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Which patients develop cryptococcal meningitis?
Patient with AIDS and CD4+ T-Lymphocyte Counts of Less Than 200 Cells/μL
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Which is the most common opportunistic meningitis in AIDS?
Cryptococcal meningitis
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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.
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What are the symptoms of cryptococcal meningitis?
- fever and headache
- Confusion, blindness, or altered state of consciousness occurs in severe cases
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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.)
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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
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What is the role of brain imaging in cryptococcal meningitis?
Brain imaging is usually negative unless an associated cryptococcoma or hydrocephalus is present.
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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.
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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
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Can fluconazole be used for initial treatment of cryptococcal meningitis?
NO
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What is the value of maintenance therapy?
Prevent relapses
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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
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is cryptococcal meningitis fatal?
YES, early mortality still reaches 6%.
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What are the complications of cryptococcal meningitis?
- -Increased intracranial pressure greater than 200 mm H2O occur (in nearly all patients)
- - cryptococcosis associated immune reconstitution inflammatory syndrome (C-IRIS) (26% of patients)
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What is the treatment of increased intracranial pressure in cryptococcal meningitis?
- -mechanical drainage:
- -repeat lumbar punctures, -temporary external lumbar drainage -intraventricular shunts.
- Corticosteroids, acetazolamide, and mannitol have not been shown to be effective.
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How to prevent C-IRIS?
Delaying ART 28 days after onset of antifungal therapy.
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What are predictors of C-IRIS?
- -persistent CSF cryptococcal growth at ART initiation
- -poor CD4+ T-cell increases on ART
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What is the management of C-IRIS?
- -continuation of ART.
- -antifungal therapy
- -a course of corticosteroids
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