Cryptococcosis

Cryptococcus neoformans is an encapsulated yeast-like fungus with a worldwide distribution. It is a common cause of meningitis in AIDS patients with CD4 cell counts of less than 100 per microlitre.63,64 In many parts of Africa where HIV is very prevalent, it is now the commonest cause of meningitis. Patients present with an acute or insidious onset of nonspecific symptoms such as headache, nausea, irritability, confusion, and drowsiness. Signs too are often non-specific with low grade fever and minimal neck stiffness. Focal neurological abnormalities are rare but papilloedema may occur in up to one third of patients.

Diagnosis is made by examination of the CSF. The opening pressure is usually elevated, but microscopy may reveal minimal or no abnormalities or a lymphocytosis with raised protein and low glucose. An India ink stain of the CSF will detect cryptococci in 25-50% of patients with cryptococcal meningitis, whilst tests to detect the cryptococcal polysaccharide capsular antigen (CRAG) in cSf have a sensitivity of 90%. C. neoformans will grow in culture. The differential diagnosis of a lymphocytic CSF in the context of HIV infection is wide and includes tuberculous meningitis, other mycoses, viral meningoencephalitis, meningeal metastases, and syphilis.

Treatment of cryptococcal meningitis should probably be with amphotericin B in the initial phase, possibly combined with flucytosine.65 Some advocate the use of fluconazole in the absence of poor prognostic factors (positive blood culture, CRAG > 128, positive India ink stain of CSF, or an impaired mental status). The continuation phase of treatment should be with fluconazole 400 mg per day for 8 weeks and then maintenance therapy with fluconazole 200 mg per day for life or until there is improvement of CD4 cell count to 100-200 cells/mm3 with HAART.57 Even with aggressive management the prognosis associated with cryptococcal meningitis is poor with 25-30% mortality and a relapse rate of 20-25% after initial cure.

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