Archives of Clinical Microbiology

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Cryptococcal Meningitis in People Living with HIV (PLHIV): A Comparative Analysis of the Diagnostic Tests

S. Anuradha, Mahaveer Singh, Ravinder Kaur, K. Rajeshwari

Background: Cryptococcal meningitis (CM) is associated with a high mortality rate among people living with HIV (PLHIV). CM often presents with subtle features delaying the diagnosis. The diagnosis of CM can be challenging, especially with limited access to the newer diagnostic techniques. This study compared the utility of various tests in the diagnosis of CM in a resource constrained setting.

Methods : In this prospective study conducted in a tertiary care public facility in New Delhi, India, PLHIV with chronic meningitis were screened for CM. A comparison of clinical assessment, Cerebrospinal fluid (CSF) analysis [cytology, biochemistry (sugar/protein), and microbiology (India ink staining/Latex Agglutination Test (LAT)], CSF and blood cultures and radiology (MRI brain) in 25 subjects of CM was done.

Results: The mean age of subjects was 37 ± 11.25 years and 88% were men. The mean BMI of subjects was 21.28 ± 3.65 kg/m2, 36% were undernourished. The mean CD4 count was 87 ± 66 cells/mm3 and 68% had CD4 count < 100 cells/ mm3. Headache (92%), vomiting (68%), fever (44%), altered consciousness (36%), and seizures (20%) were common symptoms. Median duration of headache (24 days) and fever (20 days) corroborated late presentation of patients. Cryptococcal antigen detection by Latex agglutination (LAT) in the CSF was the positive in 100%. The India ink staining of CSF was positive in only 60% of subjects. CSF culture isolated Cryptococcus in 64% cases. On MRI of the brain, only 28% had a normal scan and leptomeningeal enhancement was the commonest abnormality seen (28%).

Conclusions: CM can present with subtle findings- about 1/3rd patients do not have classical features of meningitis. Patients tend to present late; the paucity of CSF abnormalities further delays the diagnosis. India ink staining is useful in diagnosis in only 2/3rd of cases. Even though LAT is more expensive it should be the preferred diagnostic modality. Early clinical suspicion and antigen detection tests are recommended for the early and timely diagnosis of CM.