Cryptococcal meningitis

  1. Which patients develop cryptococcal meningitis?
    Patient with AIDS and CD4+ T-Lymphocyte Counts of Less Than 200 Cells/μL
  2. Which is the most common opportunistic meningitis in AIDS?
    Cryptococcal meningitis
  3. 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.
  4. What are the symptoms of cryptococcal meningitis?
    • fever and headache
    • Confusion, blindness, or altered state of consciousness occurs in severe cases
  5. 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.)
  6. 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
  7. What is the role of brain imaging in cryptococcal meningitis?
    Brain imaging is usually negative unless an associated cryptococcoma or hydrocephalus is present.
  8. 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

  9. 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
  10. Can fluconazole be used for initial treatment of cryptococcal meningitis?
  11. What is the value of maintenance therapy?
    Prevent relapses
  12. 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
  13. is cryptococcal meningitis fatal?
    YES, early mortality still reaches 6%.
  14. 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)
  15. 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.
  16. How to prevent C-IRIS?
    Delaying ART 28 days after onset of antifungal therapy.
  17. What are predictors of C-IRIS?
    • -persistent CSF cryptococcal growth at ART initiation
    • -poor CD4+ T-cell increases on ART
  18. What is the management of C-IRIS?
    • -continuation of ART.
    • -antifungal therapy
    • -a course of corticosteroids
Card Set
Cryptococcal meningitis