Synopsis
Recognise pulmonary, meningeal and disseminated cryptococcosis, secure antigen, culture and opening-pressure data, deliver phased antifungal therapy safely, control intracranial pressure mechanically, and coordinate immune restoration.
- Cryptococcus neoformans commonly affects people with advanced HIV, transplantation, haematological disease or corticosteroid exposure; C. gattii can cause severe disease in apparently immunocompetent hosts.
- Meningitis is often subacute, with headache, fever, malaise, personality change, visual disturbance or confusion and surprisingly little meningism.
- First-line diagnosis uses serum and CSF cryptococcal antigen plus CSF microscopy and culture; measure opening pressure at every diagnostic lumbar puncture.
- Neuroimaging before lumbar puncture is reserved for standard contraindication features such as focal deficit, papilloedema, new seizure or markedly impaired consciousness; routine imaging must not create avoidable delay.
- High-income-setting first-line induction for CNS, disseminated or severe pulmonary disease is liposomal amphotericin B 3 to 4 mg/kg intravenously daily plus flucytosine 25 mg/kg orally four times daily for two weeks.
- After successful induction, consolidate with fluconazole 400 to 800 mg daily for eight weeks, then use fluconazole 200 mg daily as maintenance in HIV until sustained immune recovery.
- Treat raised intracranial pressure by repeated lumbar drainage to a closing pressure at or below 20 cm CSF or about half the opening value; mannitol, acetazolamide and routine corticosteroid are ineffective or harmful.
- In HIV-associated meningitis, defer antiretroviral therapy for approximately four to six weeks and involve the HIV team; treat other immune causes without abrupt unsafe withdrawal.
Key red flags
Reduced consciousness, seizure, focal neurology, papilloedema or rapidly worsening headache requires urgent CNS imaging, specialist review and intracranial-pressure management.
Opening pressure above 20 cm CSF with symptoms, or persistently raised pressure, requires repeated therapeutic lumbar puncture rather than antifungal therapy alone.
New visual loss, diplopia or cranial-nerve palsy can reflect pressure-related optic injury or cryptococcoma and needs urgent ophthalmic and neurological input.
Positive blood culture or serum cryptococcal antigen with systemic symptoms should trigger assessment for CNS and disseminated disease even without headache.
Starting antiretroviral therapy too early in cryptococcal meningitis increases dangerous immune-reconstitution inflammation; HIV and infection teams should coordinate timing.
Renal injury, hypokalaemia, hypomagnesaemia or cytopenia during induction can become life threatening and demands active replacement, drug-level and dose review.
Headache, fever, nausea, lethargy, cognitive change and visual symptoms evolve over days to weeks, often without neck stiffness or photophobia.
Investigation priorities
Rapidly detect capsular antigen in suspected disseminated, CNS or pulmonary cryptococcosis.
Management branches
A vulnerable patient has subacute headache, cognitive change, visual symptoms, seizure or positive serum antigen.
- Assess consciousness, focal neurology, papilloedema and seizure; obtain urgent imaging first only when these or another standard contraindication make immediate lumbar puncture unsafe.
- Perform lumbar puncture promptly, record opening pressure accurately and send sufficient CSF for antigen, cell count, chemistry, microscopy and fungal culture.
- Take serum antigen, blood fungal cultures, HIV testing and baseline renal, electrolyte, liver and blood-count measurements.
- Start induction immediately after specimens when possible; do not wait for fungal culture in a compatible antigen-positive illness.