Infectious Diseases

Cryptococcosis

Not yet clinically reviewed

This protocol was migrated from the earlier Pharmapedia and Ward Guide apps for educational use. Follow your hospital's own policies and consult seniors when in doubt.

Introduction

Cryptococcosis is a noncontagious, systemic mycotic infection caused by the ubiquitous encapsulated soil yeast Cryptococcus neoformans.

Clinical Presentation and Diagnosis

Primary cryptococcosis in humans almost always occurs in the lungs. Symptomatic infections are usually manifested by cough, rales, and shortness of breath that generally resolve spontaneously.
Disease may remain localized in the lungs or disseminate to other tissues, particularly the CNS, although the skin can also be affected.
In the non-AIDS patient, the symptoms of cryptococcal meningitis are nonspecific. Headache, fever, nausea, vomiting, mental status changes, and neck stiffness are generally observed. In AIDS patients, fever and headache are common, but meningismus and photophobia are much less common than in non-AIDS patients.
Examination of cerebrospinal fluid (CSF) in patients with cryptococcal meningitis generally reveals an elevated opening pressure, CSF pleocytosis (usually lymphocytes), leukocytosis, a decreased CSF glucose, an elevated CSF protein, and a positive cryptococcal antigen.
Antigens to C. neoformans can be detected by latex agglutination. C. neoformans can be detected in ~60% of patients by India ink smear of CSF and cultured in more than 96% of patients.

Treatment

The use of intrathecal amphotericin B is not recommended for the treatment of cryptococcal meningitis except in very ill patients or in those with recurrent or progressive disease despite aggressive IV amphotericin B therapy. The dosage of amphotericin B employed is usually 0.5 mg administered via the lumbar, cisternal, or intraventricular (via an Ommaya reservoir) route two or three times weekly.
Amphotericin B with flucytosine is the initial treatment of choice for acute therapy of cryptococcal meningitis in AIDS patients. Many clinicians will initiate therapy with amphotericin B, 0.7 to 1 mg/kg/day IV (with flucytosine, 100 mg/kg/day). After 2 weeks, consolidation therapy with fluconazole 400 mg/day orally can be administered for 8 weeks or until CSF cultures are negative.