Clinical Analysis of 62 Patients with Cryptococcal Meningitis

  Objective  The aim was to study the clinical characteristics and therapeutic strategies of cryptococcal meningitis and provide further evidence for clinical diagnosis and therapy.

  Methods  Data of the inpatients with cryptococcal meningitis who were admitted in the Department of Infectious Diseases, Peking Union Medical College Hospital from January 2000 to December 2016, including clinical data (age, gender, comorbidity, history of avian contact), clinical manifestations, laboratory examination, CT and magnetic resonance imaging findings, therapy, and prognosis, were analyzed retrospectively.

  Results  The age of the 62 enrolled inpatients ranged from 16 to 68 years (median 39). 41 patients were male and 21 were female. There were 37 patients (59.7%, 37/62) with comorbidity and 23 patients (37.1%, 23/62) had contacted with pigeons or poultries. The number of cases misdiagnosed with tubercular meningitis or virus meningitis was 20 (32.3%, 20/62) and 9 (14.5%, 9/62), respectively. The main clinical symptoms included headache (98.4%, 61/62) and fever (82.3%, 51/62); 19 (30.6%, 19/62) patients had blurred vision; 13(21.0%, 13/62) had organ involvement beyond the central nervous system. The intracranial pressure increased in 55 patients (88.7%, 55/62) and 34 (61.8%, 34/55) had an opening pressure of more than 330 mm H₂O. The white blood cell count of cerebrospinal fluid had a median of 71×10⁶ cells/L(range 0-408×10⁶ cells/L), dominated by mononuclear cells in 55 patients (88.7%, 55/62). Fifty-three (85.5%) of the 62 cases were positive of cryptococcus by India ink stain of cerebrospinal fluid; latex coagulate test was performed in 55 cases with 51 (92.7%, 51/55) positive; cerebrospinal fluid culture was positive in 28 cases (49.1%, 28/57). Twenty-five patients with a dilated ventricle received brain ventricular drainage. Only 4 cases used fluconazole monotherapy; 7 patients received intravenous amphotericin B (AmB) and flucytosine combined therapy; 16 patients took AmB and fluconazole combined therapy; 35 patients received AmB, flucytosine, and fluconazole combined therapy. The average dosage of AmB was 4139 mg; the median treatment duration was 19.6 weeks (range 2-42 weeks). In general, 10 of the 62 cases were cured, 44 improved, 6 no response, and 2 died; the total effective rate was 87.1% (54/62).

  Conclusions  Cryptococcal meningitis might occur in immunocompetent patients with a high misdiagnosis rate. India ink stain and cryptococcal antigen test of cerebrospinal fluid are useful assays for early diagnosis of cryptococcal meningitis and therapeutic effect evaluation. We recommend the combination of amphotericin B with flucytosine and fluconazole as the standard therapy for cryptococcal meningitis. Early ventricular drainage is the key point to improve the treatment success for cryptococcal meningitis.