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ORIGINAL CONTRIBUTIONS
Year : 2002  |  Volume : 56  |  Issue : 7  |  Page : 325-329
 

Prevalence of fungal meningitis among HIV positive & negative subjects in Indore (MP State)


Deptt of Medicine, Choithram Hospital & Research Centre, Manik Bagh Road, Indore-452 001,

Correspondence Address:
S P Jaiswal
Deptt of Medicine, Choithram Hospital & Research Centre, Manik Bagh Road, Indore-452 001

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PMID: 12645168

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How to cite this article:
Jaiswal S P, Hemwani N, Sharma N, Athale S, Chitnis D S. Prevalence of fungal meningitis among HIV positive & negative subjects in Indore (MP State). Indian J Med Sci 2002;56:325-9

How to cite this URL:
Jaiswal S P, Hemwani N, Sharma N, Athale S, Chitnis D S. Prevalence of fungal meningitis among HIV positive & negative subjects in Indore (MP State). Indian J Med Sci [serial online] 2002 [cited 2014 Oct 30];56:325-9. Available from: http://www.indianjmedsci.org/text.asp?2002/56/7/325/11986


The infection of brain & meninges is the most common clinical manifestation of cryptococcosis. Sporadic cases of the disease have been noticed infrequently all over the world. However, its incidence has increased over the years with the predisposing immunodeficiency factors such as in immunosuppressive therapies following transplantation, patients on cancer chemotherapy, sarcoidosis, diabetes mellitus etc.[1] Further, the AIDS pandemic has been posing a major precipitating cause for the increased incidence of cryptococcal meningitis.[2] In USA, more than 50% of the cases of cryptococcal meningitis occur in AIDS patients.[3] Its prevalence among AIDS cases has been reported to range from 2-30%[4],[5],[6],[7] in various parts of the world. Isolated cases of cryptococcosis had been reported from some centres in India but prevalence studies have been very scanty for the country.[2] In view of this, data on the fungal meningitis among AIDS cases and other patients from Indore city is communicated presently.


 € Materials & Methods Top


The present data is retrospective data at Choithram Hospital & Research Centre, Indore during the period 1992­Mar 2001. The hospital has also been functioning as a blood testing centre for HIV for NACO. During 1989-2001, 483 AIDS cases have been detected at the centre. Among the AIDS cases, CSF samples from 15 suspected cases of meningitis were tested for routine CSF analysis. During 1995 to 2000, ten cases of fungal meningitis were recorded at our end among HIV negative subjects and are included presently for comparison.


 € Bacteriological & Fungal Studies Top


India ink preparation and Gram's staining procedures were carried out on the centrifuged CSF deposits. The CSF deposits were also used for bacterial and fungal culture. Agar slants containing 30­mg/ml chloramphenicol were inoculated & incubated at room temperature for 2 weeks. Identification of fungal growth was carried out using biochemical tests as described by Milne et al.[8] Cases of suspected fungal meningitis admitted at our hospital whose CSF samples had come for fungal culture during 1992-Mar 2001 were included in the present study.

Samples analysis was carried out as mentioned above & cases that were nonreactive for HIV antibody tests were included in the group.


 € Results Top


Our blood testing centre had reported seven AIDS cases till 1992 and of them only 1 case was presented with meningitis and that too by Candida albicans and not by Cryptococcus neoformans. During 1995 to 2001, 450 AIDS cases have been notified at our centre and 15 of them developed fungal meningitis; only two of them had candidal meningitis while the remaining 12 had cryptococcal meningitis. Five of the AIDS cases were presented primarily as acute meningitis cases and had no history of other opportunistic infections earlier. In fact, HIV status was confirmed after the detection of Cryptococci in 4 of the 5 cases. The remaining 10 cases had shown other symptoms of AIDS before manifestation of meningitis. The 13 of the 15 cases were in the age group 26-40 yrs while one case was 55 yrs old and one was a child of 16 months. The child had a vertical transmission of the disease and his mother received HIV infection through blood transfusion. The 55 yr male in the series also received HIV infection through blood transfusion. Two other females as well got HIV infection through blood transfusion. Among 8 of the 11 males of the sexually active age group sexual transmission was the route o transmission. Follow-up was not available for 7 of the 15 cases but the remaining cases died in hospital within 2 to 3 weeks following fungal meningitis.

