Objectives. These cases are often viral, and enterovirus is the most common pathogen in immunocompetent individuals.2,4 The most common etiology in U.S. adults hospitalized for meningitis is enterovirus (50.9%), followed by unknown etiology (18.7%), bacterial (13.9%), herpes simplex virus (HSV; 8.3%), noninfectious (3.5%), fungal (2.7%), arboviruses (1.1%), and other viruses (0.8%).5 Enterovirus and mosquito-borne viruses, such as St. Louis encephalitis and West Nile virus, often present in the summer and early fall.4,6 HSV and varicella zoster virus can cause meningitis and encephalitis.2, Causative bacteria in community-acquired bacterial meningitis vary depending on age, vaccination status, and recent trauma or instrumentation7,8 (Table 29 ). Vaccination against the most common pathogens that cause bacterial meningitis is recommended. Specific pathogens are more prevalent in certain age groups, but empiric coverage should cover most possible culprits. Preventing relapse of cryptococcosis reduces mortality and morbidity and slows the progression of HIV disease. In both HIV-negative and HIV-positive patients with cryptococcal meningitis, elevated intracranial pressure occurs in excess of 50% of patients [22]. Patients in the amphotericin B group had significantly more relapses, more drug-related adverse events, and more bacterial infections, including bacteremia [24]. In cases where repeated lumbar punctures or use of a lumbar drain fail to control elevated pressure symptoms, or when persistent or progressive neurological deficits are present, a ventriculoperitoneal shunt is indicated [21, 22] (BII). People with advanced HIV should be tested early for cryptococcal infection. CSF antigen titers are higher and the India ink smear is more frequently positive among patients with elevated opening pressure than among patients with normal opening pressure. C. neoformans infection statistics. For patients who are unable to tolerate fluconazole, itraconazole (200 mg twice daily) may be substituted (CIII). As a result, most clinicians are uncertain about which agents to use for which underlying disease state, in what combination, and for what duration. C. gattii is more likely to infect someone with a healthy immune system than C. neoformans. Because of the risk of increased intracranial pressure with brain inflammation, the Infectious Diseases Society of America recommends performing computed tomography of the head before LP in specific high-risk patients to reduce the possibility of cerebral herniation during the procedure (Table 4).7,21,22 However, recent retrospective data have shown that removing the restriction on LP in patients with altered mental status reduced mortality from 11.7% to 6.9%, suggesting it may be safe to proceed with LP in these patients.22, The CSF findings typical of aseptic meningitis are a relatively low and predominantly lymphocytic pleocytosis, normal glucose level, and a normal to slightly elevated protein level (Table 59 ). An alternative to this regimen is amphotericin B (0.71 mg/kg/d) plus 5-flucytosine (100 mg/kg/d) for 2 weeks, followed by fluconazole (400 mg/day) for a minimum of 10 weeks. Prolonged external lumbar drainage places patients at major risk for bacterial infection. Amphotericin B, flucytosine, and fluconazole are antifungal medications shown to improve survival in patients with cryptococcal infections. Worldwide, approximately 1 million new cases of cryptococcal meningitis occur each year, resulting in 625,000 deaths. Its far more common in people with HIV or AIDS patients in Sub-Saharan Africa, where people with this disease have a mortality rate thats estimated to be 50 to 70 percent. In conjunction with antiretroviral therapy, long-term maintenance antifungal therapy should be administered. In addition, the test doesnt require costly laboratory equipment and expertise, making it ideal for low-resource settings. Three percent of fluconazole patients and 37% of placebo patients relapsed at any site. Therapy with amphotericin B (0.71 mg/kg/d) for 2 weeks, followed by 810 weeks of fluconazole (400800 mg/d), is followed with 612 months of suppressive therapy with a lower dose of fluconazole (200 mg/d) (BIII). Options. In each case, careful assessment of the CNS is required to rule out occult meningitis. These materials are intended to support cryptococcal screen-and-treat programs. Dexamethasone should be given before or at the time of antibiotic administration to patients older than six weeks who present with clinical features concerning for bacterial meningitis. Fluconazole (400800 mg/d) plus flucytosine (100150 mg/kg/d) for 6 weeks is an alternative to the use of amphotericin B, although toxicity with this regimen is high. We take your privacy seriously. Reprints or correspondence: Dr. Michael S. Saag, University of Alabama at Birmingham, 908 20th Street South, Birmingham, AL 35294-2050 (. HIV-negative, immunocompromised hosts should be treated in the same fashion as those with CNS disease, regardless of the site of involvement. 2023 Healthline Media LLC. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. For those patients with HIV who present with isolated pulmonary or urinary tract disease, fluconazole at 200400 mg/d is indicated. To receive email updates about this page, enter your email address: We take your privacy seriously. Aggressive management of elevated intracranial pressure is perhaps the most important factor in reducing mortality and minimizing morbidity of acute cryptococcal meningitis. This helps to ensure recovery and reduce the risk of complications, such as brain swelling and seizures. In cases where fluconazole is not an option, an acceptable alternative regimen is itraconazole, 200400 mg/d, for 612 months [9] (BIII). Oxford University Press is a department of the University of Oxford. Let's look at the symptoms to know. This test cannot be used to rule out bacterial meningitis.7. To screen people living with HIV for early