUx4Qz6tXew1uRz_aOQqOYdkT06NR5jIhbJqhQPa6d2T7FGn-oDH-_Uo-_zh_fXibLa8_Hi-mC9nUIh8mrFOtxxUU2NR1ryDluU1CNAdZaXOeVlowYokAk8da91p0SHUqqxaXlWKYn6Uvd35jrEdUEO626tejt4Mym-kU0beP7FmLVfuu2yKsqC8SQYv9wbefYsYJjmYANj3yqKLQfKa5Tktc14l9PkOXakepbGdS46wxeW8rsumEkzUiTr5B5WGxsGAs-nnk36v4NWuALwLwWN32z2jcpsNuc2G3Gcj4c_uvvgW_puEBLzYAS6O_7f6DWbyyOA</recordid><startdate>20220901</startdate><enddate>20220901</enddate><creator>Kagimu, Enock</creator><creator>Engen, Nicole</creator><creator>Ssebambulidde, Kenneth</creator><creator>Kasibante, John</creator><creator>Kiiza, Tadeo K</creator><creator>Mpoza, Edward</creator><creator>Tugume, Lillian</creator><creator>Nuwagira, Edwin</creator><creator>Nsangi, Laura</creator><creator>Williams, Darlisha A</creator><creator>Hullsiek, Kathy Huppler</creator><creator>Boulware, David R</creator><creator>Meya, David B</creator><creator>Rhein, Joshua</creator><creator>Abassi, Mahsa</creator><creator>Musubire, Abdu K</creator><general>Oxford University Press</general><scope>TOX</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0002-2754-3473</orcidid><orcidid>https://orcid.org/0000-0002-4715-0060</orcidid><orcidid>https://orcid.org/0000-0002-0480-9646</orcidid><orcidid>https://orcid.org/0000-0001-9601-3006</orcidid><orcidid>https://orcid.org/0000-0002-0291-651X</orcidid><orcidid>https://orcid.org/0000-0003-1118-4194</orcidid></search><sort><creationdate>20220901</creationdate><title>Therapeutic Lumbar Punctures in Human Immunodeficiency Virus–Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management?</title><author>Kagimu, Enock ; Engen, Nicole ; Ssebambulidde, Kenneth ; Kasibante, John ; Kiiza, Tadeo K ; Mpoza, Edward ; Tugume, Lillian ; Nuwagira, Edwin ; Nsangi, Laura ; Williams, Darlisha A ; Hullsiek, Kathy Huppler ; Boulware, David R ; Meya, David B ; Rhein, Joshua ; Abassi, Mahsa ; Musubire, Abdu K</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c483t-1fdb2ca97e4572fcb137c8cdf015d3254d814b13c2defddfd8fec7a56b266a0e3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2022</creationdate><topic>Analysis</topic><topic>Blood cell count</topic><topic>Cryptococcal meningitis</topic><topic>Editor's Choice</topic><topic>Health aspects</topic><topic>HIV (Viruses)</topic><topic>Major</topic><topic>Mortality</topic><topic>Penetrating wounds</topic><topic>Seizures (Medicine)</topic><topic>Uganda</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Kagimu, Enock</creatorcontrib><creatorcontrib>Engen, Nicole</creatorcontrib><creatorcontrib>Ssebambulidde, Kenneth</creatorcontrib><creatorcontrib>Kasibante, John</creatorcontrib><creatorcontrib>Kiiza, Tadeo K</creatorcontrib><creatorcontrib>Mpoza, Edward</creatorcontrib><creatorcontrib>Tugume, Lillian</creatorcontrib><creatorcontrib>Nuwagira, Edwin</creatorcontrib><creatorcontrib>Nsangi, Laura</creatorcontrib><creatorcontrib>Williams, Darlisha A</creatorcontrib><creatorcontrib>Hullsiek, Kathy Huppler</creatorcontrib><creatorcontrib>Boulware, David R</creatorcontrib><creatorcontrib>Meya, David B</creatorcontrib><creatorcontrib>Rhein, Joshua</creatorcontrib><creatorcontrib>Abassi, Mahsa</creatorcontrib><creatorcontrib>Musubire, Abdu K</creatorcontrib><collection>Open Access: Oxford University Press Open Journals</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Open forum infectious diseases</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Kagimu, Enock</au><au>Engen, Nicole</au><au>Ssebambulidde, Kenneth</au><au>Kasibante, John</au><au>Kiiza, Tadeo K</au><au>Mpoza, Edward</au><au>Tugume, Lillian</au><au>Nuwagira, Edwin</au><au>Nsangi, Laura</au><au>Williams, Darlisha A</au><au>Hullsiek, Kathy Huppler</au><au>Boulware, David R</au><au>Meya, David B</au><au>Rhein, Joshua</au><au>Abassi, Mahsa</au><au>Musubire, Abdu K</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Therapeutic Lumbar Punctures in Human Immunodeficiency Virus–Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management?