Cryptococcosis

Background

• Can produce focal cerebral lesions or diffuse meningoencephalitis

Clinical Features

1. Fever
2. Headache
3. Nausea
4. AMS
5. Focal neurologic deficits

Diagnosis

• Neuroimaging usually normal
• CSF Studies
  • Crypto antigen (100% Sn & Sp)
  • Crypto culture (95%-100% Sn)
  • India Ink (60-80% Sn)
• Opening pressure
  • Usually elevated; drain CSF until pressure is <20 or 50% of opening presure
• Serum
  • Cryptococcal antigen testing (95% Sn)

Treatment

Pulmonary (not AIDS associated)

• Fluconazole 400mg PO IV q24hrs x 6-12 months OR
• Itraconazole 200mg PO q12hrs daily x 6-12 months OR
• Voriconazole 200mg PO q12hrs x 6-12 months

Pulmonary (with AIDS)

• Fluconazole 400mg PO q24hrs x 6-12 months

Meningitis (not AIDs associated)

• Amphotericin B 0.7-1mg/kg IV q24hrs AND Flucytosine 25mg/kg PO q6hrs x 4 weeks
  • Followed by Fluconazole 400mg PO q24hrs x 8 weeks

Meningitis (with AIDS)

• Amphotericin B 0.7-1mg/kg IV q24hrs AND Flucytosine 25mg/kg PO q6hrs x 2 weeks
  • Followed by Fluconazole 400mg PO q24hrs x 8 weeks
• Initiation of HAART is delayed by 2 to 10 weeks to minimize the risk of immune reconstitution syndrome

Disposition

• Admit to Medicine with ID consult
• Once the CD4 count > 200 and the patient is asymptomatic therapy x 6 months, therapy can be discontinued
• Some patients can require longer durations of therapy depending on symptom persistence

Source

• Tintinalli