L Ibanez-Valdes, H Foyaca-Sibat, K Mfenyana, J Chandia, H Gonzalez-Aguilera
crytococcal meningitis, neuropsychiatry
L Ibanez-Valdes, H Foyaca-Sibat, K Mfenyana, J Chandia, H Gonzalez-Aguilera. Neuropsychiatry Manifestations In Patients Presenting Cryptococcal Meningitis. The Internet Journal of Neurology. 2004 Volume 5 Number 1.
Background and objectives: the incidence of crytococcal meningitis (cm), formerly a relatively rare disease, has markedly increased in recent years due to the frequent occurrence of the opportunistic infection in human immunodeficiency virus (hiv)-positive patients1 mainly in places where protease inhibitor, nucleoside reverse transcriptase, and non-nucleoside reverse transcriptase drugs remains unavailable. The fungus is acquired by inhalation and causes the initial lesion in the lungs; the pulmonary stage of infection is usually a symptomatic. The fungus disseminates in debilitated patients, usually involving the meninges. In hiv-negative patient's incidence of cm is related to immunosuppressive drugs used to prevent allograft rejection in organ transplanted recipients, and particularly steroids therapy seems to be associated with an increased risk factor for cm2
Neuropsychiatry manifestations (npm) may be conditions that are directly attributed to hiv infection but sometimes these conditions existed before a person becomes hiv-positive and both contribute to increase level of unemployment, poverty, homeless and unhappiness. Patients presenting these conditions (npm-hiv) are more prompt to develop complications because most of them have limited access to health care, hiv primary care, new antiretroviral medications and poor compliance therefore they will have shortened hiv-related survival, severely impaired quality of life and worst prognosis compared with hiv patients without npm1. In places where traditional believes and stigmas are strong enough to modify the environment of these patients the prognosis is even worst. We recognize that despite all the scientific progress observed in the last century, the npm, epilepsies, and cognitive disorders are still surrounded by a mysterious mist for the majority of the population, mainly in developing countries,3,4,5,6 we also agree that it is abominable see at the beginning of the third millennium; npm and epilepsy are still being considered as symptom of devilish possession by some alternative therapists, adherent to distinct creeds in many societies around the world7
Based on our previous knowledge of this problem we selected a number of record from patients diagnosed as cm and hiv/aids with the aim to identify their npm and to determine any possible correlation between npm, complications, and clinical prognosis.
Material And Method
A total of 142 patients with cm presenting npm, admitted in medical wards of Umtata general hospital between December 09, 2003 and December 09, 2004 were selected retrospectively. The detailed clinical history of the patients regarding age, sex, clinical diagnosis, and drug therapy were recorded.
All patients were diagnosed as hiv/aids by Elisa test for HIV and all of them were in a late stage of hiv/aids being their cd4 count ranged between 97 and 2 cell/mm3. As a routine procedure, the purpose of each investigation or medical procedure was explained to each patient before consent was requested.
Most patients were treated with 400mg to 800mg of fluconazol, mannitol and acetazolamide; and nobody was on antiretroviral treatment; when was necessary lp to remove out from 15 to 30 ml of cerebrospinal fluid (CSF) on daily basis or alternating day was performed. From all patients, samples of CSF were sent to the laboratory for cytochemical tests, cryptococcal capsular polysaccharide antigen, gram's stain, fungal culture, and India ink smear.
Patients under suspicion of hiv-1 encephalitis, hiv-1 associated dementia, tuberculous meningitis, aseptic meningitis, partially treated meningitis, syphilis, or neurocysticercosis were excluded. Other exclusion criteria were: pregnancy, previous history of npm, cognitive problems, mood disturbances, history of panic or obsessive-compulsive disorder with or without personality disorders. Patients reported with previous or current history of stroke, alcoholism, electrolyte disturbances, were not selected for this study. Personal identification details written on their outpatient cards were omitted to ensure anonymity. To increase the confidentially of the selected patients the first page from in-patient documents regarding personal information was omitted during data collection. Correlation between symptoms of delirium (
Clinical criteria used for identification of
In 2 patients without manifestation of sarcoidosis hiv test was negative and cm was confirmed by the identification of numerous encapsulated yeasts and positive cryptococcal antigen in CSF. The commonest npm on this series was
Thirty-two patients presenting
Crytococcosis is the most common systemic fungal infection in aids8 and it is on the rise with the rapid spread of aids. The incidence of cryptococcosis is 20.9 cases / 100000 in the general population and 2 - 4 cases / 1000 in aids patients (centre for disease control and prevention: technical information, December 2000). 85% of cases occur in HIV infected persons. It is the aids defining illness in 25-30% of the cases in south east asia.8
Cm in hiv-negative patients is usually associated to neurosarcoidosis however some patients in advance stages of hiv/aids can be tested negative for Elisa test.
In spite of the chronic process seen in cm only acute manifestation (d) of organic brain syndrome (OBS) causing impairment of cognition (due to exogenous insult of the neurochemical and structural damage cortical brain functions) was observed while sub-acute (encephalopathy) and chronic manifestations (
In our series, symptoms of
Other NPM were statistically no significant therefore those symptoms were excluded from this analysis.
Currently, an increased number of accurate investigations can be done for confirmation of diagnosis of CM14,15,16 but in our experiences the classical India ink smear and determination of cryptococal antigen still have a high value, and for the other hand quantitative determination of cryptococcal antigen is an expensive test but has an important prognostic value.
Without treatment cryptococcosis is invariably fatal 17,18,19. In series of patients with cm without npm the mortality rate was 83. 3%.20 mortality rate in our group was 76%. An associated npm implies other CNS lesions, some of them affecting deeper areas of the brain that can explain fatal outcomes when complications such as
Nevertheless, when NPM like
The positive rates of cryptococci in the CSF as shown by India ink stain and positive crytococcal antigen were very high. Delirium and mania were the commonest npm. Hydrocephalus and