ID
Cryptococcal Meningitis
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Cryptococcal Meningitis
, Cryptococcal Meningoencephalitis
See Also
Headache in HIV
Neurologic Manifestations of HIV
Focal Brain Lesion in HIV
HIV Complications
AIDS-Defining Illness
Etiology
Cryptococcus neoformans (fungal infection)
Epidemiology
Incidence
United States: 2-7 cases per 1000
AIDS
patients
Worldwide: 1 Million cases annually (especially sub-Sahara Africa)
Risk Factors
Consider in all at risk and known HIV patients with
Headache
Advanced HIV (
AIDS
)
CD4 < 50 to 100 cells per mm3 or
AIDS-Defining Illness
Symptoms
Insidious onset
Typically starts as occult, asymptomatic infection in 50% of cases
Symptoms are often nonspecific at onset
Headache
(91%)
Weight Loss (90%)
Fever
(52%)
Altered Level of Consciousness
or confusion
Signs
Fever
(91%)
Muscle wasting (90%)
Motor weakness (40%)
Cranial Nerve
palsy (29%)
Hearing Loss
Vision Loss
(
Optic Neuritis
related)
May progress within 12 hours following onset of
Optic Neuritis
Organ Involvement
Neurologic involvement (
Meningitis
) (85-90%)
Lung
or skin involvement (25%)
Precautions
Do not rely on lack of meningismus (meningeal signs) to exclude Cryptococcal Meningitis
Meningeal signs are only present in one quarter of Cryptococcal Meninigitis
Evaluation
Headache in HIV
Labs
Blood Culture
s positive (>75%)
Serum cryptococcal
Antigen
positive (98%)
High titer (>1024:1)
CSF Exam
Glucose
usually normal
Protein mildly elevated
White Blood Cell Count
usually less than 20
India Ink stain usually shows organism
Cryptococcal Ag test (>95% sensitive, specific)
Increased
CSF Opening Pressure
Typically
CSF Opening Pressure
>350 mm H2O
Results from high fungal burden in CNS interfering with CSF reabsorption
Risk of obstructrive
Hydrocephalus
presenting as cognitive deficit and ataxic gait
High pressure responsible for adverse sequelae
Treat with serial LPs, lumbar drain or
VP Shunt
Differential diagnosis (other causes of increased
CSF Opening Pressure
in HIV)
Toxoplasma
Encephalitis
CNS
Lymphoma
Tuberculous Meningitis
Management
Acute (CNS and extraneural involvement)
Amphotericin B (High dose): 0.7 mg/kg/day
Flucytosine (100 mg/kg/day) may be added
Fluconazole
(200 to 400 mg/day) Indications
Normal Mental Status at baseline
Time to sterilization of CSF is slower
Prefer amphotericin B (short course first)
Avoid harmful measures
Avoid
Dexamethasone
Associated with increased mortality
Beardsley (2016) N Engl J Med 374(6): 542-4 +PMID: 26863355 [PubMed]
Management
Prophylaxis
Gene
ral
Relapse occurs in >80% if no suppression given
Fluconazole
200 mg/day
Prognosis
Uniformly fatal if left untreated
Overall Mortality: 12%
References
Perkins (2013) Crit Dec Emerg Med 27(3): 2-9
Friedmann (1995) Arch Intern Med 155(20): 2231-7 [PubMed]
Mwaba (2001) Postgrad Med J 77(814): 769-73 [PubMed]
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