eMedicine Specialties > Neurology > Neurological Infections

HIV-1 Associated Opportunistic Infections - CNS Cryptococcosis: Follow-up

Author: Niranjan N Singh, MD, DNB, Assistant Professor of Neurology, University of Missouri Columbia
Coauthor(s): Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University; Vitor Pacheco, MD, Staff Physician, Department of Neurology, St Louis University Hospital
Contributor Information and Disclosures

Updated: Mar 14, 2007

Follow-up

Further Outpatient Care

  • Lifelong secondary prevention may be required. Fluconazole 200 mg/d was shown to be more effective than amphotericin B.
  • Itraconazole 400 mg/d can be an alternative to fluconazole, but it is less effective.
  • In case of recurrence despite compliance, amphotericin B 1 mg/kg/wk IV is an alternative.
  • Some reports suggest that oral prevention can be stopped if CD4+ counts rise higher than 100 with HAART and the HIV load becomes undetectable.

Complications

  • Relapses occur if secondary prevention is stopped or becomes ineffectual. Relapse rates without prevention range from 15-27%; this drops to 0-7% with prophylactic antibiotics.
  • Seizures should be treated with standard therapy. Drugs that are less likely to affect bioavailability of HAART agents or anticryptococcal therapy are preferred.
  • Cognitive impairment may improve with successful anticryptococcal therapy.
  • Immune reconstitution inflammatory syndrome occurs in some patients after treatment with HAART. This syndrome is a paradoxical deterioration in the clinical status despite satisfactory control of viral replication and improvement of CD4+ counts as a result of an exuberant inflammatory response toward previously diagnosed or latent opportunistic pathogens.

Prognosis

  • Relapse rate is high.
  • Predictors of poor prognosis are controversial, but have included the following:
    • High CSF cryptococcal antigen titer (>1:1024)
    • Minimal CSF pleocytosis
    • Altered mental status at presentation
  • Positive India Ink preparation
  • Hyponatremia
  • Positive cultures from extrameningeal sites

Miscellaneous

Medicolegal Pitfalls

  • Delay in diagnosis and treatment may lead to permanent neurological disability or death.
 


More on HIV-1 Associated Opportunistic Infections - CNS Cryptococcosis

Overview: HIV-1 Associated Opportunistic Infections - CNS Cryptococcosis
Differential Diagnoses & Workup: HIV-1 Associated Opportunistic Infections - CNS Cryptococcosis
Treatment & Medication: HIV-1 Associated Opportunistic Infections - CNS Cryptococcosis
Follow-up: HIV-1 Associated Opportunistic Infections - CNS Cryptococcosis
Multimedia: HIV-1 Associated Opportunistic Infections - CNS Cryptococcosis
References
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References

  1. Antinori S, Radice A, Galimberti L. The role of cryptococcal antigen assay in diagnosis and monitoring of cryptococcal meningitis. J Clin Microbiol. Nov 2005;43(11):5828-9. [Medline].

  2. Gendelman HE, Lipton SA, Epstein L. The Neurology of AIDS. New York: Chapman & Hall;1998.

  3. Hajjeh RA, Conn LA, Stephens DS, et al. Cryptococcosis: population-based multistate active surveillance and risk factors in human immunodeficiency virus-infected persons. Cryptococcal Active Surveillance Group. J Infect Dis. Feb 1999;179(2):449-54. [Medline].

  4. Kaplan JE, Hanson D, Dworkin MS, et al. Epidemiology of human immunodeficiency virus-associated opportunistic infections in the United States in the era of highly active antiretroviral therapy. Clin Infect Dis. Apr 2000;30 Suppl 1:S5-14. [Medline].

  5. Klepser ME, Klepser TB. Drug treatment of HIV-related opportunistic infections. Drugs. Jan 1997;53(1):40-73. [Medline].

  6. Mirza SA, Phelan M, Rimland D, et al. The changing epidemiology of cryptococcosis: an update from population-based active surveillance in 2 large metropolitan areas, 1992-2000. Clin Infect Dis. Mar 15 2003;36(6):789-94. [Medline].

  7. Offiah CE, Turnbull IW. The imaging appearances of intracranial CNS infections in adult HIV and AIDS patients. Clin Radiol. May 2006;61(5):393-401. [Medline].

  8. Pappas PG, Bustamante B, Ticona E, et al. Recombinant interferon- gamma 1b as adjunctive therapy for AIDS-related acute cryptococcal meningitis. J Infect Dis. Jun 15 2004;189(12):2185-91. [Medline].

  9. Quality Standards Subcommittee of the AAN. Evaluation and management of intracranial mass lesions in AIDS. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Jan 1998;50(1):21-6. [Medline].

  10. Saag MS, Graybill RJ, Larsen RA, et al. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society of America. Clin Infect Dis. Apr 2000;30(4):710-8. [Medline].

  11. Said G, Saimont AG, Lacroix C. Neurological complications of HIV and AIDS. Philadelphia: WB Saunders;1998.

  12. Schwartz P, Janbon G, Dromer F. Combination of amphotericin B with flucytosine is active in vitro against flucytosine-resistant isolates of Cryptococcus neoformans. Antimicrob. Agents Chemother. 2006;51:383-85. [Medline].

  13. de Gans J, Portegies P. Neurological complications of infection with human immunodeficiency virus type 1. A review of literature and 241 cases. Clin Neurol Neurosurg. 1989;91(3):199-219. [Medline].

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Further Reading

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Keywords

acquired immunodeficiency syndrome, fungal infection of the nervous system, space-occupying lesion, meningitis, meningoencephalitis, HIV infection, AIDS-defining illness, Cryptococcus neoformans, C neoformans, cryptococcal CNS disease, cryptococcal disease, cryptococcal meningitis, highly active antiretroviral therapy, HAART, immune reconstitution inflammatory syndrome, CNS cryptococcosis, HIV-1 associated opportunistic infections

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Contributor Information and Disclosures

Author

Niranjan N Singh, MD, DNB, Assistant Professor of Neurology, University of Missouri Columbia
Niranjan N Singh, MD, DNB is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

Vitor Pacheco, MD, Staff Physician, Department of Neurology, St Louis University Hospital
Disclosure: Nothing to disclose.

Medical Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard J Caselli, MD, Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair, Department of Neurology, Mayo Clinic of Scottsdale
Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Neurological Association, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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