Outpatient Cryptococcal Antigen Screening Is Associated With Favorable Baseline Characteristics and Improved Survival in Persons With Cryptococcal Meningitis in Uganda
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Date
2023Author
Levin, Anna E.
Bangdiwala, Ananta S.
Nalintya, Elizabeth
Kagimu, Enock
Kasibante, John
Rutakingirwa, Morris K.
Mpoza, Edward
Jjunju, Samuel
Nuwagira, Edwin
Naluyima, Rose
Kirumira, Paul
Hou, Cody
Ssebambulidde, Kenneth
Musubire, Abdu K.
Williams, Darlisha A.
Abassi, Mahsa
Muzoora, Conrad
Hullsiek, Katherine H.
Rajasingham, Radha
Meya, David B.
Boulware, David R.
Skipper, Caleb P.
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Background: It is unknown whether persons with symptomatic cryptococcal meningitis detected during routine blood cryptococcal antigen (CrAg) screening have better survival than persons presenting with overt meningitis.
Methods: We prospectively enrolled Ugandans with HIV and cryptococcal meningitis from December 2018 to December 2021. Participants were treated with amphotericin-based combination therapy. We compared outcomes between persons who were CrAg screened then referred to hospital with those presenting directly to the hospital with symptomatic meningitis.
Results: Among 489 participants with cryptococcal meningitis, 40% (194/489) received blood CrAg screening and were referred to hospital (median time to referral 2 days; interquartile range [IQR], 1–6). CrAg-screened persons referred to hospital had lower 14-day mortality than non–CrAg-screened persons who presented directly to hospital with symptomatic meningitis (12% vs 21%; hazard ratio, .51; 95% confidence interval, .32–.83; P=.006). Fewer CrAg-screened participants had altered mental status versus non–CrAg-screened participants (29% vs 41%; P=.03). CrAg-screened persons had lower quantitative cerebrospinal fluid (CSF) culture burden (median [IQR], 4570 [11–100 000] vs 26 900 [182–324 000] CFU/mL; P=.01) and lower CSF opening pressures (median [IQR], 190 [120–270] vs 225 [140–340] mmH2O; P=.004) compared with non–CrAg-screened persons.
Conclusions: Survival from cryptococcal meningitis was higher in persons with prior CrAg screening than those without CrAg screening. Altered mental status was the most potent predictor for mortality in a multivariate model. We suggest that CrAg screening detects cryptococcal meningitis at an earlier stage, as evidenced by a favorable baseline risk profile and notably fewer persons with altered mental status.
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