Among HIV nonreactive subjects, during 1995 to 2001, 10 cases of fungal meningitis were admitted in our hospital. The age ranged from 44 to 70 for 7 cases and two were five days old neonates while 1 was 8 months old infant. Among adults, 4 were males while 3 cases were females. Three of the seven adults had undergone renal transplant surgery and were on immunosuppressive therapy. Two of the remaining adults were diabetic. Three of the 10 cases of meningitis were due to Candida albicans while the remaining were due to Cryptococcus neoformans. The striking observation in the group was relatively low mortality (4 out of 10) as compared to fungal meningitis among AIDS cases. Further, only two of the four died within one month of the diagnosis while the remaining two died over 10 months to 2 years period; both had undergone renal transplant surgery & were on immuno­suppressive drugs.


 € Discussion Top


Since the first report of cryptococcosis in India in 1952[9] isolated case reports from different parts of the country have been published[10] but the subsequent rising trend in its incidence is well reflected with report on 54 cases during 1983-94 in Chandigarh.[2] However, only 5 AIDS cases with cryptococcal meningitis noted in the report as against 12 cases in the present series. The prevalence of fungal meningitis was 3.10% in the present series while 7-8% of AIDS patients in United States[11] manifest cryptococcal meningitis and more than 50% of the cryptococcal meningitis cases reported are from AIDS patients.[12] Cryptococcal meningitis is reported to be as high as 30% in AIDS cases in Africa.[5],[6],[7] In the present study 12 of the 19 cryptococcal meningitis cases (63.15%) occurred among HIV positive subjects.

Fatal outcome of cryptococcal meningitis was often rapid at our end with death in 2-3 weeks of the diagnosis among AIDS cases. Besides Cryptococci, Candida albicans was responsible for meningitis in 3 of the 15 cases of meningitis among AIDS cases and the cases proved fatal. The data suggest that fungal meningitis manifests as a severe form of disease in AIDS cases. Similar data is not available for AIDS cases in India. More interesting observation in the present series was a fungal meningitis as a primary opportunistic infection among 5 of the 15 AIDS cases. This gives us a lesson to raise a suspicion for AIDS in all cases of fungal meningitis with no other underlying cause of immunodeficiency.

Male predominance among cryptococcal cases of meningitis has been documen­ted in many studies [13] In the present study as well, 13 of the 15 cases of meningitis among AIDS patients were males. However, among HIV negative adult subjects, 4 males and 3 females were noted. The increased males with fungal meningitis among AIDS cases could be due to overall male predomin­ance among AIDS cases (not shown in the results but 341 of 483 AIDS cases were males). Similarly route of HIV transmission among meningitis cases in the series was mainly sexual as expected for over all HIV transmission in India. Further, published data on fungal meningitis among AIDS cases in India is virtually non-existent. Only one of the 15 cases was documented at our end before 1995 and the reason could be lack of awareness or efforts among clinicians at that time. In consideration of the point, 14 cases of fungal meningitis among 450 AIDS cases between 1995­2001 at our end raises the prevalence of fungal meningitis to 3.15% for AIDS subjects.

As against 15 AIDS cases, ten HIV ­negative cases of fungal meningitis were noted at our end during 1995 to 2001. Three of the cases had renal transplant and were on immunosuppressive therapy and two were diabetic subjects. Among three neonates/infants, two were five days old neonates born prematurely as low birth weight baby while the infant was with microcephaly. Thus, only one of the ten cases had apparently non immunocompromised status. Overall data in the present series suggest that more than 50% of the cases of fungal meningitis occur among HIV infected persons at our end and the prognosis is often poor with relatively rapid mortality for HIV infected persons.


