Cryptococcal Meningitis in Hospitalized Hiv Patients at the Fevers’ Unit, Korle-Bu Teaching Hospital, Accra

Abstract

Introduction: Cryptococcal meningitis (CM) is the leading form of meningitis in HIV/AIDS patients and causes significant morbidity and mortality, even in the advent of accessibility of antiretroviral therapy. Globally, the burden of CM is estimated to be at 9.6 million cases and results in about 6.2 million deaths within three months of infection. General aim: The aim of the study was to determine the prevalence of Cryptococcal meningitis in hospitalized HIV-infected patients at the Fevers’ Unit, Korle-Bu Teaching Hospital. Method: A cross sectional study on fifty-three consecutive hospitalized HIV patients with clinical presentations suggestive of meningitis at the Fevers’ Unit of the Korle-Bu Teaching Hospital was undertaken within a period of 12 months. Cerebrospinal fluid (CSF) Cryptococcal Antigen Lateral Flow Assay (CrAgLFA), culture and microscopy (India ink, Gram stain) were performed on CSF samples taken by lumbar puncture. Sensitivity and specificity analysis of serology, India ink and Gram stain microscopy were performed using culture as gold standard. CSF White Blood Cell (WBC) count, CSF biochemistry and viral load were also done. Patient’s folders were also audited and analyzed. Results: A total of 53 CSF specimens were collected for the study. Out of 53 subjects, 28 (53%) were males and 25 (47%) were females with mean age of 40.7 years. Headache, fever, confusion-neurosymptoms, oral thrush, meningismus and tachycardia were major clinical presentations shown by the subjects. One participant was confirmed positive for cryptococcal meningitis by CrAgLFA, India ink and Gram stain but not culture giving a prevalence of 1.9% among the study subjects. The sensitivity and specificity of CrAg and microscopy against culture were 0% and 98.1% respectively. The confirmed CM patient showed headache, stiff neck and unstable gait. Twelve (22.6%) had CSF WBC counts above 20 cells/mm3 with lymphocytic predominance. CD4 count below 100 cells/μl were seen in 20 (37.7%) of the subjects and 43.3% of them had viral loads above 1.0×105 RNA copies/ml. Eleven (20.8%) were on Anti-retroviral therapy (ART) with 46 (86.8%) in WHO stage IV of HIV. Nine (17.0%) of subjects had CSF glucose below 2.5 mmol/L, 31 (58.5%) had positive CSF globulin and 32 (60.4%) had CSF total protein greater than 0.45 g/L. Forty-three (81.1%) had haemoglobin level below 12.0 g/dl with 19 (35.9%) having abnormal Total WBC. Fourteen (26.4%) presented with abnormal platelet count while 9 (17.0%) had abnormal Random blood glucose. Thirty (56.6%) and 5 (9.4%) were put on oral fluconazole and IV fluconazole whiles others were put on antibiotics, antimalarials and analgesic. The CM confirmed patient had haemoglobin level of 10.5 g/dl, WBC of 6.8×109/L, Platelet of 129×109/L, RBS of 8.0 mmol/L, CSF glucose of 2.8 mmol/L, CSF/Serum glucose ratio of 0.35, CSF protein of 0.47 g/L, Globulin was negative, CSF WBC count of 235 cells/mm3 with lymphocytic predominance, CD4 count of 182 cells/μl, viral load of 482 RNA copies/ml, was ART compliant, Glasgow coma score of 15/15, WHO stage IV and was put on oral fluconazole. The mortality rate for the study was 39.6%. Conclusion: There was low prevalence of cryptococcal meningitis which suggests that CM may not necessarily be the leading form of meningitis among HIV/AIDS subjects at the Fevers’ Unit, Korle-Bu Teaching Hospital. The sensitivities and specificities of serology, India ink and Gram stain were 0% and 98.1% each respectively. Culture should be coupled with other diagnostic parameters (Serology, India ink and Gram stain) for reliable CM diagnosis.