HIV screening among patients followed for cryptococcal meningitis in developing countries : Data from Bukavu in the Democratic Republic of Congo

We conducted a retrospective cohort study in the Departments of Internal medicine of 2 main Bukavu hospitals, in the South Kivu, DRC. The medical records of 7542 patients were reviewed. We observed 56 cases (11%) of cryptococcocal meningitis (CM) among 514 human immunodeficiency virus (HIV)infected subjects. No case of CM was seen in HIV negative and 70 % of them had a concurrent diagnosis of tuberculosis as other active AIDS related diseases. Despite antifungal therapy, 90% of CM cases died.


INTRODUCTION
In the low-income countries we can make the diagnosis of cryptococcocal meningitis (CM) on cerebro-spinal fluid (CSF) sample stained with India ink and examinated on light microscopy.Once this diagnosis is done, the main fear is that cryptococcocal meningitis remains one of major reason for HIV testing in some world's regions like in central Africa (Mbuagbaw et al., 2006).

MATERIALS AND METHODS
This retrospective cohort study focused on patients diagnosed with cryptococcocal meningitis (CM) in the two main hospitals of Bukavu, located in South Kivu province of the Democratic republic of Congo (DRC).This province is in the eastern DRC bordering Rwanda and Burundi.We reviewed inpatient hospital admissions at the Panzi Hospital (HGRP) and the Provincial Hospital of Bukavu (HPGRB).Panzi Hospital is a 350-bed general hospital for the local population, serving a significant population of sexual violence survi-survivors.The population of Bukavu is approximatily 800,000 and the provincial hospital is the referral hospital for approximately 4.6 millions in the South Kivu province.We retrospectively reviewed 7542 medical records of hospitalized patients in the Departments of internal medicine over a 5 year period from May 1, 2007 to April 30, 2011.During this period, routine screening of HIV-infection occurred for all consenting patients admitted to hospital.The primary objective was to determine the rate of HIV positive tests among cryptococcocal meningitis (CM) cases.Secondary objectives were to determine the treatment received and the clinical outcomes.Analysis is primarily descriptive.

RESULTS
Among 7542 hospital admissions over a 5 year period, only 56 patients (0.7%) were hospitalized for cryptococcocal meningitis (CM) as diagnosed by India ink in light microscopy.Their mean age was 31.6 ± 2.9 years, and the *Corresponding author.E mail: jooohn5@yahoo.com.the sex ratio of women to men was 2:1 (Figure 1).All 56 patients with CM were screened HIV positive.But, among all hospital admissions, 6.4 % (n=514) were HIV-infected (Figure 2).Thus, cryptococcocal meningitis accounted for 11% of all hospital admissions for HIV-infected persons (95% CI: 8.2 to 13.6%).The most common symptoms present in persons with CM were weight loss (100%) and meningeal syndrome (100%) (Table 1).Concurrent Mycobacterium tuberculosis infection (TB) was diagnosed in 70% of those with CM cases (Table 2).The main antifungal therapy received was fluconazole alone in 82% (46/56) or others drugs that each patient received (Table 3).Overall, the in-hospital mortality rate in the CM group was 90% (50/56) (Figure 3).

DISCUSSION
In a five year period from 2007 to 2011, 56 hospitalized patients were diagnosed with cryptococcocal meningitis (CM) in the two main hospitals of Bukavu in the eastern DRC, accounting for 11 % of hospital admissions of HIV- infected persons.This prevalence of 11% is similar with the results of others studies in central Africa from Cameroon and Burundi (Mbuagbaw et al., 2006;Swinne et al., 1999).In our setting, all CM patients were HIVinfected, and there was a female predominance (sex ratio F: M = 2:1).But, in others African studies, more of male predominance with some sporadic cases of Cryptococcus neoformans infection occurring among HIV-negative patients was reported (Mbuagbaw et al., 2006;Eholié et al., 1997;Soumaré et al., 2005)

Figure 1 .
Figure 1.Histogram of the gender distribution.

Figure 2 .
Figure 2. Histogram of the HIV screening.

Table 1 .
Symptoms associated with the meningeal cryptococcosis.

Table 2 .
Other AIDS related diseases associated with the meningeal cryptococcosis.

Table 3 .
Antifungal drugs used in main hospitals of Bukavu, South Kivu (DRC).
(Masimango et al., 2006)aran African studies on cryptococcocal meningitis, clinical features were variable; however, meningismus and weight loss were universally present.Concurrent TB was also commonly thought to be present in 70%.This high rate association of Cryptococcus and TB, > 50% was previously reported once again in Bukavu City in 2006(Masimango et al., 2006).HIV/AIDS remains the only cause of cryptococcocal meningitis in the eastern DRC.The diagnosis of C. neoformans can be improved with the specific cryptococcocal antigen (CrAg) test.The CrAg latex agglutination test is not available; however, the new CrAg lateral flow immunochromatographic assay (LFA) distick test (Immy, Inc.Norman, Oklahoma, USA) at US$2 per test would be revolutionary for diagnostics in resource-limited settings.The medical care of this severe AIDS-related infection needs also to be optimized in this region where a high rate of cryptococcocal mortality occurs in routine care.