Cryptococcal Meningitis

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Sparda29

Sparda29

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What do you guys see being used the most often as a treatment for this?

We have a 50 yo male patient. He came into the emergency room complaining of a bad headache for the last 2 weeks that wouldn't go away with NSAIDs or tylenol. Also had a low grade fever for the past few days. Diagnosed with HIV 25 years ago but never took ART for it. His CD4 count is 8. Serum cryptococcal antigen was positive. Other than those things, all labs are normal.

Physician started him initially on fluconazole, and broad spectrum abx. After the antigen test came back, took off abx, kept him on fluconazole and added amphotericin B and 5-FC. 2 days later, he took him off fluconazole.

What do you guys think about this? John Hopkins chart says that amphotericin B and 5-FC are first line agents for this, but all throughout school I kept hearing that amphotericin B is the suck because of the adverse effects. (Human membranes have sterols which amphotericin targets.)

Also convinced him to start HAART. Started on Atripla. Once we told him that his HIV meds would be free, his entire demeanor changed.

Anyone?
 
Last edited:
Sparda29 said:
What do you guys see being used the most often as a treatment for this?

We have a 50 yo male patient. He came into the emergency room complaining of a bad headache for the last 2 weeks that wouldn't go away with NSAIDs or tylenol. Also had a low grade fever for the past few days. Diagnosed with HIV 25 years ago but never took ART for it. His CD4 count is 8. Serum cryptococcal antigen was positive. Other than those things, all labs are normal.

Physician started him initially on fluconazole, and broad spectrum abx. After the antigen test came back, took off abx, kept him on fluconazole and added amphotericin B and 5-FC. 2 days later, he took him off fluconazole.

What do you guys think about this? John Hopkins chart says that amphotericin B and 5-FC are first line agents for this, but all throughout school I kept hearing that amphotericin B is the suck because of the adverse effects. (Human membranes have sterols which amphotericin targets.)

Also convinced him to start HAART. Started on Atripla. Once we told him that his HIV meds would be free, his entire demeanor changed.

Anyone?
Click to expand...

Definitely dying of cryptococcal meningitis is worse than potentially damaging kidneys with amphotericin. Lipid formulations and hyperhydration have also somewhat lessened the incidence of renal damage.

Couple of things: first, as the thought behind the practice, look at the nature of the antifungal activity for the two drugs, and then think about what type of antibiotics you would use in bacterial meningitis. Second, look at the guidelines and the level of evidence supporting the use of ampho over fluconazole.
 
rxlea said:
Curious P1 here...


In this case, would you use amphotericin B or Ambisome?

Can you use penicillin G?
Click to expand...

Either AmBisome or Abelcet is used, most likely AmBisome. The majority of the efficacy data is from traditional amphotericin, but as Sparda mentioned, the toxicity is a huge issue. Lipid formulations allow for higher doses with less worry about toxicity.

And why would you even think about PenG?
 
Praziquantel86 said:
Either AmBisome or Abelcet is used, most likely AmBisome. The majority of the efficacy data is from traditional amphotericin, but as Sparda mentioned, the toxicity is a huge issue. Lipid formulations allow for higher doses with less worry about toxicity.

And why would you even think about PenG?
Click to expand...

I thought he had a bacterial infection too. Nevermind.
 
And while we are on this topic....since the dude does have HIV, would they ever give abx while he is in the hospital or is it ONLY if he for sure contracts something? Or can he just come in for the ambisome infusions outpatient (I have seen that before).
 
rxlea said:
And while we are on this topic....since the dude does have HIV, would they ever give abx while he is in the hospital or is it ONLY if he for sure contracts something? Or can he just come in for the ambisome infusions outpatient (I have seen that before).
Click to expand...

Well, his CD4 count is 8 right now. After everything resolves with the cryptococcal infection I would hope that they put him on:

TMP/SMX DS 1 tablet daily for PCP prophylaxis
Azithromycin 1200 mg weekly for MAC prophylaxis
Routine eye examinations from opthalmologist for monitoring of possible CMV infection

Also check if he has the IgG antibody to Toxoplasma. If he does then that requires TMP/SMX DS 1 tablet daily, which he is already on anyway because of PCP prophylaxis.
 
Good list...you are missing one important thing, though. Specific to this case.

Also, what do you worry for with a treatment-naive patient initiated on HAART, and how would you prevent this?
 
Praziquantel86 said:
Good list...you are missing one important thing, though. Specific to this case.

