Cryptococcal Menigitis Flashcards
Define cryptococcal meningitis and likely pathogen
Infection of the meninges of the brain caused by cryptococcus neoformans which is an encapsulated yeast that colonize airways
Severe in HIV pt, organ transplant, chemo, high dose and long term corticosteroid therapy
Which other areas can be affected
CNS -cryptococcal meningitis
Lungs-pulmonary cryptococcosis
Skin-cutaneous manifestations
Prostate
Aetiology CM
Pt with CD4 count <100cells/microL and AIDS as it is one of the AIDS defining illnesses spreads from lungs to rest of body
Pathophysiology CM
Inhalation of cryptococcus neoformans commonly found in soil contaminated with bird droppings. In Immunocompromised spreads from lungs to other areas , invades CNS and cover brain, spinal cord leading to meningitis. Immune response triggered then leads to formation of granulomas which can be found in meninges, brain parenchyma
Diagnosis CM
CSF and serum cryptococcal antigen tests
CT/MRI on patients suspected to have CM presenting with neurological deficits to rule out tumors
CSF analysis- increased protein level, increased intracranial pressure, increased lymphocytes, ratio of CSF glucose:serum glucose <60%
Differential diagnosis of meningitis in patients with HIV
Migraine headache
Neurosyphillis
Bacterial/meningococcal meningitis
Neurosyphilis
Clinical presentation
Headache, fever, malaise, stiff neck( nuchal rigidity) photophobia, papilledema
N/V
Altered mental status ie irritability, personality changes, confusion
Treatment of CM
A. Induction phase
B. Consolidation
C. Maintenance
What drugs do we give in induction phase
Amphotericin B deoxycholate 0.7-1.0 mg/kg IV daily with or without flucytosine 25 mg/kg PO q6h for at least 2 weeks
Alternative liposomal amphotericin B 3-4mg/kg IV daily with or without flucytosine
Compare convention amphotericin B with liposomal one
Conventional- made with deoxycholate admin IV ,other encased with lipids admin IV
Liposomal better tolerated ie s/e of infusion related rxns, hypotension less
Liposomal more expensive
Liposomal good for cases of renal toxicity or when rapid administration is needed
Conventional you need premedication with antihistamines, antipyretics, corticosteroids to prevent infusion related reactions
Consolidation and maintenance phase
2 weeks after successfully therapy
Fluconazole 400ng PO/IV w24 for 8 weeks
Followed by 200 mg daily maintenance for chronic maintenance
Alternative give itraconazole 200mg q12h for chronic then fluconazole 200mg for maintenance
When is therapy discontinued for CM
CD4>100cells/ mm3 and viral load suppressed for at least 3 months and pt on ART
Cytomegalovirus meningitis
Present in severe Immunocompromised
Consider combination foscarnet and ganciclovir maintenance with valganciclovir 900mg/day
Mechanism of amphotericin B
Medicine 1st choice , mister into cytoplasmic membrane lead to accumulation at sterol site and increase in permeability hence fungi static activity
Also release toxic free radicals
ADR of amphotericin B
Bone marrow suppression check FBC
Hypokalemia, hypomangesemia, hypotension, tachypnea, general malaise , pain at site of injection
Renal impaired