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Cryptococcal Disease Background Cryptococcosis is a systemic or central nervous system (CNS) fungal infection caused by the yeast Cryptococcus neoformans. The organism is ubiquitous, but is particularly plentiful in soils enriched with bird droppings. It may also be present in fruit skins or juices, as well as in unpasteurized milk. In immunocompetent patients, cryptococcal infection is usually asymptomatic, self-limited, and confined to the lungs. In persons with advanced HIV infection (eg, those with CD4 counts
6–18 | Clinical Manual for Management of the HIV-Infected Adult/2006 Patients with a positive serum CrAg, another positive test for Cryptococcus, or signs or symptoms of meningitis should undergo analysis of the cerebrospinal fluid (CSF). If neurologic symptoms or signs are present, obtain a computed tomography (CT) scan of the brain before performing a lumbar puncture (LP) to rule out a mass lesion or increased intracranial pressure (ICP), which could cause herniation upon LP. Always measure the CSF opening pressure; a high ICP contributes to morbidity and mortality and determines the need for serial LPs to manage the increased ICP. Send the CSF for the following: ♦ ♦ ♦ ♦ ♦ ♦ CrAg (usually positive at high titer in meningitis) Fungal culture India ink stain (lower sensitivity than CrAg) Cell counts Glucose Protein For exclusion of other etiologies, check CSF with the Venereal Disease Research Laboratory (VDRL) test, bacterial culture, AFB culture or polymerase chain reaction (PCR), if tuberculosis is suspected, and other tests as indicated by the patient's symptoms and exposures. Treatment Cryptococcal meningitis Acute treatment of cryptococcal meningitis consists of 2 phases: induction and consolidation. Acute treatment is followed by chronic maintenance (suppressive) therapy. Induction Patients with cryptococcal meningitis should be hospitalized to start 2 weeks of induction therapy with amphotericin B (0.7 mg/kg/day) given intravenously plus flucytosine (25 mg/kg) given orally every 6 hours. Amphotericin B causes many adverse effects, including fever, rigors, hypotension, nausea, nephrotoxicity and electrolyte disturbances, anemia, and leukopenia. The patient’s hemoglobin, white blood cell (WBC) count, platelets, electrolytes, magnesium, and creatinine must be monitored closely during treatment. Note that liposomal forms of amphotericin (AmBisome and Abelcet) cause fewer adverse effects and appear to be effective. These liposomal forms should be considered for patients who have difficulty tolerating the standard amphotericin B. Because amphotericin B is highly irritating to the veins, it should be given through a central line. High levels of flucytosine are associated with bone marrow toxicity, and levels should be monitored (target peak 70-80 mg/L; trough 30-40 mg/ L). Note that the dosage of flucytosine must be adjusted for patients with renal insufficiency. If amphotericin is not available, is contraindicated, or is not tolerated by the patient, alternative induction therapies may be considered. The primary alternative to amphotericin-based therapy is fluconazole (400- 800 mg orally per day), with or without flucytosine. Of the newer antifungal agents, echinocandins have little activity against Cryptococcus. Voriconazole has good in vitro activity, but few clinical data are available and none suggest superiority over fluconazole. The efficacy of alternative regimens is not well defined. Consolidation After clinical improvement with 2 weeks of induction therapy (possibly sooner for patients with substantial improvement), the treatment can be switched to oral fluconazole (400 mg once daily to complete 8 weeks of acute treatment). Itraconazole (200 mg orally twice daily) sometimes is used as an alternative for patients who cannot take fluconazole. It should be noted that itraconazole is less effective than fluconazole and has significant drug interactions with commonly used medications. Maintenance After completing acute treatment, the patient should receive chronic maintenance therapy with fluconazole (200 mg orally once daily) to prevent recurrence of cryptococcosis. An alternative treatment is itraconazole (200 mg orally once or twice daily)—with the caution as indicated above. Maintenance therapy should be continued for life, unless the patient has sustained CD4 cell recovery in response to effective antiretroviral therapy (ART) (CD4 count >100-200 cells/µL for at least 6 months during ART). Maintenance therapy should be restarted if the CD4 count declines to 250 mm H 2 O, remove
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Clinical Manual for Management of t
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Page 202 and 203: Eye Problems Background The immunos
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Page 210 and 211: Fever Background Although fever may
Page 212 and 213: Headache Background Headache may ha
Page 214 and 215: Lymphadenopathy Background Lymphade
Page 216: Treatment Treatment will depend on
Page 222 and 223: Neurologic Symptoms Background The
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Page 226 and 227: Pulmonary Symptoms Background Short
Page 228: Treatment Once the diagnosis is mad
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Page 238 and 239: Candidiasis, Oral and Esophageal Ba
Page 240: Maintenance therapy Use caution whe
Page 246 and 247: Cervical Dysplasia Background Cervi
Page 248: Patient Education ♦ ♦ ♦ ♦ P
Page 254 and 255: Cryptosporidiosis Background Crypto
Page 256: Patient Education ♦ ♦ ♦ ♦
Page 266 and 267: Gonorrhea and Chlamydia Background
Page 268 and 269: Treatment of Gonorrhea Treatment op
Page 270 and 271: Hepatitis B Infection Background He
Page 272 and 273: ♦ ♦ ♦ ♦ ♦ Some patients t
Page 274 and 275: Hepatitis C Infection Background He
Page 276 and 277: pregnancy. Ribavirin is teratogenic
Page 278 and 279: Herpes Simplex, Mucocutaneous Backg
Page 280: References ♦ ♦ ♦ ♦ ♦ Cent
Page 288 and 289: Kaposi Sarcoma Background Kaposi sa
Page 290 and 291: Treatment Treatment of KS is not co
Page 292 and 293: Molluscum Contagiosum Background Mo
Page 294 and 295: Mycobacterium avium Complex Backgro
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Page 298 and 299: Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Non-Hodgkin Lymphoma Background Non
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Patient Education ♦ ♦ ♦ ♦ S
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Toxoplasmosis Background Toxoplasma
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♦ Atovaquone 1,500 mg orally twic
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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