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a and b Head CT of a 40-year-old VPSWOV patient before and after operation. a Pre-operative CT shows no dilation of the cerebral ventricles (b) postoperative CT shows no dilation of the cerebral ventricles. c and d Head MR of a 28-year-old VPSV patient before and after operation. a Pre-operative axial T2-weighted image shows dilation of the cerebral ventricles (b) postoperative T2-weighted shows narrowing of the cerebral ventricles
Source publication
Background:
Persistent and uncontrollable intracranial hypertension (ICH) and difficulty in reducing Cryptococcus count are severe problems in cryptococcal meningitis (CM) patients. The therapeutic effects of ventriculoperitoneal shunts (VPS) in non-HIV CM patients are not fully known, and the procedure is somewhat unusual. Here, our study offers...
Context in source publication
Context 1
... of 427 non-HIV infected CM patients were reviewed. A total of 378 patients without surgery were excluded. A total of 23 patients satisfied the diagnostic criteria and were recruited into our study. The details of the enrolment process are presented in Fig. 1. The typ- ical brain images of patients with ventriculomegaly or without were shown in Fig. ...
Citations
... 2 It is unusual in immunocompetent patients, but they may account for up to one-third of all cases. 3,4 Cryptococcosis results in up to 280,000 cases and 130,000 deaths yearly, with an estimated 152,000 cases and 112,000 deaths in patients with acquired immunodeficiency syndrome. 5 Both C. neoformans and C. gatti have marked neurotropism, therefore cryptococcal meningitis (CM) is the most common clinical presentation. ...
... Only nine studies (45%) did specify dosage and timing. 4,16,21,22,24,28,29,31,32 Type of shunts used The type of shunt used was reported for 397 patients. VPS was the most frequent one (82.1%), ...
Objective
This scoping review aimed to describe studies that evaluate the management of cryptococcal meningitis (CM) using cerebrospinal fluid (CSF) shunts, types of shunts used, and clinically relevant patient outcomes.
Methods
We searched in the following databases: PubMed, Web of Science/Core collection, Embase, the Cochrane Library, and clinicaltrials.gov on 1 April 2022. We included two-arm and one-arm cohort studies that evaluated clinically relevant patient outcomes. Case reports were used to describe the type of CSF shunts used and the rationale behind its selection. The selection and extraction processes were independently performed by two authors.
Results
This study included 20 cohort studies and 26 case reports. Only seven cohort studies compared two groups. Ventriculoperitoneal shunt was the most commonly used type of shunt (82.1%). The main indications for placing a shunt were persistently high opening pressure (57.1%) and persisting neurological symptoms or deterioration (54.3%). Cohort studies suggest that patients with shunt showed improvement in some outcomes such as neurological symptoms and hospital stay length. The most common shunt complications were post-operative fever (1–35.6%) and shunt obstruction (7–16%).
Conclusion
CSF shunts may improve some clinically relevant outcomes in patients with CM, but the evidence is very uncertain.
... Retrospective studies confirmed that VPS effectively reduced ICP while accelerating the clearance rate of Cryptococcus in the CSF, significantly improving neurological function and shortening hospitalization time. Thus, the early placement of a VPS may benefit CM patients with apparent ICP [135,142,143]. Nevertheless, surgical site infections are a severe complication of VPS, with a prevalence of roughly 13% in HIV-infected CM patients, and more than 60% of CM patients develop VPS-associated surgical site infections within the first week after surgery, which adversely affects the CM administration outcomes [144]. ...
Cryptococcal meningitis (CM) is a fatal fungal central nervous system (CNS) infection caused by Cryptococcus infecting the meninges and/or brain parenchyma, with fever, headache, neck stiffness, and visual disturbances as the primary clinical manifestations. Immunocompromised individuals with human immunodeficiency virus (HIV) infection or who have undergone organ transplantation, as well as immunocompetent people can both be susceptible to CM. Without treatment, patients with CM may have a mortality rate of up to 100% after hospital admission. Even after receiving therapy, CM patients may still suffer from problems such as difficulty to cure, poor prognosis, and high mortality. Therefore, timely and effective treatment is essential to improve the mortality and prognosis of CM patients. Currently, the clinical outcomes of CM are frequently unsatisfactory due to limited drug choices, severe adverse reactions, drug resistance, etc. Here, we review the research progress of CM treatment strategies and discuss the suitable options for managing CM, hoping to provide a reference for physicians to select the most appropriate treatment regimens for CM patients.
... Liu et al. reported that persistent and uncontrollable intracranial pressure is a serious complication in patients suffering from cryptococcal meningitis and it is closely associated with the cryptococcus count. They reported a case with a lower cryptococcus count after the VP shunt procedure with an improved headache, with no change in altered mental status [9]. This was inconsistent with our study, counts were high, and intracranial pressure was found to be high, even with a VP shunt in our patient. ...