Also, what do you worry for with a treatment-naive patient initiated on HAART, and how would you prevent this?
Click to expand...

Yeah, the amphotericin + 5-FC is continued for 2 weeks or until the CSF results come negative and then add fluconazole 800 mg daily for 6-8 weeks. Also consider keeping him on fluconazole 200 mg after that for thrush prophylaxis.

Hmm, worry about resistant HIV? (Could have been infected multiple times.) Check for the resistance status of the HIV.

Adherence --> educate the patient about this.

Renal and hepatic status are currently fine.
 
Sparda29 said:
Yeah, the amphotericin + 5-FC is continued for 2 weeks or until the CSF results come negative and then add fluconazole 800 mg daily for 6-8 weeks. Also consider keeping him on fluconazole 200 mg after that for thrush prophylaxis.

Hmm, worry about resistant HIV? (Could have been infected multiple times.) Check for the resistance status of the HIV.

Adherence --> educate the patient about this.

Renal and hepatic status are currently fine.
Click to expand...

Close, but still not there. You'll be continuing fluconazole for a different reason and for a different duration. Check the IDSA cryptococcus guidelines, and then look into the references if you're really interested.

The other bits are good points, but not the main issue. What is the patient's current immune status? What is the ultimate goal of initiating HAART in this patient? I'll give you a hint: Nic Cage and the Goo Goo Dolls.
 
Praziquantel86 said:
Close, but still not there. You'll be continuing fluconazole for a different reason and for a different duration. Check the IDSA cryptococcus guidelines, and then look into the references if you're really interested.

The other bits are good points, but not the main issue. What is the patient's current immune status? What is the ultimate goal of initiating HAART in this patient? I'll give you a hint: Nic Cage and the Goo Goo Dolls.
Click to expand...


Aha, fluconazole to keep the cryptococcal infection suppressed until immune function is brought back up via the HAART therapy.

Why initiate HAART? His CD4 count is only 8. Need to bring the viral load down to undetectable and bring the CD4 count out of the danger zone.

No idea what that hint meant. A google search of Nic Cage and the Goo Goo Dolls brought me to the movie City of Angels.
 
Sparda29 said:
Aha, fluconazole to keep the cryptococcal infection suppressed until immune function is brought back up via the HAART therapy.

Why initiate HAART? His CD4 count is only 8. Need to bring the viral load down to undetectable and bring the CD4 count out of the danger zone.

No idea what that hint meant. A google search of Nic Cage and the Goo Goo Dolls brought me to the movie City of Angels.
Click to expand...

Fair enough...there is something called Immune Reconstitution Inflammatory Syndrome (IRIS) that may occur after initiating HAART. Iris was the name of the Goo Goo Dolls song in City of Angels.

I'll let you take it from there.
 
Interesting. I used to work at an infusion center co-located with an ID group practice. We had a similar case. 50 yr oldish male, HIV + with same diagnosis. The ID doc went with Ambisome. I think we did at least 10 days of therapy and we had to monitor him closely. We were drawing BMPs at least every couple of days to watch his magnesium and potassium.

Yeah, amphotericin is rough on the kidneys but it's one of those risk vs. benefit deals. I actually had a preceptor put it this way: "Do you want the patient to have good kidney function and be dead? Or, take a hit on the renal function and still be alive?" 🙂
 
That guy must have an awesome immune system. 25 years without treatment seems like a long time.
 
museabuse said:
That guy must have an awesome immune system. 25 years without treatment seems like a long time.
Click to expand...

25 years ago = 1985... the year the first blood test for HIV was approved by the FDA. So it's possible that the patient was diagnosed that year and has survived this long without treatment, but I would not say it's probable. You are right, that is a LONG time to go without treatment. Most of the people who were diagnosed with HIV/AIDS in that time period are now dead, regardless of whether they were treated or not.
 
All4MyDaughter said:
25 years ago = 1985... the year the first blood test for HIV was approved by the FDA. So it's possible that the patient was diagnosed that year and has survived this long without treatment, but I would not say it's probable. You are right, that is a LONG time to go without treatment. Most of the people who were diagnosed with HIV/AIDS in that time period are now dead, regardless of whether they were treated or not.
Click to expand...

Yeah well, he was also saying that prior to the headache related to this case he didn't see a physician in 23 years because of a lack of trust. He told me he probably got it from sharing needles back when he was addicted to heroin.
 
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