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PubMed1992

Cryptococcal meningitis in systemic lupus erythematosus.

Two cases of cryptococcal meningitis occurring in patients with systemic lupus erythematosus (SLE) are presented, and 24 additional cases from the literature are reviewed. The insidious onset of this infrequent complication is emphasized. The nonspecific neurological findings associated with this infection are often mistakenly diagnosed as a central nervous system manifestation of SLE. Earlier diagnosis and effective antifungal therapy have improved the prognosis of cryptococcal meningitis in SLE patients in recent years. Strategies for the treatment of patients with this complication are discussed.

Adult↗

PubMed1993

[Clinical experience with fluconazole monotherapy in cryptococcal meningitis: report of four cases].

Four patients with cryptococcal meningitis have been treated with fluconazole in the past two years at the Department of Neurology, National Cheng Kung University Medical Center. There were three women and one man. Two patients had a history of anemia and one had undergone a splenectomy due to hypersplenism. Two patients were healthy before the onset of meningitis. After receiving fluconazole 300 mg per day for 8 to 13 weeks, three patients were cured without clinical evidence of recurrence during follow-up lasting from 2 to 17 months. One patient died from pneumothorax as a complication of subclavian vein cannulation. During the treatment course, there was no side effect except for one patient who had transient elevation of the GOT and GPT values which reversed spontaneously without a change in dosage. In the three successfully treated cases, the cryptococcal antigen titers began to decrease after the first week of treatment. Our preliminary experience shows that fluconazole alone is an effective and safe drug for the treatment of cryptococcal meningitis.

Adult↗

PubMed1998

Microscopy and latex antigen negative cryptococcal meningitis.

A HIV-positive patient presented with cryptococcal meningitis that was not detected by cerebrospinal fluid (CSF) latex antigen and direct microscopy. The diagnosis was confirmed by culture of the CSF and subsequent urine culture, both of which yielded an apparently acapsular strain of Cryptococcus neoformans. After 19 months the patient relapsed and capsulated yeasts were observed on this occasion on direct microscopy of the CSF. The latex antigen test was strongly positive. Culture again yielded an apparently acapsular isolate. Retrospective culture of all isolates obtained from this patient in sterile CSF resulted in the formation of capsules. This was confirmed by the requirement of normal non heat inactivated serum for neutrophil-cryptococcus attachment to occur in vitro. Although antigen and direct microscopy are frequently relied upon to diagnose cryptococcal meningitis, a negative result does not exclude the condition.

AIDS-Related Opportunistic Infections↗

PubMedDate not supplied

Unusual pattern of enhancement in cryptococcal meningitis: in vivo findings with postmortem correlation.

Leptomeningeal enhancement on CT and MR imaging studies secondary to cryptococcal meningitis is an uncommon finding. In immunocompromised patients, this meningitis incites only a mild inflammatory reaction and abnormalities are often absent on imaging studies. We recently encountered two patients with cryptococcal meningitis in whom postcontrast MR imaging showed thick enhancing subarachnoid spaces. Both had cryptococcal meningitis at autopsy. In a different patient with cryptococcal meningitis, postmortem MR imaging and pathologic examinations showed that these areas of enhancement correspond to abundant mucoid material secreted by the yeasts.

AIDS-Related Opportunistic Infections↗

PubMed2001

[A case of SLE presenting the features of antiphospholipid antibody syndrome during a treatment for complicated cryptococcal meningitis].

A 39-year-old woman had developed systemic lupus erythematosus(SLE) at the age of 29. She had a long history of immunosuppressant therapies such as corticosteroid. On admission, she presented a headache due to the cryptococcal meningitis which was confirmed by lumbar puncture. Combined medications of amphotericin B and fluconazole were not effective, and combined amphotericin B and flucytosine were replaced. Prednisolone and methotrexate had been tapered gradually. Fifty days after the initial treatment for meningitis Cryptococcal neoformans was not observed in the cerebrospinal fluid. Sixty days after the treatment, thrombocytopenia was observed with positive lupus anticoagulant and anticardiolipin antibody. Following which, thrombophlebitis occurred in the left brachium. We suggest that the provoked pathoimmunological reaction such as antiphospholipid antibody syndrome during the treatment for meningitis needs to be cared during the course of SLE.

