Cryptococcus: Difference between revisions
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Cryptococcus
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+ | == Clinical Manifestations == |
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+ | * Infects CNS, lung, and bloodstream |
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+ | * Pulmonary infection more common with [[Cryptococcus gattii]] while CNS infection and fungemia were more common with [[Cryptococcus neoformans]] |
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+ | == Investigations == |
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+ | * Cryptococcal antigen (CRAG) from CSF or serum |
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+ | * CT chest for pulmonary infection |
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+ | ** Most commonly shows clustered nodular pattern |
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+ | ** May also show solitary pulmonary nodule/mass with or without cavitation, scattered nodules, or peribronchovascular consolidation |
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** IV formulations may be used in severe cases and in those without oral intake where the preparation is available) for at least 2 weeks |
** IV formulations may be used in severe cases and in those without oral intake where the preparation is available) for at least 2 weeks |
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− | * Consolidation: fluconazole (400 mg [6 mg/kg] per day orally) for a minimum of 8 weeks |
+ | * Consolidation: [[Is treated by::fluconazole]] (400 mg [6 mg/kg] per day orally) for a minimum of 8 weeks |
* Maintenance: |
* Maintenance: |
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− | ** Fluconazole (200 mg per day orally) or |
+ | ** [[Is treated by::Fluconazole]] (200 mg per day orally) or [[Is treated by::itraconazole]] (200 mg twice per day orally; drug-level monitoring strongly advised) |
** Start HAART 2–10 weeks after starting antifungals |
** Start HAART 2–10 weeks after starting antifungals |
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** Consider stopping antifungals once CD4 >= 100 for 3 months |
** Consider stopping antifungals once CD4 >= 100 for 3 months |
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==== Fungemia ==== |
==== Fungemia ==== |
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* First, rule out meningitis with an LP |
* First, rule out meningitis with an LP |
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* If no meningitis, can treat with fluconazole 400 mg po daily until immune reconstitution |
* If no meningitis, can treat with fluconazole 400 mg po daily until immune reconstitution |
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− | === Organ |
+ | === Organ Transplant Patients === |
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* Always consider decreasing immunosuppression if able to |
* Always consider decreasing immunosuppression if able to |
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− | ==== CNS, |
+ | ==== CNS, Severe, or Disseminated Disease ==== |
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* Includes mild-to-moderate pulmonary disease |
* Includes mild-to-moderate pulmonary disease |
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− | * Fluconazole (400 mg [6 mg/kg] per day) for 6–12 months |
+ | * [[Fluconazole]] (400 mg [6 mg/kg] per day) for 6–12 months |
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− | * Induction (first 4+ weeks): |
+ | * Induction (first 4+ weeks): [[Is treated by::amphotericin B deoxycholate]] (0.7–1.0 mg/kg per day IV) plus [[Is treated by::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 neurological complications or positive CSF cultures after 2 weeks of treatment, consider extending to 6 weeks total |
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** If not including flucytosine, then extend induction by 2 weeks |
** If not including flucytosine, then extend induction by 2 weeks |
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− | ** |
+ | ** If there is [[amphotericin B deoxycholate]] toxicity, [[Is treated by::liposomal amphotericin B]] may be substituted in the second 2 weeks |
− | * Consolidation: fluconazole (400 mg per day) for 8 weeks |
+ | * Consolidation: [[Is treated by::fluconazole]] (400 mg per day) for 8 weeks |
− | * Maintenance: fluconazole (200 mg [3 mg/kg] per day orally) for 6–12 months |
+ | * Maintenance: [[Is treated by::fluconazole]] (200 mg [3 mg/kg] per day orally) for 6–12 months |
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+ | === Pregnant Patients === |
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+ | * See review at [https://doi.org/10.1093/mmy/myz084] |
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+ | * In short, [[Is treated by::amphotericin B]] monotherapy is recommended, since [[fluconazole]] is teratogenic |
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== Further Reading == |
== Further Reading == |
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* [https://doi.org/10.1086/649858 IDSA Guidelines] 2010 |
* [https://doi.org/10.1086/649858 IDSA Guidelines] 2010 |
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+ | [[Category:Yeasts]] |
Latest revision as of 11:02, 30 March 2022
Clinical Manifestations
- Infects CNS, lung, and bloodstream
- Pulmonary infection more common with Cryptococcus gattii while CNS infection and fungemia were more common with Cryptococcus neoformans
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
- See review at [1]
- In short, amphotericin B monotherapy is recommended, since fluconazole is teratogenic
Further Reading
- IDSA Guidelines 2010