Diagnosis and Management of Increased Intracranial Pressure in Patients with AIDS and Cryptococcal Meningitis

TLDR

The study aimed to describe the laboratory and clinical course of AIDS patients with cryptococcal meningitis who had normal or elevated cerebrospinal fluid pressure. Retrospective data from a multicenter phase III trial comparing amphotericin B with or without flucytosine were analyzed, with CSF pressure measured before treatment and at two weeks and repeated lumbar punctures performed to drain fluid and lower pressure. Patients with baseline opening pressures ≥ 250 mm H₂O had higher antigen titers, more positive India ink smears, and more neurological symptoms, and those whose pressure decreased by > 10 mm or did not change had better 2‑week clinical responses and higher short‑term survival, leading to a recommendation for large‑volume CSF drainage when pressures are ≥ 250 mm H₂O.

Abstract

This study was undertaken to characterize the laboratory and clinical course of patients with AIDS and cryptococcal meningitis who had normal or elevated cerebrospinal fluid (CSF) pressure. Data were obtained retrospectively from a randomized multicenter quasifactorial phase III study comparing amphotericin B with or without flucytosine in primary treatment of cryptococcal meningitis. CSF pressure was measured before treatment and at 2 weeks. Repeated lumbar punctures were done to drain CSF and to reduce pressure. Patients with the highest baseline opening pressures (> or = 250 mm H2O) were distinguished by higher titers of cryptococcal capsular polysaccharide antigen in CSF; more frequently positive India ink smears of CSF; and more frequent headache, meningismus, papilledema, hearing loss, and pathological reflexes. After receiving antifungal therapy, those patients whose CSF pressure was reduced by >10 mm or did not change had more frequent clinical response at 2 weeks than did those whose pressure increased >10 mm (P<.001). Patients with pretreatment opening pressure <250 mm H2O had increased short-term survival compared with those with higher pressure. We recommend that opening pressures >/=250 mm H2O be treated with large-volume CSF drainage.