Patient with AIDS and CD4+ T-Lymphocyte Counts of Less Than 200 Cells/μL
Which is the most common opportunistic meningitis in AIDS?
Cryptococcal meningitis
What is the clinical characteristic of cryptococcal meningitis?
In Cryptococcal meningitis meningismus is present in less than 40% of cases, and patients may present with only fever and headache, which become progressively more debilitating.
What are the symptoms of cryptococcal meningitis?
fever and headache
Confusion, blindness, or altered state of consciousness occurs in severe cases
Describe CSF in cryptococcal meningitis
-markedly elevated opening pressure
- mononuclear pleocytosis- elevated protein
-decreased glucose concentration( in 50% of the cases)
- direct detection of the organism by India ink staining (in 80% of the cases.)
What are the lab investigations to perform when you suspect cryptococcal meningitis?
-CSF: Detection of Cryptococcus neoformans antigen titres by enzyme immunoassay Culture
Direct detection of organisms by India ink staining
-Serum: cryptococcal antigen Blood culture
-Urine: culture
What is the role of brain imaging in cryptococcal meningitis?
Brain imaging is usually negative unless an associated cryptococcoma or hydrocephalus is present.
What are poor prognosis factors for cryptococcal meningitis?
Poor prognosis factors include :
-altered mental status
-absence of CSF pleocytosis
-CSF antigen titer greater than 1 : 1024
- a positive blood culture
-hyponatremia.
What is the treatment of cryptococcal meningitis?
-Therapy: -amphotericin B (0.7 mg/kg) + flucytosine (100 mg/kg PO in four divided doses per day) for at least 2 weeks
-Consolidation therapy: fluconazole (400 mg PO once or twice daily) administered for 8 weeks or until CSF cultures are sterile
-maintenance therapy using fluconazole 200 mg/day
Can fluconazole be used for initial treatment of cryptococcal meningitis?
NO
What is the value of maintenance therapy?
Prevent relapses
When can maintenance therapy for cryptococcal meningitis be discontinued?
if a patient has received a minimum of 12 months of antifungal treatment
CD4+ counts reach greater than 100 cells/μL,
and there is a sustained undetectable or very low HIV RNA level for ≥3 months
is cryptococcal meningitis fatal?
YES, early mortality still reaches 6%.
What are the complications of cryptococcal meningitis?
-Increased intracranial pressure greater than 200 mm H2O occur (in nearly all patients)