Cryptococcal meningitis comes from either Cryptococcus neoformans or Cryptococcus gattii. It will typically present in an immunocompromised patient (usually HIV patients with CD4 counts of < 100) sub-acutely with headache and fevers. Elevated ICP is common when connected with HIV (~60-80% will have an opening pressure >25 cm H20), and this should be treated. Antibiosis is challenging, but typically consists of three phases: induction, consolidation, and maintenance. Total treatment duration is 1 year. See table below (Br Med Bull 2004; 72 (1): 99-118.):
1. What is the clinical implication of gattii? Not much. Epidemiologically, non-HIV infected patients will more often be infected with gattii especially in areas where this is endemic, such as the pacific northwest of the United States or Australia. Treatment does not differ between species.
2. What to do if patients experience toxicity with induction? Induction therapy is usually a combination of a liposomal formulation of amphotericin B and flucytosine. Amphotericin can lead to bone marrow, hepatic, or renal toxicity, and if these develop you can switch to fluconazole. Flucytosine can have significant bone marrow toxicity as well, which is worse when combined with amphotericin. Switch to fluconazole is again, the only option.