</atitle><jtitle>Open forum infectious diseases</jtitle><addtitle>Open Forum Infect Dis</addtitle><date>2022-09-01</date><risdate>2022</risdate><volume>9</volume><issue>9</issue><spage>ofac416</spage><epage>ofac416</epage><pages>ofac416-ofac416</pages><issn>2328-8957</issn><eissn>2328-8957</eissn><notes>ObjectType-Article-1</notes><notes>SourceType-Scholarly Journals-1</notes><notes>ObjectType-Feature-2</notes><notes>content type line 23</notes><notes>M. A. and A. K. M. contributed equally to this work.</notes><notes>Potential conflicts of interest. All authors: No reported conflicts of interest.</notes><abstract><![CDATA[Abstract
Background
Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs.
Methods
We prospectively enrolled human immunodeficiency virus (HIV)–seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within 7 days.
Results
Our analysis included 533 participants. Participants with baseline ICP >350 mm H2O were more likely to have Glasgow Coma Scale (GCS) score <15 (P < .001), seizures (P < .01), and higher quantitative cryptococcal cultures (P < .001), whereas participants with ICP <200 mm H2O were more likely to have baseline sterile CSF cultures (P < .001) and CSF white blood cell count ≥5 cells/µL (P = .02). Thirty-day mortality was higher in participants with baseline ICP >350 mm H2O and ICP <200 mm H2O as compared with baseline ICP 200–350 mm H2O (hazard ratio, 1.55 [95% confidence interval, 1.10–2.19]; P = .02). Among survivors at least 7 days, the 30-day relative mortality was 50% higher among participants who did not receive any additional therapeutic LPs compared to those with ≥1 additional follow-up LP (33% vs 22%; P = .04), irrespective of baseline ICP.
Conclusions
Management of increased ICP remains crucial in improving clinical outcomes in cryptococcal meningitis. Guidelines should consider an approach to therapeutic LPs that is not dictated by baseline ICP.
Baseline opening pressure was associated with mortality in cryptococcal meningitis; 2 therapeutic lumbar punctures had survival benefit irrespective of baseline opening pressure.]]></abstract><cop>United States</cop><pub>Oxford University Press</pub><pmid>36092828</pmid><doi>10.1093/ofid/ofac416</doi><orcidid>https://orcid.org/0000-0002-2754-3473</orcidid><orcidid>https://orcid.org/0000-0002-4715-0060</orcidid><orcidid>https://orcid.org/0000-0002-0480-9646</orcidid><orcidid>https://orcid.org/0000-0001-9601-3006</orcidid><orcidid>https://orcid.org/0000-0002-0291-651X</orcidid><orcidid>https://orcid.org/0000-0003-1118-4194</orcidid><oa>free_for_read</oa></addata></record> |
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| ispartof | Open forum infectious diseases, 2022-09, Vol.9 (9), p.ofac416-ofac416 |
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| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_9454029 |
| source | Oxford Academic Journals (OUP); PubMed Central |
| subjects | Analysis Blood cell count Cryptococcal meningitis Editor's Choice Health aspects HIV (Viruses) Major Mortality Penetrating wounds Seizures (Medicine) Uganda |
| title | Therapeutic Lumbar Punctures in Human Immunodeficiency Virus–Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management? |
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