- The severity of infection depends on the degree of the patient's immunosuppression.
- Cryptococcal meningitis is the most frequent CNS fungal infection in AIDS patients
- Patients with CNS infection usually present with headaches, fever, and possibly mental status changes, but presentation can be more subtle.
- Cryptococcal infection can present as pulmonary or cutaneous disease.
- Diagnosis is based on lumbar puncture results and on the determination of latex cryptococcal antigen, which is usually positive in the serum and in the CSF.
- CSF opening pressure should always be measured to assess the possibility of elevated intracranial pressure.
- Initial treatment is with amphotericin B, 0.7 mg/kg/d IV, and 5-flucytosine, 25 mg/kg PO q6h for 2-3 weeks, followed by fluconazole, 400 mg PO daily for 8-10 weeks and then 200 mg PO daily indefinitely.
- The 5-flucytosine level should be monitored during therapy to avoid toxicity. A lipid preparation of amphotericin can be used in patients with renal insufficiency.
- Repeat lumbar punctures (removing up to 30 mL CSF until the pressure is below 20-25 cm H2O) may be required to relieve elevated intracranial pressure.
- In persons who have persistent elevation of intracranial pressure, a temporary lumbar drain is indicated.