Monday, May 27, 2019

Cryptococcal Meningitis

emDocs - May 27, 2019 - Authors: Kathryn Fisher and Tim Montrief
Edited by Alex Koyfman and Brit Long
..."Take Home Points:
  • Cryptococcal meningitis (CM) is the most common cause of fungal meningitis and the most common cause of extrapulmonary cryptococcosis worldwide with over 220,000 cases per year, and a mortality of ~30% worldwide.
  • CM occurs primarily in immunocompromised patients. Patients with HIV, cancer, iatrogenic immunosuppression, transplants, drug or alcohol abuse, chronic kidney disease, diabetes and other immunodeficiencies are at high risk.
  • The clinical course of CM is variable, although it typically presents as a subacute meningoencephalitis characterized by an initially indolent course of neurological symptoms including headache, altered mental status, lethargy, fever, meningismus, nausea and vomiting for days to weeks that progressively worsens.
  • CM may be the initial AIDS-defining illness in up to 84% of patients.
  • Emergency providers must have a high index of suspicion for CM in the immunocompromised patient. This is especially true for patients with repeated visits for increasing and atypical neurological symptoms including headache.
  • Initial CSF studies (including India ink stain) may be normal in up to 17% of patients, especially in HIV-positive populations. CSF culture is the current gold-standard for ruling in or out CM, but commonly takes up to 10 days to result.
  • Patients should be treated empirically for bacterial, fungal, and viral meningitis.
  • Initial antifungal regimen for CM includes amphotericin B + flucytosine for 2 weeks"