Ctyptococcal disease (CD) in AIDS: The detroit medical center (DMC) experience. A comparison of clinical features, laboratory findings and outcome

We retrospectively reviewed clinical aspects and laboratory results and correlated the outcome in 34 HIV-positive patients admitted with CD between 1\92-4\96 to the DMC. 97% were male with a median age of 41yrs. Most presented within 23 months after HIV diagnosis, 26% had CD as their AIDS defining illness. All patients had CD4 counts <100, 76% had CD4 <50. Headache, fever, neck pain and stiffness, oral thrush and papilledema were the most common manifestations. Cryptococcus was isolated from the CSF of all patients. The initial mean opening pressure was 34 cm H ₂0. 60% had CSF WBC <20, a mean CSF cryptococcal antigen of 1:6, 166 and serum titer of 1:18, 106. Blood cultures were positive in 10% of cases. For increased ICP, 18% required a lumbar drain, a shunt was placed in 9% and 20% had frequent lumbar punctures, 48% received steroid/ mannitol therapy. 4 patients died within the 1 ^st 12 days, 2 of whom had extraneural disease. 3 patients relapsed and 3 others had delayed responses to therapy. The mortality rate was 11% during the study period. Poor prognostic indicators were increased ICP >20 cm H ₂0, CSF WBC <6, positive blood cultures, urinary and pulmonary disease. CSF cryptococcal antigen was independent from outcome but an increasing serum titer at wk 2 predicted slow response in 60% of the cases, but not failure or mortality. Dilantin use was associated with a slow response and a need for longer therapy but did not increase mortality, it did predict a 33% relapse rate. Unrecognized, suboptimal treatment of ICP may lead to ↑ morbidity and mortality.