Cryptococcal meningitis

Patient with AIDS and CD4+ T-Lymphocyte Counts of Less Than 200 Cells/μL

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.

• fever and headache
• Confusion, blindness, or altered state of consciousness occurs in severe cases

• -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.)

• -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

Brain imaging is usually negative unless an associated cryptococcoma or hydrocephalus is present.

Poor prognosis factors include :

-altered mental status

-absence of CSF pleocytosis

-CSF antigen titer greater than 1 : 1024

- a positive blood culture

-hyponatremia.

• -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

NO

Prevent relapses

• 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

YES, early mortality still reaches 6%.

• -Increased intracranial pressure greater than 200 mm H2O occur (in nearly all patients)
• - cryptococcosis associated immune reconstitution inflammatory syndrome (C-IRIS) (26% of patients)

• -mechanical drainage:  
•    -repeat lumbar punctures,                   -temporary external lumbar drainage                      -intraventricular shunts.
• Corticosteroids, acetazolamide, and mannitol have not been shown to be effective.

Delaying ART 28 days after onset of antifungal therapy.

• -persistent CSF cryptococcal growth at ART initiation
• -poor CD4+ T-cell increases on ART

• -continuation of ART.
• -antifungal therapy
• -a course of corticosteroids