Cryptococcosis is a fungal infection caused by encapsulated yeast in the genus Cryptococcus. It is mostly observed in immunocompromised, organ transplant, and human immunodeficiency virus (HIV) positive patients, but it is also seen in non-HIV and immunocompetent patients. The majority of the cases have been reported in patients suffering from cryptococcal meningitis in HIV/acquired immunodeficiency syndrome. In this study, we reported a case series of three cases of cryptococcal meningitis in non-HIV patients. These cases were suspected and diagnosed according to their underlying immune status and clinical presentations.
... Cryptococcal meningitis is one of the most common fungal infections in immunodeficient patients, especially in those with HIV (14). Meanwhile, the increasing number of organ transplantations and the widespread use of immunosuppressive therapies have led to a dramatic increase in the incidence of non-HIV-associated cryptococcosis (15,16). In our study, we also found that corticosteroid use and rheumatological and liver diseases were some of the other major underlying diseases. ...
... An elevated CSF pressure has been proven to be correlated with increased mortality and worse outcomes (19,20). Many studies have proved that VPS or external ventricular drainage is an effective method in relieving high intracranial pressure of patients with CM with or without ventriculomegaly (16,21). Some authors suggest prophylactic shunt placement avoid irreversible neurological complications (22,23). ...
Objective
The purpose of this study was to assess the short-term and long-term outcomes of ventriculoperitoneal shunt (VPS) placement in patients with cryptococcal meningitis (CM).
Methods
We performed a retrospective analysis of all patients with CM admitted to the Peking Union Medical College Hospital from September 1990 to January 2021. We collected related clinical features to analyze the short- and long-term outcomes of VPS at 1 month and 1 year at least the following therapy, respectively. Overall survival (OS) was compared with all patients and a subgroup of critically ill cases by the Kaplan–Meier method with the log-rank test. Univariable and multivariable analyses were also performed using the Cox proportional hazard model to identify statistically significant prognostic factors.
Results
We enrolled 98 patients, fifteen of whom underwent VPS. Those who received VPS had a lower cerebrospinal fluid (CSF) Cryptococcus burden (1:1 vs. 1:16; p = 0.046), lower opening pressures (173.3 mmH2 O vs. 224 mmH2O; p = 0.009) at lumbar punctures, and a lower incidence of critical cases (6.7 vs. 31.3%; p = 0.049). According to our long-term follow-up, no significant difference was shown in the Barthel Index (BI) between the two groups. Two patients in the VPS group suffered postoperative complications and had to go through another revision surgery. According to survival analysis, overall survival (OS) between the VPS and non-VPS groups was not significantly different. However, the Kaplan–Meier plots showed that critical patients with VPS had better survival in OS (p < 0.009). Multivariable analyses for critical patients showed VPS was an independent prognostic factor.
Conclusion
A VPS could reduce the intracranial pressure (ICP), decrease the counts of Cryptococcus neoformans by a faster rate and reduce the number of critical cases. The VPS used in critical patients with CM has a significant impact on survival, but it showed no improvement in the long-term Barthel Index (BI) vs. the conservative treatment and could lead to postoperative complications.
... Ventriculoperitoneal shunt (VPS), as a solution of high intracranial pressure, is now also widely used in patients with CM-associated ICH [9]. Several studies conducted to verify the therapeutic effects of VPS in non-HIV CM patients confirmed that the placement of a VPS is helpful in decreasing ICH and fungal overload in non-HIV CM patients [9,10]. ...
... Ventriculoperitoneal shunt (VPS), as a solution of high intracranial pressure, is now also widely used in patients with CM-associated ICH [9]. Several studies conducted to verify the therapeutic effects of VPS in non-HIV CM patients confirmed that the placement of a VPS is helpful in decreasing ICH and fungal overload in non-HIV CM patients [9,10]. However, one of the serious surgical complications, surgical site infections (SSIs) which has a range of 1-39% incidence [11,12], would lead to re-implantation and longer duration of hospitalization, increased of hospitalization expense and even death [13][14][15]. ...
Background
To investigate the clinical features and risk factors of ventriculoperitoneal shunt (VPS) associated surgical site infections (SSIs) in HIV-negative patients with cryptococcal meningitis (CM).
Methods
We retrospectively reviewed the medical records of HIV-negative patients with CM underwent VPS operation admitted to The Third Affiliated Hospital of Sun Yat-sen University in Southwest China over the past 7 years.
