The Effect of Therapeutic Lumbar Punctures on Acute Mortality from Cryptococcal Meningitis.
Clin Infect Dis. 2014 Jul 23;
Authors: Rolfes MA, Hullsiek KH, Rhein J, Nabeta HW, Taseera K, Schutz C, Musubire A, Rajasingham R, Williams DA, Thienemann F, Muzoora C, Meintjes G, Meya DB, Boulware DR
INTRODUCTION: Cryptococcal meningitis is the most common cause of adult meningitis in sub-Saharan Africa. Raised intracranial pressure (ICP) is common in cryptococcosis. Prior studies suggest elevated ICP is associated with mortality, and guidelines recommend frequent lumbar punctures (LPs) to control ICP. However, the magnitude of the impact of LPs on cryptococcal-related mortality is unknown.
METHODS: 248 individuals with HIV-associated cryptococcal meningitis, screened for the Cryptococcal Optimal ART Timing (COAT) trial in Uganda and South Africa, were observed. Individuals received an LP to diagnose meningitis and subsequent therapeutic LPs were recommended for elevated ICP (>250 mmH2O) or new symptoms. We compared survival, through 11 days, between individuals receiving at least one therapeutic LP with individuals not receiving therapeutic LPs. The COAT trial randomized subjects at 7-11 days, thus follow-up stopped at time of death, randomization, or 11 days.
RESULTS: 75 (30%) individuals had at least one therapeutic LP. Individuals receiving therapeutic LPs had higher cerebrospinal fluid (CSF) opening pressures, higher CSF fungal burdens, and were more likely to have altered mental status at baseline than those with no therapeutic LPs. 31 deaths (18%) occurred among 173 individuals without a therapeutic LP and 5 deaths (7%) among 75 with at least one therapeutic LP. The adjusted relative risk of mortality was 0.31 (95% confidence interval: 0.12-0.82). The association was observed regardless of opening pressure at baseline.
CONCLUSIONS: Therapeutic LPs were associated with a 69% relative improvement in survival, regardless of initial intracranial pressure. The role of therapeutic LPs should be re-evaluated.
PMID: 25057102 [PubMed - as supplied by publisher]