Cryptococcal Meningitis

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  • 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 B + 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 B.

  • 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