Results
193 patients were included, of whom 25 (12.95%) had SSIs in 6 (median duration, 1–48 days) days after operation. Compared with patients without SSIs, patient with SSIs tended to be shorter preoperative stay. 52% patients in SSIs group and 25% patients in no-SSIs group underwent VPS operations within 3 days after admission (p = 0.017). Although body temperature and infectious indicators slightly elevated postoperative in both groups. The patients with SSIs experienced more fever; more central nervous system symptoms; higher PCT value and lower cerebrospinal fluid (CSF) glucose in contrast to the no-SSIs group. Multivariate regression analysis found a 2.653 fold increase in the risk of infection for every 1 °C increase in postoperative body temperature. Among the 25 patients, 9 patients had positive culture results, three samples reported to be oxacillin resistant coagulase-negative Staphylococci.
Conclusions
SSIs was one of the serious surgical complications after VPS operation. High body temperature, the occurrence of dizziness and headache, low postoperative hemoglobin are risk factors. Postoperative patients with high fever, high PCT and low CSF glucose should be paid more attention to.
... Ventriculoperitoneal shunt (VPS), as a solution of high intracranial pressure, is now also widely used in patients with cryptococcus meningitis-associated ICH [9]. Several studies conducted to verify the therapeutic effects of VPS in non-HIV CM patients con rmed that the placement of a VPS is helpful in decreasing ICH and fungal overload in non-HIV CM patients [9,10]. ...
... Ventriculoperitoneal shunt (VPS), as a solution of high intracranial pressure, is now also widely used in patients with cryptococcus meningitis-associated ICH [9]. Several studies conducted to verify the therapeutic effects of VPS in non-HIV CM patients con rmed that the placement of a VPS is helpful in decreasing ICH and fungal overload in non-HIV CM patients [9,10]. However, one of the serious surgical complications, surgical site infections (SSIs) which has a range of 1% -39% incidence [11,12], would lead to re-implantation and longer duration of hospitalization, increased of hospitalization expense and even death [13][14][15]. ...
Background: To investigate the clinical features and risk factors of ventriculoperitoneal shunt (VPS) associated surgical site infections (SSIs) in HIV-negative patients with cryptococcal meningitis (CM).
Methods: We retrospectively reviewed the medical records of HIV-negative patients with CM underwent VPS operation admitted to The Third Affiliated Hospital of Sun Yat-sen University in Southwest China over the past 7 years.
Results: 193 patients were included, of whom 25 (12.95%) had SSIs in 6 (median duration, 1-48 days) days after operation. Compared with patients without SSIs, patient with SSIs tended to be shorter preoperative preparation time. 52% patients in SSIs group and 25% patients in no-SSIs group underwent VPS operations within 3 days after admission (p=0.017). Although body temperature and infectious indicators slightly elevated postoperative in both groups. The patients with SSIs experienced more fever; more central nervous system symptoms; higher PCT value and lower cerebrospinal fluid (CSF) glucose in contrast to the no-SSIs group. Multivariate regression analysis found a 2.653 fold increase in the risk of infection for every 1℃ increase in postoperative body temperature. The most prevalent organisms were oxacillin resistant coagulase-negative Staphylococci (found in 33% of positive specimens).
Conclusions: SSIs was one of the serious surgical complications after VPS operation. High body temperature, the occurrence of dizziness and headache, low postoperative hemoglobin are risk factors. Postoperative patients with high fever, high PCT and low CSF glucose should be paid more attention to.
... Meanwhile, other studies have demonstrated that VPS placement can rapidly relieve symptoms and improve the prognosis of HICP patients with rare postoperative infections. In addition, VPS placement could decrease the excess volume of cerebrospinal fluid (CSF) and the fungal polysaccharide load in the ventricles [9][10][11][12]. VPS is more reliable and stable than lumber puncture and can maintain long-term shunt effects [6]. ...
Abstract Background The impact of ventriculoperitoneal shunt on cerebrospinal fluid (CSF) biochemical profiles in HIV-associated cryptococcal meningitis (HCM) patients remains unclear. Methods Twenty-nine HCM patients who underwent ventriculoperitoneal shunt (the VPS group) and 57 HCM patients who did not undergo ventriculoperitoneal shunt (the non-VPS group) were enrolled in this propensity score matching analysis. Demographic characteristics, symptoms, CSF biochemical profiles, and adverse events were compared between the two groups. The Kaplan–Meier method was used to analyze the survival rate. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for increased CSF protein levels. Results After 24 weeks of treatment, the intracranial pressure was significantly lower in the VPS group than in the non-VPS group (mmH2O; 155.0 [120.0–190.0] vs. 200.0 [142.5–290.0]; P = 0.025), and the rate of neuroimaging improvement was significantly higher in the VPS group (16/17 [94.1%] vs. 2/10 [20%]; P
... They experiences a worse response rate to available therapies as well as poorer outcomes as compared to HIV-infected individuals [2,3]. Recent studies have provided several treatment recommendations as the disease is being explored more in depth in these patients [4,5]. However, for some rare cases of cryptococcal neurological infections, such as cryptococcal abscess, we still need to explore affordable therapies given limited information [6]. ...
