Abstract
Prior to the AIDS-era, elevation of intracranial pressure was known to be a typical complication of cryptococcal meningitis associated with an increased risk of early death. In AIDS-patients, however, the prevalence and clinical significance of this complication are as yet unclear. We analysed clinical features and courses, CSF findings, serological results and neuroimaging scans in acute cryptococcal meningitis in eight patients with AIDS. Five showed symptoms and signs compatible with raised intracranial pressure, which was life-threatening in one and the most probable cause of death in another. Serial monitoring of intracranial pressure together with repeated CSF analysis revealed that severe intracranial pressure elevation in AIDS related cryptococcal meningitis can occur in spite of effective antimycotic treatment, does not depend on an increased CSF/serum osmolality ratio or CSF overproduction and can be associated with normal cranial computed tomography and magnetic resonance imaging findings. Our data support the hypothesis that CSF reabsorption failure plays the crucial role in the pathophysiological mechanism. External lumbar drainage may be of benefit in selected cases of acute AIDS related cryptococcal meningitis with persisting life threatening elevation in intracranial pressure and normal computed tomogram.
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Abbreviations
- AIDS:
-
acquired immune deficiency syndrome
- CM:
-
cryptococcal meningitis
- CSF:
-
cerebrospinal fluid
- CT:
-
computed tomography
- HIV:
-
human immunodeficiency virus
- ICP:
-
intracranial pressure
- MRI:
-
magnetic resonance imaging
References
Alksne JF, Lovings ET (1972) The role of the arachonoid villus in the removal of red blood cells from the subarachnoid space. Neurosurgery 36:192–200
Cutler RW, Page L, Galicich J et al (1968) Formation and adsorption of cerebrospinal fluid in man. Brain 91:707–720
Denning DW, Armstrong RW, Bradley HL, Stevens DA (1991) Elevated cerebrospinal fluid pressures in patients with cryptococcal meningitis and acquired immunodeficiency syndrome. Am J Med 91:267–272
Diamond RD, Bennett JE (1974) Prognostic factors in cryptococcal meningitis. Ann Intern Med 80:176–181
Ellington E, Margolis G (1969) Block of arachnoid villus by subarachnoid hemorrhage. Neurosurgery 30:651–657
Epstein MH, Feldman AM, Brusilow SW (1977) Cerebrospinal fluid production: stimulation by cholera toxin. Science 196:1012–1013
Feldman AM, Smith T, Epstein MH et al (1978) Effects of indomethacin on cholera toxin-induced cerebrospinal fluid production. Brain Res 142:379–383
Hussey F, Schanzer B, Katzman R (1970) A simple constant-infusion manometric test for measurement of CSF absorption. II. Clinical studies. Neurology 20:665–680
Johnston SR, Corbett LE, Foster O et al (1992) Raised intracranial pressure and visual complications in AIDS patients with cryptococcal meningitis. J Infect 24:185–189
Kovacs JA, Kovacs AA, Polis M et al (1985) Cryptococcosis in the acquired immunodeficiency syndrome. Ann Intern Med 103:533–538
Levine JE, Povlishock JT, Becker DP (1982) The morphological correlates of primate cerebrospinal fluid absorption. Brain Res 241:31–41
McComb MD (1983) Recent research into the nature of cerebrospinal fluid formation and adsorption. Neurosurgery 59:369–383
Pappenheimer JR, Heisey SR, Jordan EF, et al (1962) Perfusion of the cerebral ventricular system in unanesthetized goats. Am J Physiol 203:763–774
Powderly WG (1992) Therapy for cryptococcal meningitis in patients with AIDS. Clin Infect Dis 14 [Suppl]1:54–59
Saag MS, Powderly WG, Cloud GA et al (1992) Comparison of amphotericin B with fluconazole in the treatment of acute AIDS-associated cryptococcal meningitis. The NIAID Mycoses Study Group and the AIDS Clinical Trials Group. N Engl J Med 326:83–89
Stein SC, Corrado ML, Friedlander M et al (1982) Chronic mycotic meningitis with spinal involvement (arachnoiditis). Ann Neurol 2:519–524
Van Gemert HMA, Vermeulen M (1991) Treatment of impaired consciousness with lumbar punctures in a patient with cryptococcal meningitis and AIDS. Clin Neurol Neurosurg 93:257–258
Welch K, Pollay M (1961) Perfusion of particles through arachnoid villi of the monkey. Am J Physiol 201:651–654
Wong B, Perfect JR, Beggs S, Wright KA (1990) Production of the hexitol D-mannitol byCryptococcus neoformans in vitro and in rabbits with experimental meningitis. Infect Immun 58:1664–1670
Zoller WG, Kellner H, Goebel FD, Schmiedtke K, Holecek B, Staib F, Seibold M, Zollner N (1989)Cryptococcus neoformans meningoencephalitis and multiple infections in AIDS. Klin Wochenschr 67:598–604
Zuger A, Louie E, Holzman RS et al (1986) Cryptococcal disease in patients with the acquired immunodeficiency syndrome. Ann Intern Med 104:234–240
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Correspondence to: R. Malessa
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Malessal, R., Krams, M., Hengge, U. et al. Elevation of intracranial pressure in acute AIDS-related cryptococcal meningitis. Clin Investig 72, 1020–1026 (1994). https://doi.org/10.1007/BF00577748
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DOI: https://doi.org/10.1007/BF00577748