Source: Carver PL. Invasive
Fungal Infections. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=8005562.
Accessed June 24, 2012.
- Systemic fungal infection
- Caused by ubiquitous encapsulated soil yeast Cryptococcus neoformans.
- Acquired by inhalation.
- Stimulates minimal inflammatory response in tissue.
- Polysaccharide capsule appears to allow resistance to host
- Four serotypes of C. neoformans
- Cell-mediated immunity plays major role in host defense.
- 29–55% of patients with cryptococcal
meningitis have predisposing condition.
- C. neoformans found in soil,
particularly in pigeon droppings
- Incidence has risen; increased numbers of immunocompromised
- No geographic area of endemic focus
- Immunocompromised patients
- Chronic renal failure
- Organ transplantation
- Receiving immunosuppressive agents
- Disease may remain localized in lungs or disseminate to
other tissues, particularly CNS, although skin can also be affected.
- Primary cryptococcosis almost always occurs in lungs
- Usually subclinical infection
- Symptomatic infections resolve spontaneously
- Shortness of breath
- Cryptococcal meningitis
- Asymptomatic in 10–12% of
- Non-AIDS patient
- Mental status changes
- Neck stiffness
- AIDS patient
Means of Confirmation
- Examination of cerebrospinal fluid (CSF)
agglutination to detect antigens to C. neoformans
- India ink smear of CSF detects ~60% of C. neoformans.
- C. neoformans can be cultured
in 96% of patients.
- Serologic testing: Latex agglutination
- India ink smear of CSF
- Serum cryptococcal antigen
- MRI more sensitive than CT to detect CNS abnormalities
- Lumbar puncture
- Elevated opening pressure
- CSF pleocytosis (usually lymphocytes)
- Decreased CSF glucose
- Elevated CSF protein
- Positive cryptococcal antigen
- Tuberculous meningitis
- Other fungal infection
- Lyme meningitis
- Resolution of signs and symptoms of infection
- Cure infection
- Nonimmunocompromised patients
observation an option with asymptomatic, isolated pulmonary disease
and no evidence of CNS disease.
- Management of symptomatic infection in Table 1.
of amphotericin B with flucytosine for 6 weeks
- Alternative regimen: amphotericin B for 2 weeks, followed
by fluconazole for additional 8–10 weeks
- Optional: suppressive therapy with fluconazole for 6–12
months after completion of induction and consolidation therapy
- Immunocompromised patients
- Amphotericin B
with flucytosine initial treatment of choice
- After 2 weeks, consolidation therapy with either itraconazole
orally or fluconazole orally administered for 8 weeks or until CSF
cultures are negative.
- Relapse of C. neoformans meningitis
occurs in ~50% of AIDS patients after completion of primary
- Lifelong therapy with fluconazole is recommended.
Table 1. Therapy of Cryptococcocosisa