Background: Cryptococcus has been occurring in an increasing number of immunocompetent individuals, with a worse response rate to available therapies as compared with classical immunosuppressive patients.
Case presentation: Herein, we report a rare case of a cryptococcal brain abscess in an immunocompetent patient. This 25-year-old woman presented with a progressively worsening headache, a persistent fever, and a 2.4×2.2×2.0 cm frontal abscess. Cerebrospinal fluid (CSF) and blood cultures confirmed cryptococcal infection. She was administered standard antifungal treatment. The intracranial lesion shrunk and her clinical condition improved. However, medical therapy alone failed due to sustained high intracranial pressure during the consolidation phase and subsequent antibacterial treatment. Surgical excision confirmed a frontal abscess due to Cryptococcus neoformans. She had complete resolution following surgery.
Conclusions: Although medical therapy alone may be effective for small abscesses (<2.5 cm), this case highlights that if the patient has persistently high intracranial pressure, a combined medical and surgical approach is optimal for disease management.
... In this study, VPS placement signi cantly reduced HICP and 24-week mortality; however, there was a higher rate of misdiagnosis of tuberculous meningitis and steroid use in patients in the VPS group. Some studies have indicated that VPS placement could signi cantly decrease ICP and cryptococcal counts in patients without HIV infection [11][12][13]. However, there is a paucity of data on the effects of a VPS on the CSF biochemical pro les of patients with HCM. ...
Background: The long-term complications of ventriculoperitoneal shunting in patients with human immunodeficiency virus-associated cryptococcal meningitis remain unclear. We conducted a case-control study investigating the long-term effects of ventriculoperitoneal shunting in patients with human immunodeficiency virus-associated cryptococcal meningitis.
Methods: Between January 2011 and December 2019, 112 patients with human immunodeficiency virus-associated cryptococcal meningitis from our hospital were enrolled in this retrospective cohort study. Of those, 30 (26.8%) patients underwent ventriculoperitoneal shunting (VPS group); the remaining (n = 82; 73.2%) were included in the non-VPS group. Survival was estimated using the Kaplan–Meier method. Univariate and multivariate Cox regression analyses were performed to identify factors associated with ventriculoperitoneal shunting.
Results: The VPS group (n=21) had lower cerebrospinal fluid glucose (2.51±0.81 vs. 3.16±0.48 mmol/L; P=0.002) and higher cerebrospinal fluid protein levels (1.37 [0.83–1.49] vs. 0.49 [0.49–0.49] g/L; P=0.011) than did the non-VPS group (n=21). Intracranial pressure decreased from 400 (375–450) to 164 (145–172) mmH2O in the VPS group (log-rank, P<0.001). The 24-week cumulative survival rates in the VPS and non-VPS groups were 100.0% and 79.8%, respectively (P=0.035). The misdiagnosis rates of tuberculous meningitis were 28.6% and 0.0%, respectively (P=0.008).
Conclusions: Ventriculoperitoneal shunting decreased the intracranial pressure and 24-week mortality in patients with human immunodeficiency virus-associated cryptococcal meningitis, but significantly increased cerebrospinal fluid protein levels, leading to a higher misdiagnosis rate of tuberculous meningitis. Physicians should be aware of these changes in the cerebrospinal fluid profiles of patients with human immunodeficiency virus-associated cryptococcal meningitis with a ventriculoperitoneal shunt.
... The most common causes of bacterial PIH in adults include Neisseria meningitidis and Streptococcus pneumoniae [27]. Viral, fungal, and protozoan infections also contribute a significant hydrocephalus burden in immunocompromised patients [28,29]. ...
Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells, and physical irritants. However, inappropriately triggered or sustained inflammation can respectively initiate, propagate, or prolong disease. Post-hemorrhagic (PHH) and post-infectious hydrocephalus (PIH) are the most common forms of hydrocephalus worldwide. They are treated using neurosurgical cerebrospinal fluid (CSF) diversion techniques with high complication and failure rates. Despite their distinct etiologies, clinical studies in human patients have shown PHH and PIH share similar CSF cytokine and immune cell profiles. Here, in light of recent work in model systems, we discuss the concept of “inflammatory hydrocephalus” to emphasize potential shared mechanisms and potential therapeutic vulnerabilities of these disorders. We propose that this change of emphasis could shift our thinking of PHH and PIH from a framework of life-long neurosurgical disorders to that of preventable conditions amenable to immunomodulation.