Adult↗

PubMed2002

Cryptococcal meningitis and sarcoidosis.

This report describes a patient with cryptococcal meningitis and newly diagnosed sarcoidosis not taking corticosteroids. Sarcoidosis is an independent risk factor for cryptococcal infection; most patients with sarcoidosis who develop cryptococcal infection are not on immunosuppressive drugs. Cryptococcal meningitis in sarcoid patients often presents clinically with non-specific features, and should be excluded in patients with sarcoidosis and neurological disturbances.

Adult↗

PubMed2004

Combination antifungal therapies for HIV-associated cryptococcal meningitis: a randomised trial.

BACKGROUND: It frequently takes more than 2 weeks for drug treatments for cryptococcal meningitis to sterilise cerebrospinal fluid (CSF). In-vitro and animal studies lend support to the use of combinations of amphotericin B, flucytosine, and fluconazole for treatment of cryptococcosis. We compared the fungicidal activity of combinations of these drugs for initial treatment of patients with cryptococcal meningitis. METHODS: 64 patients with a first episode of HIV-associated cryptococcal meningitis were randomised to initial treatment with: amphotericin B (0.7 mg/kg daily); amphotericin B plus flucytosine (100 mg/kg daily); amphotericin B plus fluconazole (400 mg daily); or triple therapy with amphotericin B, flucytosine, and fluconazole. Our primary endpoint was fungicidal activity, measured by the rate of reduction in CSF cryptococcal colony-forming units (CFU) from serial quantitative CSF cultures on days 3, 7, and 14 of treatment. FINDINGS: Baseline CSF CFU counts were an important prognostic factor. Clearance of cryptococci from the CSF was exponential and was significantly faster with amphotericin B plus flucytosine than with amphotericin B alone (p=0.0006), amphotericin B plus fluconazole ( p=0.02), or triple therapy (p=0.02). INTERPRETATION: At these doses, amphotericin B plus flucytosine is the most rapidly fungicidal regimen. Quantification of CSF cultures provides a powerful new means to accurately assess the fungicidal activity of new treatment regimens for cryptococcal meningitis.

AIDS-Related Opportunistic Infections↗

PubMed1992

[Factors affecting prognosis of cryptococcal meningitis].

By analyzing 26 cases of clinic data in cryptococcal meningitis. The author found that the poor prognosis in cryptococcal meningitis depends on following factors: 1. younger age of patients, 2. abrupt onset, 3. course prolonged over 6 weeks, 4. complicated extracerebral cryptococcal infections and many underlying disease, 5. used corticosteroids and antibiotics longtime, 6. higher CSF pressure and lower CSF cells count most of which is neutrophilic leukocyte.

Adolescent↗

PubMed1993

Manic episode secondary to cryptococcal meningitis in a previously healthy adult.

A case of a manic episode secondary to cryptococcal meningitis is reported. Cryptococcal meningitis is the most common cause of chronic meningitis in adults in Papua New Guinea and may rarely present with features of functional psychosis. Laboratory investigations on the cerebrospinal fluid such as the India ink smear and fungal culture for the detection of the organism and the latex agglutination test to detect the cryptococcal antigen are invaluable aids for making the correct diagnosis.

Adult↗

PubMed2005

The prognosis of hearing impairment complicating HIV-negative cryptococcal meningitis.

Eight patients who had sensorineural hearing loss (SNHL) associated with cryptococcal meningitis were studied. After a minimum 3-year follow-up, one had died. Among the seven survivors, three had improved, two stabilized, and two progressed. Predictive factors included visual disturbance, meningeal enhancements on MRI, and a CSF cryptococcal antigen titer of >1:1,024. SNHL accounted for 30.8% (8/26) of cryptococcal meningitis patients in our study.

Adult↗

PubMed1999

Retracted: Rapid diagnosis of cryptococcal meningitis by microscopic examination of centrifuged cerebrospinal fluid sediment.