 € Summary Top


The aim of the study was to find out the prevalence of fungal meningitis among AIDS cases and to assess the prognosis of fungal meningitis among HIV positive & negative subjects. The study comprised of 15 & 10 cases of fungal meningitis among HIV positive & negative subjects respectively during the study period 1992-2001. India ink preparation and Gram's staining proced­ures were carried out on the centrifuged CSF deposits. The CSF deposits were also used for bacterial and fungal culture. In the present study the prevalence of fungal meningitis was noted among 15 (3.1%) of 483 AIDS cases. Twelve of them had cryptococcal meningitis while 3 were infected with Candida albicans. Four AIDS cases presented fungal meningitis as a primary opportunistic infection and HIV status was confirmed in 4 of them after the diagnosis of fungal meningitis. 13 of the 15 cases were in the age group 26-40 yrs while one was 55 yrs old and the other 16 month old child; these two cases had blood transfu­sion transmitted and vertically transmitted mode of HIV transmission respectively. Further, only two of 15 cases were females and both acquired HIV infection through blood transfusion. Overall prognosis of fungal meningitis was poor among HIV positives and 7 of the 15 cases died in hospital within 2-3 weeks after diagnosis of cryptococcal meningitis. Among HIV negative subjects, ten cases of fungal meningitis (3 with Candida albicans and 7 with Cryptococcus neoformans) were noted at our end and nine of them had immunocompromised status (3 cases of renal transplant on immunosuppressives, 3 cases neonates / infant and 2 diabetic subjects. The fungal meningitis is one of the important causes of morbidity & mortality among immunocompromised patients and has poor prognosis among HIV positive subjects.


 € Acknowledgement Top


The authors acknowledge the NACO & MP State AIDS control Society (Bhopal), for supplying the reagents for blood testing. The authors are grateful to Dr. Ravikant Saxena, Medical Director and management of Choithram Hospital and Research Centre, for providing the infrastructural & other necessary facilities.

 
 € References Top

1.Diamond RD. Cryptococci neoformans. In: Principles and practice of infectious diseases (Ed). Mandell GL et al. New York. 1995;2:2331-40.  Back to cited text no. 1  [PUBMED]  
2.Chakrabarti A, Verma SC, Roy P, et al. Cryptococossis in and around Chandigarh: an analysis of 65 cases. Indian J Med Microbiol 1995;13:65-9.  Back to cited text no. 2    
3.Bennett JE. Cryptococossis in Wilson JD, Braunwald E, et al (Eds) Harrison's Princip­les of Internal Medicine. Vol 13th Edn. McGraw Hill, New York, 1994:859-60.  Back to cited text no. 3    
4.Nair RK, Jose J. Crytococcal meningitis in immunocompromised patients. J Assoc Physicians India. 1995;43:222-5.  Back to cited text no. 4    
5.Dismukes WE. Cryptococcal meningitis in patients with AIDS. J Infect Dis 1988; 157:624-8.  Back to cited text no. 5  [PUBMED]  
6.Holmberg K, Meyer R. Fungal infections in patients with AIDS and AIDS related complex. Scand J Infect 1986;18:179-92.  Back to cited text no. 6    
7.Murphy SA, Denning DW. Cryptococcal meningoencephlitis in AIDS. Hosp Update 1994;20:151-6.  Back to cited text no. 7    
8.Milne LJR. Fungi: In Practical Medical Microbiology. 13th ed. Collee JG, Duguid JP, Fraser AG, Marmion BP. Churchill Livingstone, New York. 1989:435.  Back to cited text no. 8    
9.Rao BDN, Lilauwala NF. Cryptococossis of central nervous system. Indian J Surg 1952;14:10.  Back to cited text no. 9    
10.Mohapatra LN. Study of Medical Mycology in India-an overview. Indian J Med Res 1989;89:351-4.  Back to cited text no. 10  [PUBMED]  
11.Kovacs JA, Kovacs AA, Polls M, et al. Cryptococossis in the acquired immunodeficiency syndrome. Ann Intern Med 1985;103:533-539.  Back to cited text no. 11    
12.Known-Chung KJ, Bennet JE. Medical Mycology (Lea and Febiger, Philadelphia) 1992:p397.  Back to cited text no. 12    
13.Talwar P, Sharma M. Incidence and diagnostic aspects of cryptococosis in Chandigarh (India) during the period of 1970-1982. Indian J Pathol Microbiol 1986;29:45-49.  Back to cited text no. 13  [PUBMED]  



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