cryptococcal infection and cryptococcal meningitis, healthcare facilities and laboratories must have access to the reliable tests. Management of elevated intracranial pressure in HIV-infected patients with cryptococcal disease. Infection Control Isolation Precautions Appendix A Clinical Syndromes or Conditions Warranting Empiric Transmission-Based Precautions in Addition to Standard Precautions Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Appendix A: Table 2 Format Change [February 2017] Airborne plus Contact Precautions plus eye protection. However, the initial dose should be given earlier in the setting of a high-risk condition, such as functional asplenia or complement deficiencies, travel to endemic areas, or a community outbreak.60 There are also two available vaccines for meningococcal type B strains (MenB-4C [Bexsero] and MenB-FHbp [Trumenba]) to be used in patients with complement disease or functional asplenia, or in healthy individuals at risk during a serogroup B outbreak as determined by the Centers for Disease Control and Prevention.60. Its usually found in soil that contains bird droppings. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Healthline Media does not provide medical advice, diagnosis, or treatment. Serum procalcitonin, serum C-reactive protein, and CSF lactate levels can be useful in distinguishing between aseptic and bacterial meningitis.2833 C-reactive protein has a high negative predictive value but a much lower positive predictive value.28 Procalcitonin is sensitive (96%) and specific (89% to 98%) for bacterial causes of meningitis.29,30 CSF lactate also has a high sensitivity (93% to 97%) and specificity (92% to 96%).3133 CSF latex agglutination testing for common bacterial pathogens is rapid and, if positive, can be useful in patients with negative Gram stain if LP was performed after antibiotics were administered. Fluconazole should be continued for life. This combination helps treat the condition quicker. A summary of treatment recommendations for AIDS-associated cryptococcal meningitis is provided in table 2. Appropriate antibiotics should be given to identified contacts within 24 hours of the patient's diagnosis and should not be given if contact occurred more than 14 days before the patient's onset of symptoms.63 Options for chemoprophylaxis are rifampin, ceftriaxone, and ciprofloxacin, although rifampin has been associated with resistant isolates.62,63, This article updates a previous article on this topic by Bamberger.9. Thank you for taking the time to confirm your preferences. There are 2 key elements in preventing relapse of cryptococcal meningitis: (1) control of HIV replication by means of potent HAART and (2) the use of chronic antifungal therapy to prevent microbial relapse. Antibiotics should not be delayed if there is any lag time in performing the LP (e.g., transfer to clinical site that can perform the test, need for head computed tomography before LP).7,8 Droplet isolation precautions should be instituted for the first 24 hours of treatment.23. Our website services, content, and products are for informational purposes only. Options. Routine studies should include the following: measurement of CSF opening pressure (with the patient in the lateral recumbent position); collection of sufficient CSF for fungal culture (3 mL); and the measurement of CSF cryptococcal antigen titer, glucose level, protein level, and cell count with differential (5 mL total). This inflammation can produce a wide range of symptoms and, in extreme cases, cause brain damage, stroke, or even death. Lipid formulations of amphotericin B appear beneficial and may be useful for patients with cryptococcal meningitis and renal insufficiency [12, 1821] (CII). Combination therapy with fluconazole (400800 mg/d) and flucytosine (100 mg/kg/d in 4 divided doses) has been shown to be effective in the treatment of AIDS-associated cryptococcal meningitis [16, 29]. Update: Recommendations for healthcare workers can be found at Ebola For Clinicians. However, in patients with HIV or AIDS, the yearly incidence rate is between 2 and 7 cases per 1,000 people. Three potential options exist for antifungal maintenance therapy: fluconazole, itraconazole, and weekly or biweekly amphotericin B. Outcomes. In selected cases, susceptibility testing of the C. neoformans isolate may be beneficial to patient management, particularly if a comparison can be determined between baseline and sequential isolates. Viral meningitis (non-HSV) management is focused on supportive care. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). Adverse effects from fluconazole monotherapy at 400 mg daily are uncommon. For selected patients who have responded very well to HAART, consideration might be given to discontinuing secondary antifungal prophylaxis after 1218 months of successful suppression of HIV viral replication (CIII). CSF results can be variable, and decisions about treatment with antibiotics while awaiting culture results can be challenging. They help us to know which pages are the most and least popular and see how visitors move around the site. Drug acquisition costs are high for antifungal therapies administered for life. Ebola Virus Disease for Healthcare Workers [2014]. While awaiting the results of imaging studies, the serum should be tested for the presence of cryptococcal polysaccharide antigen. Options. The goal of treatment is control of the infection and prevention of dissemination of disease to the CNS. Pneumonia is thought to herald the onset of disseminated disease. Taking this medication helps prevent relapses. However, no randomized studies in these population groups have been completed in the era of triazole therapy. In all cases of cryptococcal meningitis, careful attention to the management of intracranial pressure is imperative to assure optimal clinical outcome. These tissues are called meninges. Most people who develop CM already have severely compromised immune systems. