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Open Access Research article

Low CD4 count plus coma predicts cryptococcal meningitis in Tanzania

Peter R Kisenge1, Alexander T Hawkins2, Venance P Maro1, John PD Mchele3, Ndealilia S Swai3, Andreas Mueller14 and Eric R Houpt2*

Author Affiliations

1 Department of Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

2 Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA

3 Biotechnology Laboratory, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

4 Medical Mission Hospital, Department of Tropical Medicine, Hermann-Schell Str. 7, D-97074 Würzburg, Germany

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BMC Infectious Diseases 2007, 7:39  doi:10.1186/1471-2334-7-39

Published: 10 May 2007

Abstract

Background

Largely due to the lack of diagnostic reagents, the prevalence and clinical presentation of cryptococcal meningitis in Tanzania is poorly understood. This in turn is limiting the impact of increased fluconazole availability.

Methods

We evaluated a cohort of 149 consecutive HIV-infected adult inpatients presenting with headache or altered mental status for clinical features, CD4 count, cryptococcal infection, and outcome. Cryptococcal meningitis was diagnosed via India ink and latex agglutination assay of CSF (n = 24 and 40 positive, respectively). Associations between cryptococcal meningitis and clinical features were evaluated by t-test. The sensitivity, specificity, and positive likelihood ratio of such features were determined.

Results

Cryptococcal meningitis was associated with confusion, social withdrawal, seizures, fever, tachycardia, meningismus, oral candidiasis, and low Glasgow coma scales and CD4 count. CD4 count < 100/μl provided the highest sensitivity for the diagnosis (93%), coma (Glasgow coma scale ≤ 8) provided the highest specificity (84%), and the combination provided the highest positive likelihood ratio (3.8). All cryptococcal meningitis patients were initiated on 800 milligrams of fluconazole daily and 50% survived to discharge, however no clinical or laboratory findings correlated with prognosis.

Conclusion

Cryptococcal meningitis is common among Tanzanian HIV inpatients presenting with headache or altered mental status. Purely clinical features are insensitive for establishing the diagnosis or prognosis. We advocate expanding laboratory capacity for cryptococcal antigen testing to maximize survival.