- Cryptococcosis is a fungal infection caused by two different yeast species, that usually manifests as meningitis or pneumonia.
- Cryptococcus neoformans meningitis is an AIDS defining illness
- Cryptococcus is distributed worldwide and exists in high concentrations in bird guano, particularly pigeons and chickens (infections do NOT usually involve direct contact with birds)
- Cryptococcus neoformans (two variants – grubei and neoformans; 4 serotypes A-D) -> AIDS and immunocompromised patients
- Cryptococcus gattii -> endemic to tropical and subtropical areas, travellers, increasing found in temperate areas
Clinical manifestations (vary with species and serotype)
- meningitis – headache of insidious onset, neck stiffness often absent, fever often late
- other sites involved in AIDS: lungs, bone marrow, skin (often resembles molluscum contagiosum), and genitourinary tract
- C. gattii predominantly causes pneumonia
- blood culture
- biopsy lesions
- CXR and/or CT chest (pneumonia)
- CT head (exclude mass lesion)
- CSF (LP must be perfromed even in the absence of neurological features)
— India ink stain (51% sensitive)
— MCS, high opening pressure, high protein, high WCC (low glucose if severe)
— Cryptococcal latex agglutination test for capsular polysaccharide antigen = 90% sensitive and specific (false positives if rheumatoid factor psotiive)
- immune reconstitution inflammatory syndrome (IRIS) with HAART in AIDS patients with Cryptococcal disease
- supportive care and monitoring
- two week induction phase, followed by an 8 week consolidation phase, and then a prolonged maintenance phase thereafter
- induction phase (2 weeks): amphotericin B (0.7 to 1 mg/kg/day) plus flucytosine (100 mg/kg/day)
- consolidation phase (8 weeks): fluconazole 400 mg daily for 8 weeks
- maintenance (at least 12 months): fluconazole (200 mg daily) is recommended once CSF sterilization has occurred
Other specific therapy
- opening pressures greater than 25 cm of CSF should be treated with serial (e.g., daily) lumbar punctures until the pressure normalizes to less than 20 cm of CSF
References and Links
- Chaturvedi V, Chaturvedi S. Cryptococcus gattii: a resurgent fungal pathogen. Trends Microbiol. 2011 Nov;19(11):564-71. doi: 10.1016/j.tim.2011.07.010. Epub 2011 Aug 29. Review. PubMed PMID: 21880492; PubMed Central PMCID: PMC3205261.
- Singh N, Dromer F, Perfect JR, Lortholary O. Cryptococcosis in solid organ transplant recipients: current state of the science. Clin Infect Dis. 2008 Nov 15;47(10):1321-7. doi: 10.1086/592690. Review. PubMed PMID: 18840080; PubMed Central PMCID: PMC2696098.
- Warkentien T, Crum-Cianflone NF. An update on Cryptococcus among HIV-infected patients. Int J STD AIDS. 2010 Oct;21(10):679-84. doi: 10.1258/ijsa.2010.010182. Review. PubMed PMID: 21139145; PubMed Central PMCID: PMC3134968.
- Wiesner DL, Boulware DR. Cryptococcus-Related Immune Reconstitution Inflammatory Syndrome(IRIS): Pathogenesis and Its Clinical Implications. Curr Fungal Infect Rep. 2011 Dec 1;5(4):252-261. PubMed PMID: 22389746; PubMed Central PMCID: PMC3289516.