Therapeutic lumbar punctures in HIV-associated cryptococcal meningitis: should opening 3 pressure direct management

Abstract

Background: Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, 4and we sought to understand the longer-term survival impact of therapeutic LPs. Methods: We prospectively enrolled HIV-seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. CSF opening pressure was measured at diagnosis. Therapeutic LPs were scheduled on days 3, 7, 10, 14, and performed additionally as clinically indicated. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within days. Results: Our analysis included 533 participants. Participants with baseline ICP>350 mmH2O were more likely to have Glasgow Coma Scale score (GCS) =5 cells/mcL (p=0.02). 30-day mortality was higher in participants with baseline ICP >350 mmH2O and ICP =1 additional follow up LP (33% vs 22%; p=0.04), irrespective of baseline ICP. Conclusion: Management of increased ICP remains crucial in improving clinical outcomes in cryptococcal meningitis. Guidelines should consider an approach to therapeutic LPs that isn’t dictated by baseline ICP.