Cryptococcal meningitis

Cryptococcal meningitis is a common opportunistic infection in AIDS patients, particularly in Southeast Asia and Africa. Cases also occur in patients with other forms of immunosupression and in apparently immunocompetent individuals. Mortality from HIV-associated cryptococcal meningitis remains high (10-30%), even in developed countries, because of the inadequacy of current antifungal drugs and the complication of raised intracranial pressure. In cohorts of HIV-infected patients from sub-Saharan Africa, cryptococcosis has accounted for 13-44% of all deaths. Optimal current therapy is with amphotericin B 0.7-1 mg/kg/day plus flucytosine 100 mg/kg/day for 2 weeks, followed by fluconazole 400 mg/day for 8 weeks and 200 mg/day thereafter. Saline loading reduces amphotericin B nephrotoxicity. If there is no contraindication on CT head scan, repeat lumbar puncture with drainage of cerebrospinal fluid (CSF) is recommended for patients with very raised CSF opening pressure. Expansion of antiretroviral programmes raises the prospect of transforming the long-term prognosis of these patients, provided that they survive the acute phase of the illness. Studies are needed to define more fungicidal drug regimens and to improve the treatment of raised intracranial pressure.