Crptococcosis

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Epidemiology
-Cryptococcus neoformans and Cryptococcus gatti usually
found to infect humans
-Cryptococcosis occurs in immunosuppressed
patients, especially patients infected with HIV

-In the non-AIDS population, cryptococcosis is a frequent
opportunistic infection in patients with:
• Solid organ transplant
• High dose/chronic corticosteroid treatment
• Uncontrolled diabetes mellitus
• Renal failure
• Cirrhosis
• Chronic pulmonary disease
Clinical Manifestations
Primary cryptococcosis is usually occurs in the
lungs
• Pulmonary symptoms generally resolve spontaneously
• Cough
• Rales
• Shortness of breath
• Most common manifestation of cryptococcosis is
CNS infection
• Subacute to chronic meningoencephalitis
• Should always rule out CNS disease with lumbar
puncture (LP)

Patients with AIDS and cryptococcal
meningoencephalitis often have elevated
intracranial pressure (ICP) due to high fungal
burden in the CSF
• Typical opening pressures during LP are > 20
cmH2O in 75% of patients (normal CSF
opening pressure 10 to 20 cmH2O)
Cryptococcal Meningoencephalitis in HIV-infected Patients:
Induction Therapy:
-AmBd (0.7-1.0 mg/kg IV daily) +
(amphotericin B deoxycholate)
-Flucytosine 25 mg/kg PO 4x/day
Duration: 2 weeks

Consolidation Therapy:
Fluconazole 400mg PO daily
Duration-8weeks

Maintenance Therapy:
-Fluconazole 200mg PO daily >1 year
Cryptococcal Meningoencephalitis in Transplant Recipients:
Induciton Therapy
Liposomal AmB (3-4 mg/kg IV daily) +
Flucytosine 25 mg/kg PO 4x/day
Duration:2 weeks

ABLC (5 mg/kg IV daily) +
Flucytosine 25 mg/kg PO 4x/day
Duration: 2 weeks

Liposomal AmB (6 mg/kg IV daily)* 4-6 weeks

ABLC (5 mg/kg IV daily)* 4-6 weeks

AmBd (0.7 mg/kg IV daily)* 4-6 weeks

Consolidation Therapy:
Fluconazole 400-800 mg daily
8 weeks

Maintenance Therapy:
Fluconazole 200-400 mg daily
6 months to 1 year
Cryptococcal Meningoencephalitis in non-HIV/non-transplant Recipients:
Induction Therapy:

AmBd (0.7-1.0 mg/kg IV daily) +
Flucytosine 25 mg/kg PO 4x/day
Duration: > 4 weeks

AmBd (0.7-1.0 mg/kg IV daily)* > 6 weeks (For Flucytosine allergic patients)

Liposomal AmB (3-4 mg/kg IV daily) +
Flucytosine 25 mg/kg PO 4x/day
Duration: > 4 weeks

ABLC (5 mg/kg IV daily) +
Flucytosine 25 mg/kg PO 4x/day
Duration:> 4 weeks

AmBd (0.7 mg/kg IV daily) +
Flucytosine 25 mg/kg PO 4x/day
Duration: 2 weeks

Consolidation Therapy:
Fluconazole 400-800 mg daily
8 weeks

Maintenance Therapy:
Fluconazole 200-400 mg daily
6 months to 1 year
Nonmeningeal, Pulmonary Cryptococcosis:
Patients with mild-to-moderate
pulmonary cryptococcosis
Fluconazole
(400 mg daily)
6-12 months

Immunosuppressed* patients with
severe pulmonary cryptococcosis
Same as CNS
disease
12 months B-III
Immunocompetent patients with
severe pulmonary cryptococcosis
Same as CNS
disease
12 months B-III

Patients with cryptococcemia Same as CNS
disease
12 months B-III
Patients a single site of infection
without CNS disease, without
fungemia, and without
immunosuppressive risk factors
Fluconazole
(400 mg daily)
6-12
months