Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Cryptococcal meningoencephalitis
Subacute headache, confusion, visual symptoms, cranial-nerve signs or seizure in advanced HIV, transplantation or corticosteroid exposure may reflect meningitis with dangerous intracranial hypertension.
Action: Perform urgent neurological assessment, neuroimage first only when clinically indicated, obtain lumbar-puncture opening pressure and CSF studies promptly, start liposomal amphotericin B plus flucytosine, and relieve raised pressure with therapeutic lumbar drainage.
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.
Key red flags
Reduced consciousness, seizure, focal neurology, papilloedema or rapidly worsening headache requires urgent CNS imaging, specialist review and intracranial-pressure management.
Subacute meningitis
Headache, fever, nausea, lethargy, cognitive change and visual symptoms evolve over days to weeks, often without neck stiffness or photophobia.
Investigation priorities
01
First-line serum cryptococcal antigenFirst stepFirst line
Rapidly detect capsular antigen in suspected disseminated, CNS or pulmonary cryptococcosis.
Management branches
DIAGNOSE NOWInvestigate suspected CNS disease
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.
Key medicines
Liposomal amphotericin BGive 3 to 4 mg/kg intravenously every 24 hours with flucytosine for at least 14 days in CNS, disseminated or severe pulmonary disease.
FlucytosineGive 25 mg/kg orally every six hours, equivalent to 100 mg/kg/day, with renal adjustment and therapeutic drug monitoring.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.