Treatment of Cryptococcus neoformans meningoencephalitis and disseminated infection in HIV seronegative patients
- Gary M Cox, MD
Gary M Cox, MD
- Professor of Medicine
- Duke University Medical Center
- John R Perfect, MD
John R Perfect, MD
- Professor of Medicine
- Duke University Medical Center
- Section Editors
- Carol A Kauffman, MD
Carol A Kauffman, MD
- Section Editor — Fungal Infections
- Professor of Internal Medicine
- University of Michigan Medical School
- Veterans Affairs Ann Arbor Healthcare System
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
Treatment of cryptococcal meningoencephalitis consists of antifungal therapy, managing intracranial pressure, and reducing immunosuppressive therapy. The choice of the antifungal regimen varies depending on the nature of the host and extent of disease.
Patients with severe pulmonary disease (eg, diffuse pulmonary infiltrates) or disseminated disease (eg, at least two noncontiguous sites or cryptococcal antigen titer ≥1:512) should be managed as for central nervous system disease, even in the setting of normal findings on cerebrospinal fluid examination.
Issues related to treatment of Cryptococcus neoformans meningoencephalitis in HIV seronegative patients will be reviewed here. In general, our recommendations are in accordance with the 2010 Infectious Diseases Society of America practice guidelines for the management of cryptococcal disease . The management of C. neoformans meningoencephalitis in HIV-infected patients, C. neoformans infection outside the central nervous system, and C. gattii infection are discussed separately. (See "Treatment of Cryptococcus neoformans meningoencephalitis in HIV-infected patients" and "Clinical management and monitoring during antifungal therapy of the HIV-infected patient with cryptococcal meningoencephalitis" and "Cryptococcus neoformans infection outside the central nervous system" and "Cryptococcus gattii infection: Treatment".)
Treatment of C. neoformans meningoencephalitis consists of antifungal therapy including induction, consolidation, and maintenance phases [1,2]. The choice of the antifungal regimen varies depending on the nature of the host and extent of disease. Antifungal regimens for organ transplant recipients and non-HIV infected, nontransplant hosts are discussed below. These strategies are largely extrapolated from studies of patients with HIV infection.
Prevention and management of the toxicities associated with amphotericin B and flucytosine are discussed in detail separately. (See "Pharmacology of amphotericin B" and "Amphotericin B nephrotoxicity" and "Pharmacology of flucytosine (5-FC)".)
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- ANTIFUNGAL THERAPY
- Organ transplant recipients
- - Induction therapy
- Repeat lumbar puncture
- - Consolidation and maintenance therapy
- Non-HIV infected, nontransplant hosts
- - Induction therapy
- - Consolidation and maintenance therapy
- Limited drug tolerance or availability
- Persistent or relapsed infection
- Pregnant women
- INTRACRANIAL PRESSURE
- MODULATING IMMUNOSUPPRESSION
- Immune reconstitution inflammatory syndrome
- SUMMARY AND RECOMMENDATIONS