Cryptococcosis

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Presentation :

Patients with immune suppression, such as AIDS, neutropenia, cirrhosis, or organ transplantation are most commonly infected, but it can occur in healthy persons
Most common cause of fungal meningitis worldwide

Cryptococcus is an encapsulated yeast that is ubiquitous in the environment
C. neoformans is the most commonly identified species, but C. gattii is seen with increasing frequency in the Pacific Northwest region of North America and appears to be spreading southward
Pathogenesis of cryptococcosis involves inhalation of spores into the respiratory tract, followed by dissemination into susceptible tissues, especially the CNS.

Cerebrospinal fluid analysis is essential to diagnose CNS involvement
- Classic findings include an increased leukocyte count (mainly lymphocytes), an increased protein level, a low to normal glucose level, and the presence of cryptococcal antigen.
CSF + Serum cryptococcal antigen is highly sensitive; positive in greater than 95% of infected patients.
Because patients with cryptococcosis-related increased intracranial pressure (ICP) may develop sudden blindness, deafness, or coma, opening pressure should always be documented during initial lumbar puncture

Amphotericin B plus flucytosine is the treatment of choice for induction therapy and is effective in more than 90% of patients.
- After at least 2 weeks of successful induction therapy, consolidation therapy with fluconazole may be initiated, continuing for at least 8 weeks.
- HIV-infected patients require maintenance (suppressive) therapy with fluconazole for at least 1 year after successful treatment AND until they have maintained their CD4 cell counts greater than 100/µL for a minimum of 3 months and have an undetectable viral load.
Symptoms of increased ICP may be improved by cerebrospinal fluid removal through sequential lumbar punctures or insertion of a shunt.
- Aggressive ICP reduction decreases early morbidity and mortality.