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.
Key red flags
Visual loss, cranial neuropathy or reduced consciousness requires urgent pressure measurement and repeated therapeutic lumbar puncture.
Progressive headache, fever, nausea, cognitive slowing and weight loss over days to weeks suggests cryptococcal or tuberculous meningitis.
Investigation priorities
Diagnose meningitis and quantify a treatable mechanical threat.
Management branches
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.
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.
Fluconazole consolidationGive fluconazole 400 mg orally once daily for at least 8 weeks after successful induction under the current HIV or infection protocol.