Question | Discussion | References

Updated October 7, 2012

Diagnosis and Management of Cryptococcal Meningitis

Authors: Paul K. Drain, MD, MPH Christopher Behrens, MD

A 28-year-old woman living in the KwaZulu-Natal Province of South Africa presents to a public hospital with a persistent fever and headache for one week. She denies blurry vision, weakness, or changes in mental status. A physical examination reveals no focal neurological signs. The patient is admitted to the Medicine Ward, where she is newly diagnosed as HIV-positive by a rapid HIV test. A head computed tomographic (CT) scan is considered, but a CT machine is not readily available. A rapid, point-of-care serum lateral flow antigen (LFA) assay for cryptococcal antigen (CrAg) is positive. Venous blood is sent to the laboratory for a CD4 T-cell count, but the results will not be available for several days. As in many resource-limited settings, flucytosine is not available from the hospital's pharmacy, but both amphotericin B and fluconazole are available.

What is your next step in the clinical management of this patient?

A Start amphotericin B immediately, while waiting for lab results. Do not perform a lumbar puncture because the intracranial pressure may be high.
B Perform a lumbar puncture to measure and reduce the intracranial pressure as needed, then start amphotericin B while waiting for lab results.
C Perform a lumbar puncture to measure and reduce the intracranial pressure as needed, then start amphotericin B plus fluconazole while waiting for lab results.
D Perform a lumbar puncture to measure and reduce the intracranial pressure as needed, then start high-dose fluconazole (800 mg daily) while waiting for lab results.