Clinical presentation, natural history, and cumulative death rates of 230 adults with primary cryptococcal meningitis in Zambian AIDS patients treated under local conditions

Setting Inpatient medical wards, Department of Medicine, University Teachin g Hospital, Lusaka, Zambia. Objective-To define the natural history, clinical presentation, and managem ent outcome of microbiologically confirmed cryptococcal meningitis in adult AIDS patients treated under local conditions where antifungal and antiretr oviral therapies are not routinely available. Design-A descriptive, longitudinal, observational study. Methods-All adult patients admitted to the medical wards of the University Teaching Hospital, Lusaka, Zambia with cerebrospinal fluid culture proved, primary cryptococcal meningitis, during a 12 month period were enrolled int o the study. The following details were acquired: clinical features, HIV st atus, laboratory data, treatment accorded, and survival. Results-A total of 230 patients with primary cryptococcal meningitis were s tudied (median age 32 years; range 15-65 years; 112 males, 118 females). Cr yptococcal meningitis was the first AIDS defining illness in 210 (91%) pati ents. One hundred and thirty of the 230 (56%) patients had received treatme nt with fluconazole monotherapy and 100 (43%) patients received palliative care only without any antifungal therapy. A 100% case fatality rate was obs erved in both groups at follow up: by seven weeks in the untreated group an d at six months in the fluconazole treated group. The cumulative median sur vival from time of diagnosis was 19 days (range 1-164 days) for the flucona zole treated group and 10 days (range 0-42 days) for the untreated group. Conclusion-Cryptococcal meningitis, under current treatment accorded at the University Teaching Hospital, Lusaka, has a 100% mortality in young Zambia n adults with AIDS. The current treatment accorded to Zambian adults with c ryptococcal meningitis is inappropriate. An urgent need exists to improve s trategies for the clinical management of AIDS patients in poor African coun tries. The wider ethical and operational issues of making available antifun gals to African AIDS patients are discussed.