Fungal meningitis

Cryptococcal meningitis

• Patients who have recovered from cryptococcal meningitis require careful follow-up for recurrence of symptoms.

• Patients who are already diagnosed with HIV should continue their antiretroviral therapy. In treatment-naive HIV-infected patients with a recent diagnosis of cryptococcal meningitis, delaying antiretroviral therapy for 5 weeks was associated with improved survival compared with therapy initiation at 1 to 2 weeks, especially among patients with a paucity of white cells in cerebrospinal fluid (CSF).[106]Boulware DR, Meya DB, Muzoora C, et al; COAT Trial Team. Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis. N Engl J Med. 2014 Jun 26;370(26):2487-98. http://www.nejm.org/doi/full/10.1056/NEJMoa1312884#t=article http://www.ncbi.nlm.nih.gov/pubmed/24963568?tool=bestpractice.com

• Treatment of cryptococcal meningitis in HIV-infected patients is complicated by the development of immune reconstitution inflammatory syndrome in nearly 1 in 8 patients.[19]Jarvis JN, Bicanic T, Loyse A, et al. Determinants of mortality in a combined cohort of 501 patients with HIV-associated cryptococcal meningitis: implications for improving outcomes. Clin Infect Dis. 2014 Mar;58(5):736-45. https://academic.oup.com/cid/article/58/5/736/365633 http://www.ncbi.nlm.nih.gov/pubmed/24319084?tool=bestpractice.com

Histoplasmal meningitis[27]Wheat LJ, Musial CE, Jenny-Avital E. Diagnosis and management of central nervous system histoplasmosis. Clin Infect Dis. 2005 Mar 15;40(6):844-52. https://academic.oup.com/cid/article/40/6/844/347054 http://www.ncbi.nlm.nih.gov/pubmed/15736018?tool=bestpractice.com

• CSF analysis should be repeated after 1 month, when liposomal amphotericin-B is replaced by an azole antifungal, and at 1 year, and if failure or relapse is suspected.

• Therapy should be continued until CSF abnormalities have resolved and CSF antigen (and serum and urine antigen if initially positive) is negative.[72]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Disease Society of America. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. September 2022 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections

• Serum and urine antigen, if initially positive, can be repeated at 2 weeks, 1 month, and then 3-monthly during therapy and for at least 6 months after treatment is terminated.

• Patients in whom treatment failure or relapse is suspected should also have antigen levels measured.

Coccidioidal meningitis[11]Johnson RH, Einstein HE. Coccidioidal meningitis. Clin Infect Dis. 2006 Jan 1;42(1):103-7. https://academic.oup.com/cid/article/42/1/103/392976 http://www.ncbi.nlm.nih.gov/pubmed/16323099?tool=bestpractice.com

• CSF analysis is repeated monthly initially.

• If response is satisfactory, CSF is repeated 3-monthly for life.

• Serum and CSF complement fixing-type antibodies decrease with successful therapy.

Candidal meningitis[75]Pappas PG, Kauffman CA, Andes DR, et al. Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-50. https://academic.oup.com/cid/article/62/4/e1/2462830 http://www.ncbi.nlm.nih.gov/pubmed/26679628?tool=bestpractice.com

• Due to the high rates of relapse in candidal meningitis, antifungal therapy must be given for a minimum of 4 weeks after resolution of all signs and symptoms.

• All CSF analysis and radiologic findings should also normalize prior to stopping antifungal therapy.