1821. Factors Associated with Need for Ventriculoperitoneal Shunting in Patients with Cryptococcal Meningitis
Session: Oral Abstract Session: Fungal Infections
Saturday, October 5, 2013: 2:30 PM
Room: The Moscone Center: 300
Background: Increased intracranial pressure (ICP) is an important complication of cryptococcal meningitis (CM) and may impact morbidity and mortality.  Baseline factors associated with the need for permanent ventriculoperitoneal (VP) shunting are poorly characterized.   

Methods: We conducted a retrospective cohort study of patients diagnosed with CM at our institution from 1996 through 2011.  Data collected included demographics, clinical features, diagnostics, permanent VP shunt placement and outcomes.  Patients with prior VP shunting were excluded.  We compared baseline characteristics of patients who did and did not receive a VP shunt with use of the two-group chi-square test, or Fisher’s exact test for categorical variables and the two-group t-test for continuous variables.  Stepwise logistic regression analysis was used to determine independent predictors of shunt placement. 

Results:  Among 204 patients identified with CM, mean age was 46.5 years; 71.6% were male and 49.5% were black.  Commonb underlying conditions included HIV (47%), solid organ transplantation (30%), no immunodeficiency (11.7%), cancer (6.9%) and chronic glucocorticosteroids (30.8%). Thirty-four (16.7%) of 204 patients received a VP shunt, of which 19 (67.9%) had normal brain imaging.  Patients who received a shunt were more likely to have no immunodeficiency (29.4% vs 8.2%; p=0.005); headache (85.3% vs 68.8%; p=0.05); cranial nerve palsy (23.5% vs 7.1%; p=0.003); visual changes (44.1% vs 17.1%; p=0.005); opening pressure >25 cm H2O (67.6 vs 33.5%; p=0.002); and were less likely male (56% vs. 74.7%; p=0.03). There were no significant differences in cryptococcal antigen, or CSF WBCs, glucose or protein.  Multivariable analysis identified no immunodeficiency (OR 4.9, 95% CI 1.7-13.6) and baseline opening pressure >25 cm H2O (OR 3.5; 95% CI 1.6-7.9) associated with VP shunting.  

Conclusion: In a single-center cohort of patients with CM, VP shunting was uncommon.  Having no identified immunodeficiency or elevated opening pressure >25 cm H2O was significantly associated with VP shunting.  Identification of prognostic factors for sustained elevation of CSF pressure may allow for earlier and more aggressive treatment and potentially decrease the morbidity and mortality observed with increased ICP from CM.

John Baddley, MD, MSPH, Infectious Diseases, University of Alabama At Birmingham, Birmingham, AL; Birmingham Veterans Affairs Medical Center, Birmingham, AL, George R. Thompson III, MD, Medical Microbiology and Immunology, University of California-Davis, Davis, CA, Benjamin Klausing, University of Alabama At Birmingham, Birmingham, AL, Kyle Brizendine, MD, Infectious Disease, Cleveland Clinic, Cleveland, OH, Carrie Huisingh, MSPH, University of Alabama At Birmingham, Birmigham, AL, Stephen A. Moser, PhD, Department of Pathology, University of Alabama At Birmingham, Birmingham, AL and Peter Pappas, MD, Division of Infectious Disease, University of Alabama At Birmingham, Birmingham, AL

Disclosures:

J. Baddley, None

G. R. Thompson III, None

B. Klausing, None

K. Brizendine, None

C. Huisingh, None

S. A. Moser, None

P. Pappas, None

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