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PubMed1996

Tuberculous meningitis. Clinical characteristics and comparison with cryptococcal meningitis in patients with human immunodeficiency virus infection.

OBJECTIVE: To determine the prevalence and causes of meningitis in patients with human immunodeficiency virus (HIV) infection. DESIGN: A prospective study of HIV-associated neurologic complications carried out from 1988 to 1992. SETTING: A tertiary care university hospital in Madrid, Spain. PATIENTS. A total of 142 patients, 65% of whom were injecting drug users. RESULTS: Thirty-six episodes of meningitis were diagnosed in 33 patients (23%). Of these, 17 cases (47%) were tuberculous meningitis (5 definite and 12 probable) and 7 (19%) corresponded to cryptococcal meningitis. Comparative studies of the tuberculous and cryptococcal meningitis cases showed injecting drug use as the most common form of HIV transmission in the tuberculous meningitis (P = .03) and a lower mean CD4+ cell count in the cryptococcal meningitis group (P = .02). CONCLUSIONS: Tuberculous meningitis was the prime type of meningitis, which was associated with HIV transmission by injecting drug use. Cryptococcal meningitis appears in more advanced stages of HIV infection, which determines its characteristic presentation.

Acquired Immunodeficiency Syndrome↗
PubMed1975

Cryptococcal meningitis: diagnostic value of cryptococcal antigen in cerebrospinal fluid.

In three previously reported cases of cryptococcal meningitis, the only laboratory evidence for this diagnosis was the presence of cryptococcal antigen in the cerebrospinal fluid (CSF). Three additional patients had chronic meningitis and repeatedly negative CSF cultures and had cryptococcal antigen demonstrated in the CSF. In our patients, the diagnosis was further supported by the complete recovery after amphotericin B therapy in two and the demonstration of Cryptococcus neoformans in the meninges at autopsy in the third. In certain patients with chronic meningitis, the detection of cryptococcal antigen in the CSF may be the only means of establishing a diagnosis during life. In such patients, if cryptococcal antigen is present in the CSF in a titer of larger than or equal to 1:8, antifungal therapy should be initiated, pending results of other diagnostic studies.

Adult↗
PubMed2002

Paradoxical recurrent meningitis following therapy of cryptococcal meningitis: an immune reconstitution syndrome after initiation of highly active antiretroviral therapy.

We report a case of paradoxical recurrent meningitis in response to initiation of highly active antiretroviral therapy in a patient receiving maintenance fluconazole for a previous diagnosis of cryptococcal meningitis. We describe the unusual radiographic and histopathologic findings which are consistent with an immune reconstitution induced paradoxical inflammatory response to residual cryptococcal infection.

Acquired Immunodeficiency Syndrome↗
PubMed2002

Management of Increased Intracranial Pressure in Cryptococcal Meningitis.

Therapy of cryptococcal meningitis has been focused primarily on optimizing the antifungal regimen to improve the previously high treatment failure rates. Until recently, relatively little attention has been paid to the impact of increased intracranial pressure, which is a frequent problem that complicates management of patients with cryptococcal meningitis. Patients with elevated baseline opening pressures have higher titers of cerebrospinal fluid cryptococcal capsular polysaccharide antigen, more frequent headaches, meningismus, papilledema, hearing loss, and pathologic reflexes, as well as increased morbidity and mortality compared with those patients with normal opening pressures. Optimal therapy has not yet been firmly established, but the diagnostic evaluation and available treatment options are reviewed here, including frequent high volume lumbar punctures, lumbar drains, ventriculoperitoneal shunting, and corticosteroids.

Journal Article↗
PubMed1995

Problems in the diagnosis of AIDS related cryptococcal meningitis: a case report.

Cryptococcal meningitis in a 35-year old male who had a history of chronic alcoholism and sexual promiscuity, is presented here. The patient presented twice, 6 weeks apart, with altered sensorium. On the earlier occasion, CSF examination and CT head scan were entirely normal, while on the second occasion CSF abnormalities were found which led to the diagnosis of cryptococcal meningitis. The patient eventually tested positive for HIV by both the ELISA and Western Blot techniques. Diagnostic problems and management difficulties in AIDS-related cryptococcal meningitis are discussed.

AIDS-Related Opportunistic Infections↗
PubMed1984

Combination of oral flucytosine and ketoconazole as therapy for experimental cryptococcal meningitis.

Current therapy for cryptococcal meningitis often is ineffective, toxic, and inconvenient. Ketoconazole has been shown to penetrate into brain tissue of mice and cerebrospinal fluid of humans and to improve the course of human coccidioidal meningitis. Ketoconazole, flucytosine, and amphotericin B, alone and in two-drug combinations, were used to treat cryptococcal meningitis in mice injected intracranially with Cryptococcus neoformans. Mortality was assessed, and numbers of cryptococci in brain and liver were counted. By both of these parameters, the combination of flucytosine and ketoconazole produced results superior to those of either agent used alone. The standard combination of amphotericin B and flucytosine also showed an additive effect in this model. However, the combination of amphotericin B and ketoconazole consistently showed no additive effect. None of the combinations of drugs was antagonistic. Our results indicate a possible role for therapy with a combination of oral flucytosine and ketoconazole as part of the treatment for cryptococcal meningitis.

