Date of Award

11-23-2009

Document Type

Thesis

Degree Name

Medical Doctor (MD)

First Advisor

Ron Adelman M.D.

Second Advisor

John Huang M.D.

Third Advisor

Susan Forster M.D., Jimmy Zhou Ph.D.

Abstract

IS PAPILLEDEMA IN HIV/AIDS PATIENTS WITH CRYPTOCOCCAL MENINGITIS RELATED TO MORTALITY? Ninani E. Coyne Kombo, and Oathokwa Nkomazana. Department of Ophthalmology, Princess Marina Hospital, Gaborone, Botswana. (Sponsored by Susan Forster, Department of Ophthalmology, Yale University School of Medicine, New Haven, CT) Once simply thought of as an obscure yeast affecting very few people worldwide, Cryptococcus has established itself as one of the most common fungal causes of death and morbidity since the beginning of the HIV/AIDS* pandemic. The HIV/AIDS prevalance in Botswana is 17% in the general population, and 35% in pregnant women between the ages of 15 to 35 years thus cryptococcal meningitis has a high incidence in Botswana. This study seeks to determine whether papilledema is related to mortality in HIV/AIDS patients with cryptococcal meningitis. The secondary goals were estimation of the incidence of visual loss and description of: the risk factors for developing vision loss; other ocular complications associated with cryptococcal meningitis; and ocular complications of HIV infection unrelated to cryptococcal infection. The setting of the study was Princess Marina Hospital, a tertiary referral center, in Gaborone, Botswana. From June to August 2008, fourteen patients were enrolled in the study and one dropped out. Their ages ranged from 16 to 52 years (median 37 years). The mean CD4+ level of the participants was 72 cells/µL (range 10 to 206cells/µL, median 45cells/µL). Twelve out of thirteen participants reported visual symptoms, the most common being: blurry vision, photophobia, and tearing. Ocular findings related to elevated intracranial pressure secondary to cryptococcal meningitis were: ophthalmoplegia (3/13), papilledema (2/13), and optic disc atrophy (3/13). No participants presented with complete blindness, nor did they become completely blind during their hospitalization. The in-hospital mortality in this study was 30.8% (4 of 13 patients). Only one of the four patients that died had papilledema, another had optic atrophy, and two had a relapse of cryptococcal meningitis. There was no Cryptococcal infection of the eye observed. Non-cryptococcal related findings were: clinically diagnosed ocular surface neoplasia (OSSN) in one patient (OD), molluscum contagiosum papules on the eyelids of 2 patients, a pterygium, and a pingueculum each in one patient. In conclusion, our data, in agreement with other studies, indicate the high in-hospital mortality (30.8%) of cryptococcal meningitis in HIV/AIDS patients and the low prevalence of intraocular cryptococcal infection. A larger study needs to be completed to further investigate the relationship between papilledema and mortality. This study is the beginning of new and important ophthalmologic research that needs to be carried out in Botswana. This research will benefit ophthalmologists and healthcare providers in Botswana. In addition it has the potential to inform other sub-Saharan nations that have similar HIV/AIDS and cryptococcal meningitis rates. *HIV/AIDS - Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

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