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Cryptococcal Meningitis

  • Ahmed Al Hammadi
  • Luis Ostrosky-Zeichner
Chapter

Abstract

Cryptococcal meningitis (CM) is the most common cause of adult meningitis in human immunodeficiency virus (HIV) patients with CD4+ cell count <100 cells/μL and is frequently seen in many immunocompromised patients. The respiratory tract is usually the primary site of infection, and the central nervous system is a major site of dissemination due to Cryptococcus neurotropism. Patients with CM present with subacute fever, headache, altered mental status, and even coma. Immune reconstitution inflammatory syndrome (IRIS) in patients with HIV and CM occurs in two forms: paradoxical and unmasking. Identification of risk factors causing IRIS and timely treatment after ruling out residual CM infection are important. Also, increased intracranial pressure plays a major rule in the pathophysiology of CM and needs to be managed promptly to avoid complications. Obtaining lumbar punctures is critical to make the diagnosis and relieve increased intracranial pressure. Cerebrospinal fluid (CSF) should be sent for analysis, fungal cultures, India ink staining, and cryptococcal antigen (CrAg) testing. The use of point-of-care tests for the detection of serum CrAg has a preemptive role in resource-limited settings in ART-naïve, high-risk HIV patients. The use of Amphotericin B formulations in combination with flucytosine is the mainstay of treatment for the induction step of the course, while fluconazole is used in consolidation and maintenance of therapy. Optimizing immunity in immunocompromised patients helps to treat CM. Alternative agents can be used to manage CM or its complications including adalimumab, sertraline, interferon-γ, and new antifungal agents such as Viamet.

Keywords

Cryptococcus Cryptococcal Meningitis Fungal IRIS Immunocompromised HIV CSF 

Abbreviations

5-FC

Flucytosine, 5-fluorocytosine

ABLC

Amphotericin B lipid complex

AIDS

Acquired immune deficiency syndrome

AmB

Amphotericin B

ART

Antiretroviral therapy

CM

Cryptococcal meningitis

CMV

Cytomegalovirus

CNS

Central nervous system

CrAg

Cryptococcal antigen

CSF

Cerebrospinal fluid

CT

Computed tomography

CYP51

Cytochrome P51

ELISA

Enzyme-linked immunosorbent assay

GM-CSF

Granulocyte macrophage colony-stimulating factor

HIV

Human immunodeficiency virus

Hsp90

Heat shock protein 90

IDSA

Infectious Disease Society of America

IFN-γ

Interferon-γ

IL

Interleukin

IRIS

Immune reconstitution inflammatory syndrome

LA

Latex agglutination

LFA

Lateral flow assay

LFAmB

Lipid formulations of AmB

MALDI-TOF-MS

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

MIC

Minimal inhibitory concentrations

MRI

Magnetic resonance imaging

PIIRS

Post-infectious inflammatory response syndrome

SOT

Solid organ transplantation

Th-1

T-helper type 1 response

TNF-α

Tumor necrosis factor-α

VP

Ventriculoperitoneal

WCC

White cell count

WHO

World Health Organization

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.UT Health-McGovern Medical SchoolHoustonUSA

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