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Cryptococcal meningitis

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Opinion statement

  • Cryptococcal meningitis, often seen in immunocompromised hosts, is also a disease of the immune-competent individual.

  • The diagnosis of cryptococcal meningitis requires a lumbar puncture with measurement of the opening pressure, standard laboratory assessment including cell count, protein and glucose, fungal culture, and cryptococcal polysaccharide antigen. Serum cryptococcal antigen is of great diagnostic value in individuals infected with HIV.

  • Hospital admission for initial therapy with amphotericin B desoxycholate is required.

  • Adjuvant oral therapy with flucytosine for the first 2 weeks of therapy is strongly recommended. If flucytosine is not well tolerated, it may be discontinued with close monitoring and follow-up of cerebrospinal fluid (CSF) response to therapy.

  • Good hydration and appropriate premedication concomitant to the use of amphotericin B are useful interventions preventing side effects. Occasionally, amphotericin B needs to be discontinued due to intolerance or side effects.

  • After CSF sterilization is completed, therapy can be switched to oral fluconazole.

  • Fluconazole is well absorbed orally. There is rarely a need to give intravenous fluconazole.

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References and Recommended Reading

  1. Murray P, Baron E, Pfaller M, et al.: Manual of Clinical Microbiology, edn 2. Washington, DC: ASM Press; 1995:732–733.

    Google Scholar 

  2. Levitz SM: The ecology of Cryptococcus neoformans and the epidemiology of cryptococcus. Rev Infec Dis 1991, 13:1163–1169.

    CAS  Google Scholar 

  3. Gottfredessen M, Perfect J: Fungal meningitis. Semin Neurol 2000, 20:307–322.

    Article  Google Scholar 

  4. Mandel G, Bennett J, Dolin R: Principles and Practices of Infectious Diseases, edn 5. London: Churchill Livingstone; 2000:2707–2718.

    Google Scholar 

  5. Kovacs J, Kovacs AA, Polis M, et al.: Cryptococcosis in the acquired immunodeficiency syndrome. Ann Intern Med 1985, 103:533.

    PubMed  CAS  Google Scholar 

  6. Saag M, Graybill R, Larsen R, et al.: Practice guidelines for the management of cryptococcal disease. Clin Infect Dis 2000, 30:710–718. An exceptional review.

    Article  PubMed  CAS  Google Scholar 

  7. Baddley J, Perfect J, Warren R, et al.: Pulmonary Cryptococcosis in patients without HIV infection: when is a lumbar puncture needed? Abstract presented at 40th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 17–20, 2000; Toronto, Canada. Abstract #707, Session 92 (J).

  8. Kerkering T, Doma R, Shadony S: The evolution of pulmonary cryptocococcis: clinical implications from a study of 41 patients with & without compromising host factors. Ann Intern Med 1981, 94:611–616.

    PubMed  CAS  Google Scholar 

  9. Kaufman L, Blumer S: Latex cryptococcal antigen test. Am J Clin Pathol 1973, 60:285.

    PubMed  CAS  Google Scholar 

  10. Go J, Kim P, Admadi J, et al.: Fungal infections of the central nervous system. Neuroimaging Clin N Am 2000, 10:409–425. A good article.

    PubMed  CAS  Google Scholar 

  11. Dugoni BM: Amphotericin B concentrations in CSF of patients with AIDS and cryptococcal meningitis. Clin Pharm 1989, 8:220–221.

    PubMed  CAS  Google Scholar 

  12. Fungizone [product information]. Irvine, CA: GensiaSicor, Inc.; 1998.

  13. Bennett J, Dismukes W, Duma R, et al.: A comparison of amphotericin B alone and combined with flucytosine in the treatment of cryptococcal meningitis. N Engl J Med 1979, 301:126–131.

    Article  PubMed  CAS  Google Scholar 

  14. Dismukes W, Cloud G, Gallis H: Treatment of cryptococcal meningitis with combination amphotericin B and flucytosine for four as compared with six weeks. N Engl J Med 1987, 317:334.

    Article  PubMed  CAS  Google Scholar 

  15. Van der Horst C, Saag M, Cloud G, et al.: Treatment of cryptococcal meningitis associated with acquired immunodeficiency syndrome. N Engl J Med 1997, 337:15–21.

    Article  PubMed  Google Scholar 

  16. Mussini C, Pini R, Borghi V, et al.: Discontinuation of secondary prophylaxis for cryptococcal meningitis in acquired immunodeficiency syndrome patients receiving HAART. Abstract presented at 40th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 17–20, 2000; Toronto, Canada. Abstract #1912, Session 212 (I).

  17. Goodwin S: Pre-treatment regimens for adverse events related to infusion with amphotericin B. Clin Infect Dis 1995, 20:755–756.

    PubMed  CAS  Google Scholar 

  18. Benson JM: Pharmacokinetics of amphotericin B in children. Antimicrob Agents Chemother 1989, 33:1989–1993.

    PubMed  CAS  Google Scholar 

  19. Baly JE: Pharmacokinetics, outcome of treatment and toxic effects of amphotericin B and 5FC in neonates. J Pediatr 1990, 116: 791–797.

    Article  Google Scholar 

  20. Sievers TM: Safety and efficacy of intralipid emulsions of amphotericin B. J Antimicrob Chemother 1996, 38:333–347.

    Article  PubMed  CAS  Google Scholar 

  21. Leenders A, Reiss P, Portegies P, et al.: Liposomal amphotericin B compared with amphotericin B: both followed by oral fluconazole in the treatment of AIDS-associated cryptococcal meningitis. AIDS 1997, 11:1463–1471.

