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Publication Details
AFRICAN RESEARCH NEXUS
SHINING A SPOTLIGHT ON AFRICAN RESEARCH
medicine
Outcomes of cryptococcal meningitis in Uganda before and after the availability of highly active antiretroviral therapy
Clinical Infectious Diseases, Volume 46, No. 11, Year 2008
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Description
Background. Cryptococcal meningitis (CM) is the proximate cause of death in 20%-30% of persons with acquired immunodeficiency syndrome in Africa. Methods. Two prospective, observational cohorts enrolled human immunodeficiency virus (HIV)-infected, antiretroviral-naive persons with CM in Kampala, Uganda. The first cohort was enrolled in 2001-2002 (n = 92), prior to the availability of highly active antiretroviral therapy (HAART), and the second was enrolled in 2006-2007 (n = 44), when HAART was available. Results. Ugandans presented with prolonged CM symptoms (median duration, 14 days; interquartile range, 7-21 days). The 14-day survival rates were 49% in 2001-2002 and 80% in 2006 (P < .001). HAART was started 35 ± 13 days after CM diagnosis and does not explain the improved 14-day survival rate in 2006. In 2006-2007, the survival rate continued to decrease after hospitalization, with only 55% surviving to initiate HAART as an outpatient. Probable cryptococcal-related immune reconstitution inflammatory syndrome occurred in 42% of patients, with 4 deaths. At 6 months after CM diagnosis, 18 persons (41%) were alive and receiving HAART in 2007. The median cerebral spinal fluid (CSF) opening pressure was 330 mm H2O; 81% of patients had elevated pressure (1200 mm H2O). Only 5 patients consented to therapeutic lumbar puncture. There was a trend for higher mortality for pressures >250 mm H2O (odds ratio [OR], 2.1; 95% confidence interval [CI], 0.9-5.2; P < .09). Initial CSF WBC counts of <5 cells/μL were associated with failure of CSF sterilization (OR, 17.3; 95% CI, 3.1-94.3; P < .001), and protein levels <35 mg/dL were associated with higher mortality (OR, 2.0; 95% CI, 1.2-3.3; P = .007). Conclusions. Significant CM-associated mortality persists, despite the administration of amphotericin B and HIV therapy, because of the high mortality rate before receipt of HAART and because of immune reconstitution inflammatory syndrome-related complications after HAART initiation. Approaches to increase acceptance of therapeutic lumbar punctures are needed. © 2008 by the Infectious Diseases Society of America. All rights reserved.
Authors & Co-Authors
Kambugu, Andrew Ddungu
Uganda, Kampala
Makerere University
Meya, David B.
Uganda, Kampala
Makerere University
Rhein, Joshua R.
United States, Minneapolis
University of Minnesota Twin Cities
O'Brien, Meagan P.
United States, New York
Nyu Grossman School of Medicine
Janoff, Edward N.J.
United States, Aurora
University of Colorado School of Medicine
Ronald, Allan R.
Uganda, Kampala
Makerere University
Canada, Winnipeg
University of Manitoba
Kamya, Moses Robert K.
Uganda, Kampala
Makerere University
Uganda, Kampala
School of Medicine, Makerere University College of Health Sciences
Mayanja-Kizza, Harriet
Uganda, Kampala
Makerere University
Uganda, Kampala
School of Medicine, Makerere University College of Health Sciences
Sande, Merle A.
Uganda, Kampala
Makerere University
Bohjanen, Paul R.
United States, Minneapolis
University of Minnesota Twin Cities
Boulware, David R.
United States, Minneapolis
University of Minnesota Twin Cities
Statistics
Citations: 296
Authors: 11
Affiliations: 6
Identifiers
Doi:
10.1086/587667
ISSN:
10584838
Research Areas
Infectious Diseases
Study Design
Cohort Study
Case-Control Study
Study Locations
Uganda