Cryptococcosis

[Lancet 2024, NEJM 2024, WHO 2022 Guidelines in HIV, Intern Med J 2021;51:118-42]

- All patients with cryptococcosis should have their immune function assessed, including:

• CBC with differential
• T lymphocyte subsets (CD4+/CD8+)
• HIV serology

- Echinocandins not active against Cryptococcus spp.

- Infectious Diseases consult recommended.

Diagnosis:

• History and examination
• Serum cryptococcal antigen
• Chest x-ray +/- chest CT
• CT or MRI brain (MRI more sensitive than CT.)
• Lumbar puncture with measurement of opening pressure and CSF analysis (biochemistry, cell counts, culture, CSF cryptococcal antigen)
• Histology and fungal culture(s) of sputum or other respiratory specimens and blood +/- urine and skin if clinically indicated.

Usual Pathogens

Cryptococcus neoformans

Cryptococcus gattii

Mild-moderate pulmonary infection without CNS involvement including asymptomatic patients with detectable serum cryptococcal antigen

Severe pulmonary or non-CNS infection

Central Nervous System (CNS) infection

- Control of intracranial pressure (ICP) is critical:

• Measure ICP at time of initial lumbar puncture (LP) and if pressure is >25cm and there are symptoms of increased ICP, CSF drainage is recommended to reduce ICP by 50% or to a normal ICP of ≤20cm.
• Repeat therapeutic lumbar drainage daily if persistent symptoms and ICP ≥25cm until stabilized for ≥2 days.