Cryptococcal meningitis — Rapid

Synopsis

Recognise subacute cryptococcal CNS disease, confirm diagnosis with antigen and culture, measure and control intracranial pressure mechanically, deliver fungicidal induction safely, and time antiretroviral therapy to reduce fatal inflammatory deterioration.

Cryptococcal meningitis usually evolves over days to weeks with headache, fever, malaise, cognitive change or visual symptoms; neck stiffness may be minimal.
Advanced HIV is the common context, but transplant, corticosteroids, malignancy and apparently immunocompetent disease occur.
Test serum and CSF cryptococcal antigen and culture; measure lumbar opening pressure every time it is clinically relevant.
Start induction with liposomal amphotericin B 4 mg/kg intravenously daily plus flucytosine 25 mg/kg orally four times daily for 2 weeks under specialist guidance.
Use serial therapeutic lumbar punctures for symptomatic or measured pressure elevation, removing sufficient CSF to reduce pressure safely.
Step to fluconazole consolidation only after clinical assessment and evidence of viable-organism clearance; antigen titre alone does not prove sterility.
Delay ART usually 4 to 6 weeks after effective antifungal treatment begins, individualised by HIV and infection teams.
Continue fluconazole consolidation and maintenance until the specified duration, viral suppression and immune-recovery criteria are met.

Key red flags

Visual loss, cranial neuropathy or reduced consciousness requires urgent pressure measurement and repeated therapeutic lumbar puncture.

A normal brain scan does not exclude dangerous raised CSF pressure in cryptococcal meningitis.

Renal decline, hypokalaemia, hypomagnesaemia or cytopenia during induction can become fatal without daily monitoring and dose adjustment.

Starting ART immediately in cryptococcal meningitis increases dangerous CNS immune-reconstitution risk and requires planned delay.

Subacute meningitis

Progressive headache, fever, nausea, cognitive slowing and weight loss over days to weeks suggests cryptococcal or tuberculous meningitis.

Raised pressure

Visual blurring, diplopia, vomiting, papilloedema or sixth-nerve palsy indicates pressure-related optic and cranial-nerve threat.

Advanced HIV context

Oral thrush, wasting, previous opportunistic illness or unknown HIV status strengthens probability and prompts urgent HIV testing.

Pulmonary or disseminated disease

Cough, skin papules, bone pain or positive blood culture indicates disease beyond meninges and influences staging.

Investigation priorities

CSF opening pressure and analysisFirst step

Diagnose meningitis and quantify a treatable mechanical threat.

Management branches

ASSESSDiagnose and measure pressure

Subacute meningitis or a positive cryptococcal antigen raises CNS cryptococcosis.

Perform neurological and visual examination, HIV testing and urgent lumbar puncture with opening pressure when safe.
Send CSF antigen, fungal culture and standard studies and obtain serum antigen, blood cultures and organ baselines.
Remove CSF during the diagnostic puncture when pressure is symptomatic or substantially elevated and schedule repeat access.
Start liposomal amphotericin B plus flucytosine promptly without waiting for fungal culture growth.

Key medicines

Liposomal amphotericin B and flucytosineGive liposomal amphotericin B 4 mg/kg intravenously once daily plus flucytosine 25 mg/kg orally every 6 hours for 2 weeks under current specialist guidance.Use protocol weight, hydrate and monitor renal function, potassium, magnesium, FBC and flucytosine exposure; adjust both agents for organ dysfunction.

Fluconazole consolidationGive fluconazole 400 mg orally once daily for at least 8 weeks after successful induction under the current HIV or infection protocol.Review liver function, QT, pregnancy and interactions and do not step down merely because antigen remains positive or symptoms briefly improve.

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