    Article  PubMed  CAS  Google Scholar 

  22. Gales MA: Acute renal failure with amphotericin B in lipid emulsion. Ann Phrmacother 1996, 30:1036.

    CAS  Google Scholar 

  23. Physicians’ Desk Reference, edn 55. Montvale, NJ: Medical Economics Company; 2001.

  24. Vermes A: Flucytosine: a review of its pharmacology, clinical indications, pharmacokinetics, toxicity and drug interactions. J Antimicro Chemother 2000, 46:171–179.

    Article  CAS  Google Scholar 

  25. Saag M, Powderly W, Cloud G, et al.: Comparison of amphotericin B with fluconazole in the treatment of acute AIDS-associated cryptococcal meningitis. N Engl J Med 1992, 326:83–89.

    Article  PubMed  CAS  Google Scholar 

  26. Clark A, Lobo B, Gelfand M: Fluconazole and amphotericin B for cryptococcal meningitis. Ann Pharmacother 1996, 30:1408–1410.

    PubMed  CAS  Google Scholar 

  27. Powderly M, Saag M, Cloud G, et al.: A controlled trial of amphotericin B to prevent relapse of cryptococcal meningitis in patients with acquired immunodeficiency syndrome. N Engl J Med 1992, 326:793–798.

    Article  PubMed  CAS  Google Scholar 

  28. Powderly W: Current approach to the acute management of cryptococcal infections. J Infect Dis 2000, 41:18–22.

    CAS  Google Scholar 

  29. Fluconazole [itpackage insert]. New York, NY: Pfizer/Roerig; 1998.

  30. Micromedex ® Healthcare Series

  31. Davey K, Johnson E, Holmes A, et al.: In-vitro susceptibility of Cryptococcus neoformans isolates to fluconazole and itraconazole. J Antimicrob Chemother 1998, 42:217–220.

    Article  PubMed  CAS  Google Scholar 

  32. Saag M, Cloud G, Graybill R, et al.: A comparison of itraconazole versus fluconazole as maintenance therapy for AIDS-associated cryptococcal meningitis. Clin Infect Dis 1999, 28:291–296. A good intraconazole and fluconazole comparison review.

    PubMed  CAS  Google Scholar 

  33. Larsen R: A comparison of itraconazole versus fluconazole as maintenance therapy for AIDS-associated cryptococcal meningitis. Clin Infect Dis 1999, 28:297–298.

    PubMed  CAS  Google Scholar 

  34. Stevens D, Denning D, Shatsky S, et al.: Cryptococcal meningitis in the immunocompromised host: intracranial hypertension and other complications. Mycophathologia 1999, 146:1–8.

    Article  CAS  Google Scholar 

  35. Graybill J, Sobel J, Saag M, et al.: Diagnosis and management of increased intracranial pressure in patients with AIDS and cryptococcal meningitis. Clin Infect Dis 2000, 30:47–54.

    Article  PubMed  CAS  Google Scholar 

  36. Evans R: Complications of lumbar puncture. Neurol Clin 1998, 16:83–100.

    Article  PubMed  CAS  Google Scholar 

  37. Park M, Hospenthal D, Bennett J: Treatment of hydrocephalus secondary to cryptococcal meningitis by use of shunting. Clin Infect Dis 1999, 28:629–633. A good review.

    PubMed  CAS  Google Scholar 

  38. Myolonakis E, Merriman N, Rich J, et al.: Use of cerebrospinal fluid shunt for the management of elevated intracranial pressure in a patient with active AIDS-related cryptococcal meningitis. Diag Microbiol Infect Dis 1999, 34:111–114.

    Article  Google Scholar 

  39. Snaches A, Fukuoka T, Filler S: In Vitro Activity of the novel triazole R-120758 against Candida species and Cryptococcus neoformans. Abstract presented at 40th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 17–20, 2000; Toronto, Canada. Abstract ® 198. Session 14 (J).

  40. Yokoyama K, Wang L, Kaji H, et al.: Therapeutic effect of SS750, a novel triazole antifungal agent, against systemic aspergillosis and cryptocococcis in mice. Abstract presented at 40th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 17–20, 2000; Toronto, Canada. Abstract # 1084, Session 111 (F,J).

  41. Nguyen M, Yu C: In vitro comparative efficacy of voriconazole and itraconazole against fluconazolesusceptible and-resistant Cryptococcus neoformans isolates. Antimicrob Agents Chemother 1998, 42:471–472.

    PubMed  CAS  Google Scholar 

  42. Marco F, Pfaller M, Messer S, et al.: In vitro activities of voriconazole (UK-109,496) and four other antifungal agents against 394 clinical isolates of Candida spp. Antimicrob Agents Chemother 1998, 42:161–163.

    Article  PubMed  CAS  Google Scholar 

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  1. Albuquerque Veterans Affairs Medical Center, 1501 San Pedro Drive, SE, 87108, Albuquerque, NM, USA

    Lourdes Irizarry MD

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  1. Lourdes Irizarry MD
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Irizarry, L. Cryptococcal meningitis. Curr Treat Options Neurol 3, 413–426 (2001). https://doi.org/10.1007/s11940-001-0029-2

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  • DOI: https://doi.org/10.1007/s11940-001-0029-2

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