Meningitis, cryptococcal

G02.1

• Description
• Diagnostic criteria
• General and supportive measures
• Medicine treatment
• Referral

DESCRIPTION

An uncommon childhood meningitis that may occur in older HIV infected children with severe CD4 T-cell depletion. Pulmonary and skin involvement can occur.

DIAGNOSTIC CRITERIA

Clinical

• Acute or chronic headache in an older HIV infected child. Meningism need not be present.
• Often presents with cranial nerve palsy.
• Can occur as result of Immune Reconstitution Inflammatory Syndrome (IRIS) after initiation of antiretroviral therapy.

Investigations

• Test all cerebrospinal fluid (CSF) specimens from HIV infected children with suspected meningitis.
• CSF: India ink stain, and/or cryptococcal antigen test (more sensitive than India ink stain). Measure CSF opening pressure.
• Fungal culture – CSF, blood and urine.

If indicated:

• Chest X-ray.
• Ophthalmological assessment.

GENERAL AND SUPPORTIVE MEASURES

• Admit to high or intensive care unit, if appropriate.
• Monitor, where indicated:
  • neurological status,
  • respiration,
  • heart rate,
  • body temperature,
  • blood pressure,
  • electrolytes,
  • haematocrit,
  • blood glucose,
  • acid-base status,
  • blood gases,
  • fluid balance, i.e. hydration,
  • serum and urine osmolality.
• Ensure adequate nutrition by enteral feeding where possible. Use a nasogastric tube if necessary. If enteral feeding is not possible, provide appropriate intravenous fluids.

MEDICINE TREATMENT

Treatment

Initial treatment (2 weeks)

• Amphotericin B deoxycholate, IV, 1mg/kg/day as a daily infusion in 5% dextrose water over 4 hours.
  PLUS
  
• Fluconazole, IV, 12mg/kg/day.
  • Maximum dose: 800 mg.

Prehydration before administering amphotericin B to prevent renal impairment:

• Sodium chloride 0.9%, IV, 15mL/kg plus potassium chloride, 20mmol/L infused over 2–4 hours.

THEN

Consolidation treatment (8 weeks)

• Fluconazole, oral, 12mg/kg/day for 8 weeks.
  • Maximum dose: 800mg.

Secondary prophylaxis (maintenance treatment)

• Fluconazole, oral, 6mg/kg/day.
  • Maximum dose: 400 mg.

Discontinue secondary prophylaxis:

• Children < 6 years on ART: CD 4 count >25% for at least 6 months.
• Children > 6 year on ART: CD 4 count >200 for at least 6 months. Adolescents on ART: CD4 count increases to between 100–200cells/mm³ for at least 6 months.
• Re-start prophylaxis if CD4 count drops below thresholds above.

For continued raised intracranial pressure:

• Daily therapeutic lumbar puncture is indicated if initial LP manometric pressure > 25 cm water in the lateral recumbent position.
• Continue until pressure stabilises below 25 cm water.
• Remove 10-20mL daily and obtain a closing pressure.
• Refer for neurosurgical intervention if pressure persistent high and/or above 40 cm water.

REFERRAL

• All cases not responding to initial treatment.
• All patients with IRIS.