Cryptococcus

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Cryptococcus / (Redirected from Cryptococcus neoformans)

Clinical Manifestations

Investigations

  • Cryptococcal antigen (CRAG) from CSF or serum
  • CT chest for pulmonary infection
    • Most commonly shows clustered nodular pattern
    • May also show solitary pulmonary nodule/mass with or without cavitation, scattered nodules, or peribronchovascular consolidation

Management

Patients with HIV

CNS Disease

  • Induction (first 2+ weeks): liposomal amphotericin B (3-4 mg/kg IV daily) plus flucytosine (100 mg/kg per day orally in 4 divided doses)
    • IV formulations may be used in severe cases and in those without oral intake where the preparation is available) for at least 2 weeks
  • Consolidation: fluconazole (400 mg [6 mg/kg] per day orally) for a minimum of 8 weeks
  • Maintenance:
    • Fluconazole (200 mg per day orally) or itraconazole (200 mg twice per day orally; drug-level monitoring strongly advised)
    • Start HAART 2–10 weeks after starting antifungals
    • Consider stopping antifungals once CD4 >= 100 for 3 months

Fungemia

  • First, rule out meningitis with an LP
  • If no meningitis, can treat with fluconazole 400 mg po daily until immune reconstitution

Organ Transplant Patients

  • Always consider decreasing immunosuppression if able to

CNS, Severe, or Disseminated Disease

  • Induction (first 2+ weeks): liposomal amphotericin B (3–4 mg/kg per day IV) plus flucytosine (100 mg/kg per day in 4 divided doses)
    • If not including flucytosine, then extend induction to 4-6 weeks
  • Consolidation: fluconazole (400–800 mg [6–12 mg/kg] per day orally) for 8 weeks, then by fluconazole (200–400 mg per day orally) for 6–12 months (B-II)

Mild-to-Moderate Non-CNS Disease

  • Includes mild-to-moderate pulmonary disease
  • Fluconazole (400 mg [6 mg/kg] per day) for 6–12 months

Patients Without HIV or Organ Transplant

  • Induction (first 4+ weeks): amphotericin B deoxycholate (0.7–1.0 mg/kg per day IV) plus flucytosine (100 mg/kg per day orally in 4 divided doses)
    • If neurological complications or positive CSF cultures after 2 weeks of treatment, consider extending to 6 weeks total
    • If not including flucytosine, then extend induction by 2 weeks
    • If there is amphotericin B deoxycholate toxicity, liposomal amphotericin B may be substituted in the second 2 weeks
  • Consolidation: fluconazole (400 mg per day) for 8 weeks
  • Maintenance: fluconazole (200 mg [3 mg/kg] per day orally) for 6–12 months

Pregnant Patients

Further Reading