Clinical Case

38 year old male with Retroviral

Dx.
CD4 of 23 Cells/uL
Progressively
worsening
headache of 3 weeks duration.
No
photophobia.
No
neck
stiffness
Assessment of CCM following
investigation

Cryptococcal Meningitis in
HIV Positive Patients

What is Cryptococcal
Meningitis?

It is a meningo-encephalitis resulting from

an infection caused by a fungus Cryptococcus neoformans

Epidemiology
Pre-HIV era : 1 case per million persons
Pre-HAART era: 66 cases per 1 000 persons
Post-HAART era: 7 cases per 1 000 persons

How Does it Present?

Headache
Unexplained fever
Nausea and vomiting
Neck stiffness
Confusion
Seizures
Abnormal behaviour / New onset psychiatric
symptoms
Altered level of consciousness / Coma
Focal Neurological signs
Diplopia / Unexplained blindness

How is the Diagnosis

made?
Lumbar Puncture
-diagnostic
-therapeutic

CT Scan ?

CSF Culture Gold Standard !

Limitation it takes 14 days

Alternatives
India ink
Latex (Cryptococcal antigene detection test)
Mucicarmine-stained histological sections
revealing the organism

Management
1st Episode
2nd Episode

1st Episode
Induction Phase
Consolidation Phase
Secondary Prophylaxis

Induction Phase

Amphoterin B 0.7-1mg/kg/dose IVI for 2

weeks

Consolidation Phase

Fluconazole 400mg o.d po for 8 weeks

Secondary Prophylaxis

Fluconazole 200mg o.d po

2nd / Subsequent Episode

Induction Phase

Amphoterin B 0.7-1mg/kg/dose IVI for 2 4

weeks (or until CSF is sterile)

Consolidation Phase

Fluconazole 800mg o.d po for 8 weeks

Secondary Prophylaxis

Fluconazole 400mg o.d po

When AmB Stocks are Low

Induction phase:
AmB + Fluc 800mg o.d for 1 week
Then Fluc 800mg o.d for a further one week

Consolidation phase:

Fluc 400mg o.d for 8 weeks

Secondary Prophylaxis:

Fluc 200mg o.d ongoing

When AmB is out of stock

Induction phase:

Fluc 800mg o.d for 4 weeks

Consolidation phase:

Fluc 400mg o.d for 8 weeks

Secondary Prophylaxis:

Fluc 200mg o.d ongoing

Complications of Management
Nephrotoxicity
Electrolyte abnormalities
Phlebitis
Febrile Reactions

Prevention
Early detection of HIV
Early initiation on HAART
Compliance

And avoidance of pigeon dung.

References

The Southern African Journal of HIV Medicine. Spring 2007.

Guidelines for the Prevention, Diagnosis and Management of
Cryptoccocal Meningitis and Disseminated Cryptococcosis in
HIV-infected patients
Bicanic, T & Harrison T.S . 2005. Cryptoccal Meningitis Available:
http://bmb.oxfordjournals.org/content/72/1/99.full.pdf+html
Accessed:08/11/2011
Sobel J. 2000. Practice Guidelines for the Treatment of Fungal
Infections. For Mycoses Study Group. Infectious diseases Society
of America. Clin Infect Dis. April;30(4):652
Van de Horst C, Saag M, Cloud G, et.al. 1997. Treatment of
Cryptoccal Meningitis Associated with the Acquired
Immunodeficiency Syndrome. National Institute of Allergy and
Infectious Diseases Mycoses Study Group and AIDS Clinical Trial
Group. N Engl J.Med. Nov;337:15-21.