Prognosis

Cryptococcal meningitis

The most important markers of poor prognosis in HIV-associated cryptococcal meningitis are altered mental status at presentation and high organism load, as determined by quantitative cerebrospinal fluid (CSF) culture or CSF antigen titre.[91] Low CSF white cell count and raised CSF opening pressure are also associated with a poor outcome. Mortality in non-HIV-associated cryptococcal meningitis is associated with chronic renal failure, liver failure, or haematological malignancy, as well as absence of headache and altered mental status.[60]

Mortality rates due to cryptococcal meningitis remain high; 10-week mortality in a large US study was around 10%.[58] In less selected series, mortality has been higher, up to 26%. Reported 10-week mortality in studies from Africa and Asia has been 20% to 40% where amphotericin-B therapy has been available.[91][121][122] Cryptococcal meningitis continues to be one of the leading causes of death in HIV-infected patients, notably in Thailand, Uganda, Malawi, and South Africa, with an estimated mortality risk of 17% at 2 weeks and 34% at 10 weeks.[19]

Chronic neuropsychiatric sequelae are common after cryptococcal meningitis and are associated with altered brain imaging parameters.[123]

Histoplasmal meningitis

Approximately 20% of patients fail initial therapy, and as many as 40% may relapse.[27]

Coccidioidal meningitis

Despite advances in antifungal therapy, the morbidity and mortality associated with coccidioidal meningitis remains high, with mortality around 30%.[11] Because there is a high risk of relapse if therapy is stopped, treatment should be lifelong.[124]

Candidal meningitis

Prognosis of candidal meningitis depends on the risk group, and mortality rates may vary from around 10% in neurosurgical patients to around 30% in HIV-infected patients.[42][67] Premature infants with candidal meningitis have a high rate of mortality and neurodevelopmental disabilities compared with matched controls: 60% versus 28%.[125]

Aspergillus meningitis

The diagnosis of Aspergillus meningitis is difficult, with an overall case fatality rate of nearly 70%; the prospect of a specific diagnosis in life is higher in immunocompetent patients.[53]

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