B20.5 + (B45.1 + G02.1*)
DESCRIPTION
Cryptococcal meningitis is the commonest manifestation of disseminated cryptococcosis in patients with advanced HIV. Severe headache is common due to raised intracranial pressure.
Diagnosis
Confirmed on lumbar puncture.
GENERAL MEASURES
Therapeutic lumbar puncture is indicated to lower pressure in symptomatic patients and should be done with pressure monitoring. Remove sufficient CSF (maximum 30 mL) to lower pressure to 50% of the opening pressure but not less than 20 cm H2O.
Therapeutic lumbar puncture should be done daily until there is clinical improvement.
MEDICINE TREATMENT
Induction phase
- Fluconazole, oral 1200 mg daily for 14 days.
AND
- Amphotericin B, slow IV infusion, 1 mg/kg daily in dextrose 5 % over 4 hours for 14 days.
- Ensure adequate hydration to minimise nephrotoxicity. (See AMPHOTERICIN B, IV for preventing, monitoring and management of toxicity).
Consolidation phase
Follow with:
- Fluconazole, oral, 800 mg daily for 8 weeks.
Maintenance phase
- Fluconazole, oral, 200 mg daily.
- Continue for at least 1 year provided that the CD4 count increases to >200 cells/mm3 on ART. If the CD4 count does not increase continue treatment indefinitely.
- Commence ART 4–6 weeks after starting antifungal therapy. See Antiretroviral therapy .
Note: Adjunctive corticosteroids have been shown to be detrimental.
REFERRAL
Specialist or tertiary
- Focal neurological signs – CT scan required to exclude other pathology e.g. toxoplasmosis.
- Persistent raised intracranial pressure despite daily therapeutic lumbar puncture.