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Cryptococcosis
From WikEM
Contents
Background
- Can produce focal cerebral lesions or diffuse meningoencephalitis
Clinical Features
- Fever
- Headache
- Nausea
- altered mental status
- Focal neurologic deficits
- Meningismus is uncommon
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Temporal arteritis
- Idiopathic intracranial hypertension (aka Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
Others
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Varicella
- Herpes
- Enterovirus
- West Nile
- Tuberculosis
- Lyme disease
- Syphilis
- Drug induced aseptic meningitis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
- Sarcoidosis
- Vasculitis
- Connective tissues disease
Evaluation
- Neuroimaging usually normal
- CSF Studies
- Crypto antigen (100% Sn & Sp)
- Crypto culture (95%-100% Sn)
- India Ink (60-80% Sn)
- Opening pressure
- Usually elevated; drain CSF until pressure is <20 or 50% of opening presure
- Serum
- Cryptococcal antigen testing (95% Sn)
Management
Pulmonary (not AIDs associated)
- Fluconazole 400mg PO IV q24hrs x 6-12 months
- Itraconazole 200mg PO q12hrs daily x 6-12 months
- Voriconazole 200mg PO q12hrs x 6-12 months
Pulmonary (with AIDS)
- Fluconazole 400mg PO q24hrs x 6-12 months
Meningitis (not AIDs associated)
- Amphotericin B 0.7-1mg/kg IV q24hrs + Flucytosine 25mg/kg PO q6hrs x 4 weeks
- Followed by Fluconazole 400mg PO q24hrs x 8 weeks
Meningitis (with AIDS)
- Amphotericine B 0.7=1mg/kg IV q24hrs + Flycytosine 25mg/kg PO q6hrs x 2 weeks
- Followed by Fluconazole 400mg PO q24hrs x 8 weeks
Disposition
- Admit to Medicine with ID consult
- Once the CD4 count > 200 and the patient is asymptomatic therapy x 6 months, therapy can be discontinued
- Some patients can require longer durations of therapy depending on symptom persistence
