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| EVIDENCE-BASED MEDICINE |
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| Year : 2017 | Volume
: 15
| Issue : 1 | Page : 66-67 |
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Are corticosteroid useful in HIV-associated cryptococcal meningitis?
Ajay Kumar Mishra
Department of General Medicine, CMC, Vellore, Tamil Nadu, India
| Date of Web Publication | 17-Feb-2017 |
Correspondence Address:
Ajay Kumar Mishra
Department of General Medicine, CMC, Vellore, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_43_16
How to cite this article:
Mishra AK. Are corticosteroid useful in HIV-associated cryptococcal meningitis?. Curr Med Issues 2017;15:66-7 |
Clinical Question: Are corticosteroids useful in the treatment of cryptococcal meningitis?
Authors' conclusion: Intravenous corticosteroids are not recommended in the treatment of cryptococcal meningitis along with antifungal agents.
Case Scenario: A 42-year-old male driver presented with chronic fever, headache, and vomiting along with constitutional symptoms of loss of weight and appetite. On examination, he was found to be drowsy and had neck stiffness. A diagnosis of chronic meningitis was made, and a lumbar puncture was done after ruling out features of raised intracranial pressure. His cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis and was positive on examination with India ink. Three days later, his CSF culture grew Cryptococcus neoformans. He was also found to have HIV seropositivity with a CD4 count of 94. Treatment was initiated with intravenous amphotericin along with flucytosine. At this point of time, the physician is questioned by the junior assistant regarding the role of corticosteroid in cryptococcal meningitis as it is used in tubercular meningitis.
| Introduction | |  |
Mortality in cryptococcal meningitis continues to be high despite treatment with amphotericin and flucytosine [Box 1]. Dexamethasone has been proven to have a mortality benefit in other central nervous infections such as acute bacterial meningitis and tuberculous meningitis. In view of similar pathophysiological features among these diseases, its role in cryptococcal meningitis still remains a possibility. This study aimed to determine the role of dexamethasone in improving survival in HIV-positive patients with cryptococcal meningitis.
| Methods | | |
This was a randomized, double-blinded, placebo-controlled trial conducted in 13 hospitals in Indonesia, Thailand, Vietnam, Laos, Uganda, and Malawi.[1] Adult patients with HIV-associated cryptococcal meningitis were included in the study. The intervention arm received intravenous dexamethasone for 6 weeks duration, in a tapering schedule as compared to the placebo arm. Both the intervention arm and the placebo arms were treated with amphotericin B deoxycholate (1 mg/kg/day) and fluconazole (800 mg/day) for 2 weeks of induction therapy, followed by fluconazole (800 mg/day) for 8 weeks of consolidation therapy and fluconazole (200 mg/day) to continuation of maintenance therapy. The primary outcome of this study was survival for 10 weeks after randomization.
| Key Results | | |
- Although the required sample size was 880, this trial was suspended after recruiting 451 patients as per recommendation by Data Safety Monitoring Committee
- The mortality in the dexamethasone arm was 47% (106 of 224) as compared to placebo arm of 41% (93 of 226) by the end of 10 weeks, with a hazard ratio for death in the dexamethasone arm being 1.11
- The 6-month mortality in the dexamethasone arm was 57% as compared to 49% in placebo. High risk of death, disability including visual impairment, slower fungal clearance in cerebrospinal fluid, and clinical and laboratory adverse events were higher among the patients in the dexamethasone arm.
| Conclusion | | |
Intravenous dexamethasone administration was not associated with reduced mortality but rather had higher rates of mortality, disability, and adverse events, and hence at this point of time with the available evidence, cryptococcal meningitis does not require coadministration of intravenous steroids.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.[3]
| References | | |
| 1. | Beardsley J, Wolbers M, Kibengo FM, Ggayi AB, Kamali A, Cuc NT, et al. Adjunctive dexamethasone in HIV-associated cryptococcal meningitis. N Engl J Med 2016;374:542-54.  |
| 2. | Abhilash KP, Mitra S, Arul JJ, Raj PM, Balaji V, Kannangai R, et al. Changing paradigm of cryptococcal meningitis: An eight-year experience from a tertiary hospital in South India. Indian J Med Microbiol 2015;33:25-9. [ PUBMED]  |
| 3. | Kuriakose CK, Mishra AK, Vanjare HA, Raju A, Abraham OC. Visual disturbance in patients with cryptococcal meningitis: The road ahead. J Neurosci Rural Pract 2017;8:151. |
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