eMedicine Specialties > Infectious Diseases > Fungal Infections

Cryptococcosis: Follow-up

Author: John W King, MD, Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center
Coauthor(s): Meredith L DeWitt, MD, Fellow, Department of Internal Medicine, Section of Infectious Diseases, Louisiana State University Health Sciences Center
Contributor Information and Disclosures

Updated: Oct 30, 2009

Follow-up

Further Inpatient Care

  • Provide immediate care of invasive cryptococcal infections in the hospital.
  • Because cryptococcal infections may have a rapid onset, administer amphotericin B desoxycholate with or without the addition of flucytosine to patients with CNS involvement, disseminated disease, or invasive pulmonary disease.
  • Carefully perform a lumbar puncture in patients who do not have symptomatic CNS disease but who do have invasive pulmonary or disseminated disease.
  • Measure opening and closing pressures and send CSF for an India ink preparation, stains, and cultures for fungi, mycobacteria, and cryptococcal antigen. In addition, obtain spinal fluid cell counts and CSF glucose and protein concentrations.
  • After the patient demonstrates significant improvement, consider switching to intravenous or oral fluconazole. Amphotericin B lipid complex is an alternative to amphotericin B desoxycholate in patients with cryptococcal meningitis who do not respond to or tolerate amphotericin B desoxycholate.

Further Outpatient Care

  • Following control of acute life-threatening cryptococcal infection, consider continuing outpatient therapy with intravenous amphotericin B, oral fluconazole, or oral itraconazole (if no evidence of CNS disease is present). Itraconazole does not cross the blood-brain barrier well; therefore, do not use it as initial therapy in patients with cryptococcal disease or in patients with known or suspected CNS involvement.
  • Following initial therapy with amphotericin B, maintenance therapy with itraconazole is still less effective than with fluconazole. An oral solution of itraconazole is available and has improved bioavailability compared with the capsules.

Inpatient & Outpatient Medications

  • Amphotericin B desoxycholate is the DOC for initial therapy of cryptococcal infection. This drug has a faster onset of action than fluconazole (even when fluconazole is administered intravenously) and crosses the blood-brain barrier more reliably than the azoles (eg, itraconazole, ketoconazole).
  • Lipid preparations of amphotericin B are very expensive and, although less nephrotoxic, are not more effective. Further, giving the daily dose of amphotericin B desoxycholate as a continuous infusion over 24 hours instead of 4-8 hours significantly reduces its nephrotoxicity.

Transfer

  • Once stable, patients with cryptococcal meningitis or disseminated cryptococcal disease can be considered for transfer to a facility where they can receive their therapy closer to their families.
  • If a patient's condition continues to deteriorate while on appropriate medical therapy, consider transferring the patient to a facility with neurosurgical and infectious disease support. Some patients may benefit from a reduction in intracranial pressure by placement of a shunt or other device.

Deterrence/Prevention

  • The principal vector of C neoformans is the pigeon, Columba livia. Pigeons contaminate their roosts with their excreta, which provides the high-nitrogen, high-salt, alkaline environment conducive to the growth of C neoformans. Because of their high regular temperature (42°C [107.6°F]), pigeons are rarely infected themselves; however, cryptococci do survive gut transport through the pigeon's intestines. Pigeon excreta contaminated with cryptococci may remain infectious for up to 2 years; thus, the principal method of prevention of infection with C neoformans is to avoid contact with areas inhabited by pigeons.
  • Unlike C neoformans, C gattii is not associated with pigeon excreta. The distribution of C gattii is tropical and subtropical and is associated with exposure to the river red gum tree (ie, E camaldulensis) and the forest red gum tree (ie, E tereticornis). During the flowering seasons, from November to February, the organism contaminates the air surrounding these tree species. Preventing exposure to an environment containing flowering eucalyptus trees may reduce the likelihood of infection; however, epidemiologic evidence indicates that eucalyptus trees are not the sole source of environmental exposure.

Complications

  • In patients with AIDS and other causes of immunosuppression who are infected with C neoformans, cure is often impossible, and patients require life-long suppressive therapy.
  • In immunocompromised patients, the overall mortality rate following treatment of cryptococcal meningitis is approximately 25%-30%. Of those who survive, 40% have significant neurological deficits, including loss of vision, decreased mental function, hydrocephalus, and cranial nerve palsies. Relapse occurs in 20%-25% of patients.

Prognosis

  • With early diagnosis, infections from cryptococcal organisms, including CNS and disseminated infections, are usually amenable to therapy. In patients with no demonstrable immunosuppression, amphotericin B therapy, with or without flucytosine, is effective in controlling or terminating infection in 70%-75% of patients.

Patient Education

  • Presently, patients with AIDS or HIV infection constitute the population at greatest risk for cryptococcal disease.
  • Alert patients with HIV infection or AIDS to seek early medical attention if they begin to experience severe or persistent headaches or other neurological symptoms. If cryptococcal CNS infection is present, early diagnosis may reduce the risk of death or permanent morbidity.
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Brain Infection.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose C neoformans CNS infection early enough to avoid disease progression may result from the nonspecific nature of symptoms: This condition can manifest as a fever of undetermined origin, with chronic headaches with or without fever, mental confusion, stroke syndrome, intracranial mass, or subacute meningitis.
  • Failure to consider cryptococcosis, mycobacterial infections, and other fungal infections in any patient with a fever of undetermined origin or new neurologic findings that are unexplained
  • Failure to include cryptococcal disease as a diagnostic possibility because the patient is afebrile or has minimal fever.

Special Concerns

  • Elderly patients require close monitoring of their renal function, electrolytes (especially serum potassium), and blood cell counts while they are taking amphotericin B, with or without flucytosine.
  • The principal vector of C neoformans is the pigeon; removing roosts near human dwellings can help avoid disease.
 


More on Cryptococcosis

Overview: Cryptococcosis
Differential Diagnoses & Workup: Cryptococcosis
Treatment & Medication: Cryptococcosis
Follow-up: Cryptococcosis
References
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Further Reading

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Keywords

cryptococcosis, Busse-Buschke disease, European blastomycosis, torulosis, cryptococcal infection, yeast infection, cryptococci, fungal infection, cryptococcoma, meningitis, cryptococcal meningitis, cryptococcal lung infection

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Contributor Information and Disclosures

Author

John W King, MD, Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi
Disclosure: emedicine $50.00 author of chapter

Coauthor(s)

Meredith L DeWitt, MD, Fellow, Department of Internal Medicine, Section of Infectious Diseases, Louisiana State University Health Sciences Center
Meredith L DeWitt, MD is a member of the following medical societies: Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey D Band, MD, Clinical Professor of Medicine, Wayne State University School of Medicine; Director, Division of Infectious Diseases and International Medicine, William Beaumont Hospital Corporation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John W King, MD, Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi
Disclosure: emedicine $50.00 author of chapter

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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