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Chapter 42 : Management of Cryptococcal Meningoencephalitis in Both Developed and Developing Countries
Category: Clinical Microbiology; Fungi and Fungal Pathogenesis
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This chapter discusses the current management of cryptococcal meningoencephalitis in terms of antifungal drug therapy, the management of complications, notably raised cerebrospinal fluid (CSF) pressure, the issues of the timing and choice of antiretroviral therapy (ART) in HIV-infected patients, and the management of symptomatic relapse, including immune reconstitution syndromes. The result is that if patients anywhere in the world with access to ART survive the initial critical months of cryptococcal meningoencephalitis, they have an excellent long-term prognosis. The chapter highlights opportunities for improved intervention, including for earlier diagnosis and treatment. The emphasis is on HIV-associated infection in resource-limited settings, which constitute the majority of the global burden of cryptococcal infection. Examination of outcomes of therapy for HIV-associated cryptococcal meningitis in resource-limited settings illustrates that a high proportion of patients with abnormal mental status at presentation is associated with high mortality irrespective of the antifungal treatment available. The chapter also summarizes some of the reasons underlying the high mortality of patients with cryptococcal meningitis, including the constraints on optimal management in developing-country settings.
Key Concept Ranking
Survival to 1 year for patients with HIV-associated cryptococcal meningitis in Cape Town, South Africa. Solid line: nonselected cohort, induction treatment with amphotericin B 1 mg/kg/day alone for 1 week. Dashed line: randomized trial, induction treatment with amphotericin B (0.7 or 1 mg/kg/day) plus flucytosine. Data from references 21 and 24 , respectively.
A model illustrating possible relationships between factors associated with rate of clearance of infection and survival. Proposed causal links are shown with solid arrows, noncausal associations with long-dashed arrows, and speculative associations with short-dashed arrows. TNF, tumor necrosis factor. From reference 22 with permission.
Outcomes of therapy for HIV-associated cryptococcal meningitis in developed-country settings
Outcomes of therapy for HIV-associated cryptococcal meningitis in resource-limited settings
Reasons for high mortality and strategies to reduce mortality in resource-limited settings.
Treatment recommendations for cryptococcal meningitis in immunocompromised patients
Studies determining the early fungicidal activity of antifungal regimens in treatment of HIV-associated cryptococcal meningitis
Data on activity of posaconazole and voriconazole in cryptococcal infection a