Amphotericin B↗
PubMed2003

The efficacy of fluconazole 600 mg/day versus itraconazole 600 mg/day as consolidation therapy of cryptococcal meningitis in AIDS patients.

UNLABELLED: Cryptococcal meningitis is one of the major complications affecting the central nervous system of patients suffering from AIDS. The results of treatment, when following current recommendation are still unsatisfactory. OBJECTIVE: This study aimed to evaluate the efficacy of a higher than recommended dose of oral fluconazole and itraconazole as consolidation therapy for cryptococcal meningitis in AIDS patients. DESIGN AND METHOD: HIV infected patients with primary cryptococcal meningitis, who had been treated initially with amphotericin B for 2 weeks were included in this study. They were randomized into two groups, to receive either fluconazole 600 mg daily or itraconazole 600 mg daily for 10 weeks. The response towards the two different treatments was clinically defined to be successful, if after 10 weeks of treatment no clinical symptoms and signs of meningitis remained and the cerebrospinal fluid (CSF) fungal culture was negative. RESULTS: The trial was performed from April 1999 to April 2000 at Srinagarind Hospital, Khon Kaen, Thailand. At the beginning of the trial 44 cases were selected, but only 35 patients proved to be suitable for the final evaluation of the study. Out of those, 19 cases were assigned to the fluconazole and 16 cases to the itraconazole group. Ten weeks after treatment, all patients clinically recovered completely. The CSF sterilization rate for the fluconazole group and for the itraconazole group were 100 and 94 per cent respectively. The Fisher's exact test showed no significant difference in the CSF sterilization rate between both groups (p = 0.26). CONCLUSION: The result of this study indicates that treatment with either 600 mg per day of fluconazole or itraconazole as consolidation treatment have the same efficacy for AIDS patients suffering from cryptococcal meningitis. The results of this study also suggest, comparing the result of this trial with the results of similar trials published somewhere else, that treatment with the higher doses may be superior to treatment regimens using lower doses, as can be judged from the clinical outcome and the results of the mycological cultures.

AIDS-Related Opportunistic Infections↗
PubMed2005

Baseline correlation and comparative kinetics of cerebrospinal fluid colony-forming unit counts and antigen titers in cryptococcal meningitis.

Cerebrospinal fluid (CSF) cryptococcal colony-forming unit counts and CSF cryptococcal antigen titers serve as alternative measures of organism load in cryptococcal meningitis. For these measures, we correlated baseline values and rates of decline during the first 2 weeks of therapy in 68 human immunodeficiency virus--seropositive patients with cryptococcal meningitis. At baseline, there was a strong correlation between CSF cryptococcal colony-forming unit counts and CSF cryptococcal antigen titers. During the first 2 weeks of therapy, CSF cryptococcal colony-forming unit counts decreased by >5 logs, and CSF cryptococcal antigen titers decreased by 1.5 dilutions. In individual patients, there was no correlation between the rate of decline in CSF cryptococcal colony-forming unit counts and that in CSF cryptococcal antigen titers.

Antifungal Agents↗
PubMed1985

Ophthalmological complications of cryptococcal meningitis.

Two patients with cryptococcal meningitis associated with ophthalmological complications are described. One patient developed a cryptococcal fundal lesion which disappeared during chemotherapy. Chronically raised intracranial pressure was associated with a visual field defect. This resolved with repeated lumbar punctures. The second patient developed visual deficits secondary to papilloedema and responded to optic nerve decompression. In both cases CT scanning demonstrated swelling of the optic nerves. In the second patient this regressed after decompression. A review of the variety of the ophthalmological complications of cryptococcal meningitis and their prevalence is presented. The risk of developing severe visual disability is assessed.

Adult↗
PubMed2001

Safety and efficacy of liposomal amphotericin B in patients with cryptococcal meningitis.

Four patients with cryptococcal meningitis were successfully treated with liposomal amphotericin B prepared at our institute using Soya phosphatidylcholine and cholesterol. In one patient, response with 1 mg/kg/day treatment was poor. However, on increasing the dose to 2 mg/kg/day, a good response was observed with CSF becoming negative for Cryptococcus neoformans after seven days of this enhanced dose. L-AMP-LRC-1 was found to be well tolerated and a major advantage was observed in two renal transplant patients in whom it could be given safely.

Adult↗
PubMed1992

Superior division paresis of the oculomotor nerve caused by cryptococcal meningitis.

A case of cryptococcal meningitis with unilateral paresis of the superior division of the oculomotor nerve was reported. The ocular signs were completely improved by antifungal therapy. This case demonstrates that divisional oculomotor paresis occurred in the subarachnoid portion of the third cranial nerve before its anatomic bifurcation.

Adolescent↗
PubMed1993

Cryptococcal intracerebral mass lesions associated with cryptococcal meningitis.

