Complications
Patients commonly develop anaemia, hypokalaemia, hypomagnesaemia, and reversible nephrotoxicity. Patients with a low baseline haemoglobin may require blood transfusion should they develop severe or symptomatic anaemia.
To minimise amphotericin-B-associated nephrotoxicity, patients should receive prehydration with intravenous normal saline, unless contraindicated.[119] Patients routinely require potassium and magnesium supplementation while receiving amphotericin-B.
Histoplasmomas are focal brain or spinal cord lesions. May occur in association with Histoplasma meningitis, in which case treatment is as for meningitis. Surgery is not recommended. If it is an isolated finding in an otherwise well patient without meningitis or disseminated infection, induction with amphotericin-B may be shortened.[27]
IRIS can complicate fungal meningitis associated with HIV infection upon initiation of antiretroviral therapy. It can cause a paradoxical precipitous neurological decline.[129]
Between 6% and 30% of patients may develop cryptococcal IRIS at a median of 1 to 2 months after starting antiretroviral therapy. Features include increased headache, fever, lymphadenopathy, and raised cerebrospinal fluid (CSF) pressure. Antiretroviral drugs should be continued. CSF should be examined to measure pressure (may require control by serial lumbar punctures) and exclude ongoing active infection and alternative diagnoses. Short-course corticosteroids may be considered in severely affected patients.[130][131][132]
Raised intracranial pressure with cryptococcal meningitis probably occurs due to impaired reabsorption of cerebrospinal fluid (CSF) at the arachnoid villi. Guidelines advocate therapeutic drainage of CSF if the CSF opening pressure is more than 25 cm H₂O.[70] The aim is to reduce the CSF closing pressure to less than 20 cm H₂O or to 50% of the opening pressure, by serial daily lumbar punctures with withdrawal of large volumes of CSF (up to 30 mL/day). If high pressure persists despite daily lumbar punctures, a temporary lumbar drain or ventriculoperitoneal shunt may be considered.[107]
Vasculitis secondary to the inflammatory process in coccidioidal infection may lead to infarction. Some (but not all) experts advocate adjunctive, high-dose, short-term corticosteroid therapy.[11]
Spinal arachnoiditis, causing back pain, paraplegia, and urinary retention, may occur as a complication of intrathecal therapy (which should, therefore, be discontinued). It can also occur as part of the disease process in patients treated with fluconazole.
Spinal arachnoiditis may rarely complicate non-HIV-associated cryptococcal meningitis.[128]
Hydrocephalus, secondary to cerebrospinal fluid obstruction by the inflammatory response to infection, is the most common complication of coccidioidal meningitis and usually requires shunt placement.
Hydrocephalus occasionally complicates Histoplasma meningitis and requires neurosurgical referral for consideration of ventricular shunt placement.[27]
Ideally, patients should receive 2 weeks of amphotericin-B treatment, to reduce the likelihood of colonisation of the new shunt. Patients with shunts should be monitored closely for relapse. In cases of relapse, shunt removal and replacement should be considered.
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