The classic India ink test is positive in only half of cryptococcal meningitis cases, and reliable, rapid cryptococcal antigen (CRAG) testing requires technical expertise and facilities not always available. We therefore examined cerebrospinal fluid (CSF) sediment using May-Giemsa, periodic acid-Schiff, and Gram stains in 16 patients with cryptococcal meningitis. The India ink test was positive in seven patients (44%), while microscopic examination of sediment revealed cryptococci in 13 (81%); in six of these 13 the India ink test was negative. Both methods failed to detect the pathogen in the remaining three patients. CRAG testing in CSF was negative in two patients (one with acquired immunodeficiency syndrome, one with diabetes mellitus) whose India ink test also was negative while cryptococci were identified in their CSF sediment. No false positives occurred with CSF May-Giemsa staining in 27 cases of aseptic meningitis with negative cultures for Cryptococcus. In all, microscopic examination of centrifuged and stained CSF sediment proved more sensitive for rapid diagnosis of cryptococcal meningitis than the India ink method, and in two of our patients cryptococci were seen in centrifuged CSF sediment despite negative CRAG and India ink tests.

Adolescent↗

PubMed1994

Fluconazole combined with flucytosine for treatment of cryptococcal meningitis in patients with AIDS.

Treatment of cryptococcal meningitis with amphotericin B or fluconazole is often unsuccessful; in only 35%-40% of cases do CSF cultures become negative by 10 weeks after initiation of such therapy. We conducted a prospective, open-label clinical trial involving persons with AIDS to determine whether the rate of clinical success would improve when fluconazole (400 mg daily) was combined with flucytosine (150 mg/kg daily). At the conclusion of 10 weeks of therapy, 75% (95% confidence interval, 58%-87%) of 32 subjects' CSF cultures were negative. The Kaplan-Meier estimate of clinical success at 10 weeks was 63% (95% confidence interval, 48%-82%). The median time to negativity of the CSF culture was 23 days. Toxic side effects that were sufficiently severe to lead to the withdrawal of flucytosine were observed in nine subjects (28%). In this pilot study of fluconazole combined with flucytosine, the rate of clinical success at 10 weeks was greater than that previously reported with regard to the use of fluconazole alone or amphotericin B alone.

AIDS-Related Opportunistic Infections↗

PubMed1995

Cryptococcal meningitis--a case report.

Two cases of Cryptococcal meningitis were encountered in the recent past. History of predisposing factors was available in both the patients. The diagnosis of these patients was made on the basis of smear, culture and animal pathogenicity tests.

Adult↗

PubMed2001

Clinical presentation, natural history, and cumulative death rates of 230 adults with primary cryptococcal meningitis in Zambian AIDS patients treated under local conditions.

SETTING: Inpatient medical wards, Department of Medicine, University Teaching Hospital, Lusaka, Zambia. OBJECTIVE: To define the natural history, clinical presentation, and management outcome of microbiologically confirmed cryptococcal meningitis in adult AIDS patients treated under local conditions where antifungal and antiretroviral therapies are not routinely available. DESIGN: A descriptive, longitudinal, observational study. METHODS: All adult patients admitted to the medical wards of the University Teaching Hospital, Lusaka, Zambia with cerebrospinal fluid culture proved, primary cryptococcal meningitis, during a 12 month period were enrolled into the study. The following details were acquired: clinical features, HIV status, laboratory data, treatment accorded, and survival. RESULTS: A total of 230 patients with primary cryptococcal meningitis were studied (median age 32 years; range 15-65 years; 112 males, 118 females). Cryptococcal meningitis was the first AIDS defining illness in 210 (91%) patients. One hundred and thirty of the 230 (56%) patients had received treatment with fluconazole monotherapy and 100 (43%) patients received palliative care only without any antifungal therapy. A 100% case fatality rate was observed in both groups at follow up: by seven weeks in the untreated group and at six months in the fluconazole treated group. The cumulative median survival from time of diagnosis was 19 days (range 1-164 days) for the fluconazole treated group and 10 days (range 0-42 days) for the untreated group. CONCLUSION: Cryptococcal meningitis, under current treatment accorded at the University Teaching Hospital, Lusaka, has a 100% mortality in young Zambian adults with AIDS. The current treatment accorded to Zambian adults with cryptococcal meningitis is inappropriate. An urgent need exists to improve strategies for the clinical management of AIDS patients in poor African countries. The wider ethical and operational issues of making available antifungals to African AIDS patients are discussed.

