Thread by @MayoClinicINFD

52M. HIV, Rx non compliant
Current VL / CD4 not known

CC: 2mo cough, progressive dyspnea
2 wks: chills, HA, night sweats

Exposures: parakeets / pigeons

Chest imaging (photo)
BAL: Galactomannan +
Serum CrAg 1:320

Comment on diagnostic and treatment approach? #MayoIDQ MCQ next

52M HIV not on Rx, CD4?, presents with likely disseminated cryptococcosis. BAL culture: Cryptococcus neoformans.
CT head no mass.

LP performed. Which of the following CSF findings confers higher mortality? #MayoIDQ

The HIV-infected patient (prior thread) with disseminated cryptococcosis and meningitis was started on induction Rx with AmBisome + 5FC.

HIV VL 120K. CD4 36. He tells you he will now be compliant to ART. No resistance mutations detected.

When do you start antiretroviral Rx?

Final MCQ for this case - What is the effect of steroids in the treatment of cryptococcal meningitis in patients with AIDS? #MayoIDQ

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Case diagnosis:
Disseminated #cryptococcosis with meningitis in an #AIDS patient

Risk: CD4<100

Serum #CrAg >1:160 predicts CNS involvement!

Let us discuss this case to highlight some learning pearls! Read on....

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No growth of Aspergillus sp in cultures.

What is the potential explanation for the elevated #galactomannan in this patient?

Cross reaction between #Cryptococcus antigen and #Aspergillus galactomannan

doi.org/10.1086/644499

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HIV-infected patients with #cryptococcus infection should be evaluated for CNS involvement!

Meningitis is very frequent manifestation of Cryptococcus in ICH! (Even in patients with no CNS symptoms)

- CSF analysis: opening pressure, cell count, chemistries, culture, CrAg

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Prognostic factors for mortality in HIV patients with cryptococcal meningitis

- CSF CrAg >1:1024 (super high)
- CSF WBC <20 (immune suppressed)
- High ICP (HA, mental status)

Majority pick the correct answer to the MCQ: “high ICP”

dovepress.com/getfile.php?fi…

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Why measure CSF opening pressure in #cryptococcal meningitis?
- To assess ICP (poor outcome)

Management of high ICP is essential to reduce mortality
- Repeated LP
- Ventricular drain (VP shunt)

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Rx of #cryptococcal meningitis in AIDS

Induction for at least 2 weeks (extend if no CSF fungal clearance)
- First line - Ampho B (#AmBisome preferred / lower toxicity) plus #5FC

Alternatives - not as good
- If no 5FC: AmB plus Fluconazole
- If no AmB: Fluconazole plus 5FC

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Rx of #cryptococcal meningitis in patients with AIDS

Following induction Rx -
Consolidation (8wks) and maintenance phase (at least 1 year): #Fluconazole (doses vary)

apps.who.int/iris/bitstream…

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When to start #ART in HIV patients with #cryptococcal meningitis (in patients not already on ART)

The COAT Trial showed lower mortality when ART deferred to 5 weeks after start of antifungal Rx (compared to 1-2 weeks)

nejm.org/doi/pdf/10.105…

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When to start #ART in HIV patients with #cryptococcal meningitis

Recommendation:
2-10 weeks after start of antifungal Rx (WHO: 4-6 weeks)

Deferred ART —> lower mortality
- Reduce potential for #IRIS

Majority pick the correct answer to MCQ!

apps.who.int/iris/bitstream…

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Steroids NOT recommended in Rx of #cryptococcal meningitis

Dexamethasone
- No reduction in mortality
- Higher adverse events / disability
- No reduction in IRIS (although faster decline in OP)
- Longer time to fungal clearance

N Engl J Med. 2016 Feb 11; 374(6): 542–554.

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While steroids are NOT recommended routinely to prevent IRIS in #cryptococcal meningitis
- steroids recommended for Rx of established IRIS in cryptococcal meningitis

Clin Infect Dis. 2010 Feb 1; 50(3): 291–322.

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#Cryptococcal meningitis in AIDS: Summary #IDDailyPearl
1. CD4<100
2. CrAg, LP - measure OP
3. AmB/5FC —> Fluconazole
4. ART 2-10 weeks after start of antifungals
5. Steroids DO NOT prevent IRIS (but may be used to Rx IRIS)

Thank you all for your participation!