Cryptococcosis

Background

• Can produce focal cerebral lesions or diffuse meningoencephalitis

Clinical Features

• Fever
• Headache
• Nausea
• altered mental status
• Focal neurologic deficits
• Meningismus is uncommon

Differential Diagnosis

Headache

Common

• Migraine headache
• Tension headache
• Cluster headache

Killers

• Meningitis/encephalitis
  • Neoplastic meningitis
• Myocardial ischemia
• Retropharyngeal abscess
• Intracranial Hemorrhage (ICH)
  • SAH / sentinel bleed
• Acute obstructive hydrocephalus
• Space occupying lesions
• CVA
• Carbon monoxide poisoning
• Basilar artery dissection
• Preeclampsia
• Cerebral venous thrombosis
• Hypertensive emergency
• Depression

Maimers

• Giant cell arteritis of temporal artery (temporal arteritis)
• Idiopathic intracranial hypertension (Pseudotumor Cerebri)
• Acute Glaucoma
• Acute sinusitis
• Cavernous sinus thrombosis or cerebral sinus thrombosis
• Carotid artery dissection

Others

• Mild traumatic brain injury
• Trigeminal neuralgia
• TMJ pain
• Post-lumbar puncture headache
• Dehydration
• Analgesia abuse
• Various ocular and dental problems
• Herpes zoster ophthalmicus
• Herpes zoster oticus
• Cryptococcosis
• Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
• Ophthalmoplegic migraine
• Superior Vena Cava Syndrome

Aseptic Meningitis

• Viral
  • Varicella
  • Herpes
  • Enterovirus
  • West Nile
• Tuberculosis
• Lyme disease
• Syphilis
• Leptospirosis
• Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
• Noninfectious
  • Sarcoidosis
  • Vasculitis
  • Connective tissue disease
  • Drug induced aseptic meningitis

Evaluation

• 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)

Management

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

See Also

• Fungal infections