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      Which clinical parameters predict a CSF diagnosis of meningitis in a population with high HIV prevalence?

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          Abstract

          BACKGROUND: The HIV epidemic has changed the aetiology of meningitis in sub-Saharan Africa, and frontline clinicians are faced with a variety of meningitic presentations. Doctors working in resource-limited settings have the challenge of appropriately selecting patients for lumbar puncture (LP), a potentially risky procedure that requires laboratory analysis. METHODS: In a rural South African hospital, the practice of performing LPs was audited against local guidelines. Data were collected retrospectively between February and June 2013. Symptoms and signs of meningitis, HIV status, investigations performed prior to LP and cerebrospinal fluid (CSF) results were recorded. With the aim of determining statistically significant clinical predictors of meningitis, parameters were explored using univariate and multivariate logistic regression analyses RESULTS: A total of 107 patients were included, of whom 43% had an abnormal CSF result. The majority (76%) of patients were HIV-positive (CD4+ cell count <200 cells/µl in 46%). Cryptococcal meningitis (CCM) was the most prevalent microbiological diagnosis, confirmed in 10 out of 12 patients. Of the non-microbiological diagnoses, lymphocytic predominance was the most common abnormality, present in 17 out of 33 patients. Confusion (p=0.011) was the most statistically significant predictor of an abnormal CSF result. Headache (p=0.355), fever (p=0.660) and photophobia (p=0.634) were not statistically predictive CONCLUSION: The high incidence of CCM correlates with previous data from sub-Saharan Africa. In populations with high HIV prevalence, the classic meningitic symptoms of headache, fever and photophobia, while common presenting symptoms, are significantly less predictive of a meningitis diagnosis than confusion.

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          Cryptococcal infection in a cohort of HIV-1-infected Ugandan adults.

          Despite the recognition of Cryptococcus neoformans as a major cause of meningitis in HIV-infected adults in sub-Saharan Africa, little is known about the relative importance of this potentially preventable infection as a cause of mortality and suffering in HIV-infected adults in this region. A cohort study of 1372 HIV-1-infected adults, enrolled and followed up between October 1995 and January 1999 at two community clinics in Entebbe, Uganda. Systematic and standardized assessment of illness episodes to describe cryptococcal disease and death rates. Cryptococcal disease was diagnosed in 77 individuals (rate 40.4/1000 person-years) and was associated with 17% of all deaths (77 out of 444) in the cohort. Risk of infection was strongly associated with CD4 T cell counts 100 days in 11% of patients). Survival following diagnosis was poor (median survival 26 days; range 0-138). Cryptococcal infection is an important contributor to mortality and suffering in HIV-infected Ugandans. Improvements in access to effective therapy of established disease are necessary. In addition, prevention strategies, in particular chemoprophylaxis, should be evaluated while awaiting the outcome of initiatives to make antiretroviral therapy more widely available.
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            Clinical presentation, natural history, and cumulative death rates of 230 adults with primary cryptococcal meningitis in Zambian AIDS patients treated under local conditions.

            Inpatient medical wards, Department of Medicine, University Teaching Hospital, Lusaka, Zambia. To define the natural history, clinical presentation, and management outcome of microbiologically confirmed cryptococcal meningitis in adult AIDS patients treated under local conditions where antifungal and antiretroviral therapies are not routinely available. A descriptive, longitudinal, observational study. All adult patients admitted to the medical wards of the University Teaching Hospital, Lusaka, Zambia with cerebrospinal fluid culture proved, primary cryptococcal meningitis, during a 12 month period were enrolled into the study. The following details were acquired: clinical features, HIV status, laboratory data, treatment accorded, and survival. A total of 230 patients with primary cryptococcal meningitis were studied (median age 32 years; range 15-65 years; 112 males, 118 females). Cryptococcal meningitis was the first AIDS defining illness in 210 (91%) patients. One hundred and thirty of the 230 (56%) patients had received treatment with fluconazole monotherapy and 100 (43%) patients received palliative care only without any antifungal therapy. A 100% case fatality rate was observed in both groups at follow up: by seven weeks in the untreated group and at six months in the fluconazole treated group. The cumulative median survival from time of diagnosis was 19 days (range 1-164 days) for the fluconazole treated group and 10 days (range 0-42 days) for the untreated group. Cryptococcal meningitis, under current treatment accorded at the University Teaching Hospital, Lusaka, has a 100% mortality in young Zambian adults with AIDS. The current treatment accorded to Zambian adults with cryptococcal meningitis is inappropriate. An urgent need exists to improve strategies for the clinical management of AIDS patients in poor African countries. The wider ethical and operational issues of making available antifungals to African AIDS patients are discussed.
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              Rapid advice: diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children.

              (2011)
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                sajhivmed
                Southern African Journal of HIV Medicine
                South. Afr. j. HIV med. (Online)
                Health and Medical Publishing Group (Cape Town )
                1608-9693
                February 2014
                : 15
                : 2
                : 50-54
                Affiliations
                [1 ] Bristol Royal Infirmary UK
                [2 ] Royal Liverpool University Hospital UK
                [3 ] Great Western Hospital UK
                [4 ] Stanger Provincial Hospital South Africa
                Article
                S2078-67512014000200004
                54175b2c-e06e-47ef-adca-c5273696dba7

                http://creativecommons.org/licenses/by/4.0/

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                SciELO South Africa

                Self URI (journal page): http://www.scielo.org.za/scielo.php?script=sci_serial&pid=2078-6751&lng=en
                Categories
                Biology
                Health Care Sciences & Services
                Health Policy & Services
                Immunology

                General life sciences,Immunology,Health & Social care,Public health
                General life sciences, Immunology, Health & Social care, Public health

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