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. 2022 Aug 17;9(9):ofac416.
doi: 10.1093/ofid/ofac416. eCollection 2022 Sep.

Therapeutic Lumbar Punctures in Human Immunodeficiency Virus-Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management?

Enock Kagimu  1 , Nicole Engen  2 , Kenneth Ssebambulidde  1 , John Kasibante  1 , Tadeo K Kiiza  1 , Edward Mpoza  1 , Lillian Tugume  1 , Edwin Nuwagira  3 , Laura Nsangi  1 , Darlisha A Williams  1   4 , Kathy Huppler Hullsiek  2 , David R Boulware  4 , David B Meya  1   4   5 , Joshua Rhein  1   4 , Mahsa Abassi  1   4 , Abdu K Musubire  1
Affiliations

Therapeutic Lumbar Punctures in Human Immunodeficiency Virus-Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management?

Enock Kagimu et al. Open Forum Infect Dis. .

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.

Keywords: baseline opening pressure; cryptococcal meningitis; mortality; therapeutic lumbar puncture.

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Figures

Figure 1.
Figure 1.
Thirty-day mortality by baseline cerebrospinal fluid opening pressure (OP).
Figure 2.
Figure 2.
Thirty-day mortality by number of follow-up lumbar punctures (LPs) in the first 7 days for participants who survived at least 7 days.
See this image and copyright information in PMC

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