Cryptococcosis

Question 1

General points

Answer 1

->Cryptococcosis is a fungal infection caused by two YEAST species usually manifest as Meningitis or Pneumonia
->Cryptococcus neoformans meningitis is an AIDS-defining illness

Question 2

• Two disease causing species of Cryptococcus

Answer 2

=>Cryptococcus neoformans
* Associated with AIDS and immunocompromised patients

=>Cryptococcus gattii
* Endemic to tropical and subtropical areas–>Seen in travellers
* Increasingly found in temperate regions, may infect immunocompetent.

Question 3

Assessment

Answer 3

=>Clinical manifestations
(Vary with species and serotype)
->Meningitis
* Headache-> insidious onset
* Neck stiffness often absent
* Fever often late

=>Other sites involved in AIDS
* Lungs
* Bone marrow
* Skin–>Often resembles molluscum contagiosum
* Genitourinary tract

=>C. gattii–>Predominantly causes pneumonia

Question 4

Investigations

Answer 4

=>Blood
* Blood culture

=>Biopsy of lesions

=>Chest imaging
* CXR and/or CT chest (pneumonia)
* CT head–>To exclude mass lesion

=>CSF–>LP must be performed even in the absence of neurological features
* India ink stain–>51% sensitive
* High opening pressure, High protein, High WCC, Low glucose if severe
* Cryptococcal latex agglutination test (capsular polysaccharide antigen)->~90% sensitive and specific (False positives if rheumatoid factor positive)

Question 5

Management
for cryptococcal meningitis

Answer 5

=>General
* Resuscitation
* Supportive care and monitoring

=>Antimicrobial therapy->Three phases
1)* Induction (2 weeks)
2)* Consolidation (8 weeks)
3)* Prolonged maintenance phase

=>Induction phase (2 weeks)
* Amphotericin B 0.7–1 mg/kg/day
* Plus flucytosine 100 mg/kg/day

=>Consolidation phase (2 months)
* Fluconazole 400 mg daily

=>Maintenance (≥12 months)
* Fluconazole 200 mg daily
* Commenced once CSF sterilization has occurred

=>Other specific therapy
-> If Opening pressure >25 cm CSF, serial (e.g. daily) lumbar punctures–>Continue until pressure <20 cm CSF

=>COMPLICATIONS
Immune Reconstitution Inflammatory Syndrome (IRIS) with HAART in AIDS patients with Cryptococcal disease

Question 6

Cryptococcal pneumonia

Answer 6

Cryptococcal pneumonia-> usually tt with oral/ IV Fluconazole