Cryptococcal meningitis is a fungal infection of the brain lining caused by Cryptococcus neoformans, seen mostly in advanced HIV with a CD4 count under 100. It builds over weeks, and very high pressure in the spinal fluid is a major cause of blindness and death.
Key symptoms
- Headache that worsens over days to weeks
- Fever and malaise
- Nausea and vomiting
- Confusion, personality change or drowsiness
- Blurred or double vision
What you find on exam
- Neck stiffness is often mild or absent
- Papilledema on fundoscopy
- Cranial nerve palsy, often sixth nerve
- Altered level of consciousness
- Look for umbilicated skin papules and signs of advanced HIV
Tests
- Serum cryptococcal antigen
- Lumbar puncture with opening pressure, CSF cryptococcal antigen, India ink and culture
- HIV test, CD4 count and viral load
- Brain CT or MRI before lumbar puncture if focal signs or reduced consciousness
Treatment basics
- Induction: liposomal amphotericin B plus flucytosine for at least 2 weeks
- Then fluconazole consolidation and long-term maintenance
- Repeat lumbar punctures to lower opening pressure of 25 cm H2O or more
- Start HIV therapy 4 to 6 weeks after antifungals to lower the risk of IRIS
- Monitor kidney function, potassium and blood counts on amphotericin
Red flags
- Falling level of consciousness or seizures
- New vision loss
- Worsening headache with high opening pressure
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.