Cryptococcal Meningitis

Clinical Description

• Reference: Refer to 2021 Clinical Management of HIV in Children and Adults (5th edition, 2021)

DIAGNOSIS / INVESTIGATIONS

• Lumbar puncture (LP) feasible / not contraindicated
• Cryptococcal antigen (CrAg) rapid test or India Ink stain on CSF.

LP not feasible

• CrAg rapid test on serum, plasma or full blood.

Treatment

Primary management

Admit

• Daily therapeutic spinal tap if high intracranial pressure, severe headache or vomiting is present (up to 30 ml per puncture).
• If HIV positive, not already on ART, start ART only 5 weeks after antifungal treatment initiation.

Induction phase

• Do not give adjunctive corticosteroids during induction treatment.
• Before giving Liposomal Amphotericin B: Pre-hydrate and supplement electrolytes:

1000ml NS (weight-based for children) + Potassium 2 tabs 12-hourly + Magnesium trisilicate 1 tabs 24-hourly in the evening.

Option 1:

• Liposomal Amphotericin B1 + Flucytosine for 7 days, followed by fluconazole tabs for 7 days
• Preferred option if both meds are available

Liposomal Amphotericin B1

Adult

• 3-4 mg/kg IV over 6 hours, 24-hourly. Use up to 6 mg/kg for treatment failure or serious disease.

Child

• 6mg/kg IV over 6 hours, 24-hourly.

Flucytosine tabs

• 100mg/kg/day divided into 4 doses (6-hourly)

Fluconazole tabs

Adult

• 1200mg 24-hourly

Child

• 12mg/kg (max 800mg) 24-hourly

Option 2:

Fluconazole + Flucytosine for 14 days

• This option requires FBC monitoring: at baseline and 2-3 times in the second week of treatment.

Fluconazole tabs

Adult

• 1200mg 24-hourly

Child

• 12mg/kg (max 800mg) 24-hourly

Flucytosine tabs

• 100mg/kg/day divided into 4 doses (6-hourly)

Option 3:

Liposomal Amphotericin BError! Bookmark not defined. + Fluconazole for 14 days

• This option requires FBC, Creatinine and K+ monitoring: at baseline and 2-3 times in the second week of treatment.

Liposomal Amphotericin BError! Bookmark not defined.

• 3-4 mg/kg IV over 6 hours 24-hourly
• Use up to 6 mg/kg for treatment failure or serious disease.

Fluconazole tabs

Adult

• 1200mg 24-hourly

Child

• 12mg/kg (max 800mg) 24-hourly

Consolidation phase

Fluconazole tabs for 8 weeks

Adult

• 800mg 24-hourly

Child

• 12mg/kg (max 800mg) 24-hourly

Maintenance phase

Fluconazole tabs, lifelong

Adult

• 200mg 24-hourly

Child

• 6mg/kg 24-hourly