AIDS-Related Opportunistic Infections↗

PubMed1987

[Quasi-normal cerebrospinal fluid in patients with acquired immunodeficiency syndrome and cryptococcal meningitis].

We report eight patients with cryptococcal meningitis and a cerebrospinal fluid characterized by few or no white blood cells and chemistries that may be near normal. In four of these patients, only testing for cryptococcal antigen allowed the initial diagnosis. Seven of the patients had a certain diagnosis of AIDS. Six have died. Autopsies performed in two cases indicated a poor meningeal inflammatory response. Contrary to the findings in most immunodeficient patients, in AIDS cryptococcal meningitis may present with few cellular or biochemical abnormalities in the cerebrospinal fluid. In AIDS patients presenting with headache and fever or change in mental status, examination of the cerebrospinal fluid should not be limited to routine studies.

Acquired Immunodeficiency Syndrome↗

PubMed1987

Cryptococcal meningitis: initial presentation of acquired immunodeficiency syndrome.

Cryptococcal meningitis is an infrequent primary presentation of acquired immunodeficiency syndrome (AIDS). We report the case of a 33-year-old man with previously undiagnosed AIDS who presented with gait disturbance, acute blindness, and rapidly fatal neurologic deterioration. Cryptococcal meningitis was diagnosed by India ink smear and AIDS was diagnosed by Western Blot testing.

Acquired Immunodeficiency Syndrome↗

PubMed1992

Cryptococcal meningitis associated with acquired immunodeficiency syndrome (AIDS) in African patients: treatment with fluconazole.

Cryptococcal meningitis associated with acquired immunodeficiency syndrome (AIDS) is particularly common in tropical Africa. This could be explained by the dramatic increase in the number of human immunodeficiency virus (HIV) infections and the high prevalence of Cryptococcus neoformans var. neoformans in the domestic and general environment of HIV-positive and AIDS patients Meningoencephalitis is the usual and dominant clinical feature of cryptococcal infection in AIDS patients and 'slim disease', tuberculosis and candidiasis are the most common opportunistic infections associated with cryptococcal meningitis. In a group of 64 African patients with AIDS and cryptococcosis treatment with a daily dose of 400 mg fluconazole (FCA) during the acute phase showed a clinical cure in 63% of the evaluable patients. Mycological response to treatment with negative culture was found in 76% of our patients (at day 60-90). The overall tolerance of FCA was excellent. This treatment was also used successfully for relapse of cryptococcal meningitis.

Acquired Immunodeficiency Syndrome↗

PubMed1994

Elevation of intracranial pressure in acute AIDS-related cryptococcal meningitis.

Prior to the AIDS-era, elevation of intracranial pressure was known to be a typical complication of cryptococcal meningitis associated with an increased risk of early death. In AIDS-patients, however, the prevalence and clinical significance of this complication are as yet unclear. We analysed clinical features and courses, CSF findings, serological results and neuroimaging scans in acute cryptococcal meningitis in eight patients with AIDS. Five showed symptoms and signs compatible with raised intracranial pressure, which was life-threatening in one and the most probable cause of death in another. Serial monitoring of intracranial pressure together with repeated CSF analysis revealed that severe intracranial pressure elevation in AIDS related cryptococcal meningitis can occur in spite of effective antimycotic treatment, does not depend on an increased CSF/serum osmolality ratio or CSF overproduction and can be associated with normal cranial computed tomography and magnetic resonance imaging findings. Our data support the hypothesis that CSF reabsorption failure plays the crucial role in the pathophysiological mechanism. External lumbar drainage may be of benefit in selected cases of acute AIDS related cryptococcal meningitis with persisting life threatening elevation in intracranial pressure and normal computed tomogram.

AIDS-Related Opportunistic Infections↗