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Corticosteroids for shunted previously healthy patients with non-HIV cryptococcal meningoencephalitis
  1. Gautam U Mehta1,
  2. Anil A Panackal2,3,
  3. Roger Murayi1,
  4. John E Bennett2,3,
  5. Peter R Williamson2,
  6. Prashant Chittiboina1
  1. 1Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
  2. 2Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
  3. 3Division of Infectious Diseases, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  1. Correspondence to Dr Prashant Chittiboina, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, 10 Center Drive, Room 3D20, Bethesda, Maryland 20892-1414, US; prashant.chittiboina{at}nih.gov

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Cryptococcal meningoencephalitis (CM) can cause significant morbidity and mortality in previously healthy, non-HIV-infected patients, with all-cause mortality as high as 29% at 1 year.1 Clinical deterioration following microbiological control often results from a postinfectious inflammatory response syndrome (PIIRS). This syndrome may often result in intracranial hypertension (IH) and/or hydrocephalus (HCP).2 Ventricular shunting can provide sustained relief from IH/HCP and improve neurological outcomes.3 However, persistent neurological sequelae, which occur in a subset of patients, may lead to shunt revisions and poor long-term outcomes.3 Corticosteroids have been proposed to improve outcomes in selected, relatively immunocompetent patients with CM, but are often avoided due to presumed immunosuppressive effects.4 5 Paradoxically, the use of corticosteroids during initial therapy of other patient populations such as HIV-associated CM has been found to result in worse overall outcomes.4 We hypothesised that corticosteroid salvage therapy (CST) may have specific utility in previously healthy patients with PIIRS following microbiological control with persistent neurological sequelae and report our experience in a cohort of patients who have already undergone cerebrospinal fluid (CSF) diversion.

Previously healthy patients who were evaluated and treated for cryptococcal meningitis between 2011 and 2016 at the National Institutes of Health (NIH) were identified. Informed consent to participate in clinical research was obtained from all patients (NIH protocol 93-I-0106). We limited assessment to a relatively uniform population of patients who had previously undergone CSF …

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