12 patients with cryptococcal intracerebral mass lesions associated with cryptococcal meningitis are reported. There were 6 males and 6 females with a mean age of 41 years. Most of them presented with symptoms and signs of meningitis initially without focal neurological signs. Computed tomography revealed single or multiple, well or poorly marginated hypodense lesions without perilesional edema, except 1 case which had marked edema, with or without ring enhancement. One case had small hyperdense, diffuse, enhanced nodules. New lesions or progression of the existing lesions occurred during medical therapy in some patients. The clinical manifestations of patients with intracranial mass lesions did not significantly differ from patients without mass lesions, but the mortality was higher (50% vs 29%).

Adult↗
PubMed1996

Fluconazole and amphotericin B for cryptococcal meningitis.

OBJECTIVE: To describe a patient with cryptococcal meningitis treated with the combination of amphotericin B and fluconazole. CASE SUMMARY: A 41-year-old woman with cryptococcal meningitis who was not infected with HIV was treated with a combination of amphotericin B and fluconazole because she did not respond to amphotericin B alone and could not tolerate amphotericin B with flucytosine. She improved clinically, but it is unclear whether the combination was beneficial. DISCUSSION: Standard therapy for cryptococcal meningitis is amphotericin B with or without flucytosine. Fluconazole is an alternative therapy, but its efficacy has not been documented in the patient population not infected with HIV. Theoretically, the combination of amphotericin B and fluconazole is antagonistic, but in vitro and in vivo data suggest that antagonism may not occur. The combination of amphotericin B and fluconazole in cryptococcal meningitis has not been evaluated in clinical trials, and its use is not recommended. CONCLUSIONS: A patient with cryptococcal meningitis was treated with the combination of amphotericin B and fluconazole because of a poor response to amphotericin B monotherapy and intolerance to flucytosine. It is unclear whether her clinical response was a result of the combination.

Adult↗
PubMed1983

Cryptococcal meningitis in pregnancy.

Cryptococcal meningitis was diagnosed in a pregnant woman at 21 weeks' gestation. The availability of fetal tissues, blood, and amniotic fluid in such a patient receiving therapy with amphotericin B plus flucytosine afforded the opportunity to study the effects of the disease and therapeutic agents on the developing fetus. The amphotericin B concentration in amniotic fluid was 0.25 micrograms/ml and that of flucytosine was 168 micrograms/ml. The concentrations in cord blood were 0.3 micrograms/ml and 64.7 micrograms/ml, respectively. No evidence was found of amphotericin B or flucytosine toxicity in fetal tissues, although exposure of the fetus to these compounds was of brief duration.

Adult↗
PubMedDate not supplied

Cryptococcal meningitis: implications for the otologist.

Cryptococcal meningitis can present to the otologist with hearing loss and vestibular dysfunction. A man with cryptococcal meningitis presenting with bilateral profound sensorineural hearing loss and vestibular dysfunction is described. The difficulty in arriving at the diagnosis and consequences of misdiagnosis are discussed. Histological and clinical studies suggest that the cochlear nerve is likely to be damaged in patients who have deafness associated with this disease. Retrocochlear damage may result in cochlear implantation having a poor outcome.

Acute Disease↗
PubMed1994

[Cryptococcal meningitis in patients without predisposing immunodeficiency].

Cryptococcal meningitis is a chronic or subacute meningeal infection that may have pulmonary or systemic manifestations and is caused by the yeast Cryptococcus neoformans. It has become an increasingly important pathogen in immunocompromised hosts, whereas cryptococcal meningitis is relatively rare in immunocompetent patients. The diagnosis is often delayed because of the sparse and nonspecific symptoms. We present two cases of cryptococcal meningitis in two patients without known predisposing factors. The symptomatology, diagnosis and treatment of the disease are discussed. The two cases illustrate that Cryptococcus neoformans should be considered in patients with cerebral symptoms and fever. The disease is potentially curable and early diagnosis with specific treatment are important prognostic factors.

Aged↗
PubMed2002

Cryptococcal meningitis: an analysis among 5,521 consecutive organ transplant recipients.

Cryptococcal meningitis has been reported to be an important cause of morbidity and mortality in renal transplant recipients. However, additional studies of recipients of other organ transplants suggested that these patients might be at low risk for cryptococcal meningitis. We examined the incidence and clinical features of cryptococcal meningitis among different groups of organ transplant patients at the University of Pittsburgh Medical Center. From January 1989 through July 1999, 28 patients were diagnosed with cryptococcal meningitis among 5,521 transplant recipients. These included liver (11/2,539), heart (8/372), kidney (7/2,122), lung (1/432), and small bowel (1/56) recipients. The incidence of cryptococcal meningitis was higher in heart and small bowel recipients compared to other transplant populations (P = 0.005). The cryptococcal meningitis-related mortality in transplant recipients was 50% and was associated with altered mental status (P = 0.001), absence of headache (P = 0.02), and liver failure (P = 0.002). Multivariable analysis indicated that liver failure was the only independent risk factor for poor prognosis (P = 0.043). All cases of liver failure occurred among liver transplant recipients. Cryptococcal meningitis is associated with significant mortality among organ transplant recipients. The presence of allograft failure in liver transplant recipients with cryptococcal meningitis may be an indicator of poor prognosis in this patient population.

Cryptococcus neoformans↗