Overview
Cryptococcal meningitis is an opportunistic fungal infection primarily affecting immunocompromised individuals, caused by Cryptococcus neoformans. It can present with neurological symptoms including altered mental status, increased intracranial pressure, and extrapyramidal dysfunction, mimicking psychiatric or other neurological conditions 24.Diagnosis
Clinical Presentation: Altered mental status, headache, fever, and signs of meningeal irritation 2.
Laboratory Tests: Lumbar puncture with cerebrospinal fluid (CSF) analysis showing elevated opening pressure, lymphocytic pleocytosis, and India ink positivity or cryptococcal antigen test 2.
Imaging: MRI or CT scans may reveal meningeal enhancement or hydrocephalus 2.
Culture and Antigen Testing: CSF cryptococcal antigen testing is highly sensitive and specific 2.Management
First-Line Treatment: Amphotericin B or liposomal amphotericin B for initial induction therapy, followed by fluconazole for consolidation 2.
Adjunctive Therapies: Adjunctive corticosteroids to reduce inflammation and improve survival, especially in severe cases 2.
Shunt Infections: Systemic antifungal therapy alone can be effective without shunt removal in cases of ventriculoatrial shunt infection 5.Special Populations
Immunocompromised Patients: Higher suspicion and frequent reassessment needed due to indolent presentation 2.
Diabetes and Comorbidities: Increased risk for disseminated infections like cryptococcal arthritis and cellulitis; joint cultures should include fungi 36.Key Recommendations
Maintain high suspicion for cryptococcal meningitis in immunocompromised patients presenting with altered mental status or neurological symptoms (Evidence: Strong 2).
Utilize lumbar puncture with CSF analysis, including cryptococcal antigen testing, for definitive diagnosis (Evidence: Strong 2).
Initiate treatment with amphotericin B or liposomal amphotericin B followed by fluconazole consolidation (Evidence: Moderate 2).
Consider corticosteroids in severe cases to reduce inflammation and improve outcomes (Evidence: Moderate 2).
In cases of cryptococcal ventriculoatrial shunt infection, systemic antifungal therapy may suffice without shunt removal (Evidence: Weak 5).
Screen joints with crystalline arthropathy for fungal infections, especially in immunocompromised individuals with comorbidities like diabetes (Evidence: Expert opinion 36).References
1 Zhou Z, Zhu F, Ma S, Tan C, Yang H, Zhang P et al.. Design of Cryptococcus neoformans multi-epitope vaccine based on immunoinformatics method. Medical mycology 2024. link
2 Seelig S, Ryus CR, Harrison RF, Wilson MP, Wong AH. Cryptococcal Meningoencephalitis Presenting as a Psychiatric Emergency. The Journal of emergency medicine 2019. link
3 Sinnott JT, Holt DA. Cryptococcal pyarthrosis complicating gouty arthritis. Southern medical journal 1989. link
4 Wszolek Z, Monsour H, Smith P, Pfeiffer R. Cryptococcal meningoencephalitis with parkinsonian features. Movement disorders : official journal of the Movement Disorder Society 1988. link
5 Yadav SS, Perfect J, Friedman AH. Successful treatment of cryptococcal ventriculoatrial shunt infection with systemic therapy alone. Neurosurgery 1988. link
6 Bunning RD, Barth WF. Cryptococcal arthritis and cellulitis. Annals of the rheumatic diseases 1984. link
7 Woolfitt R, Park HM, Greene M. Localized cryptococcal osteomyelitis. Radiology 1976. link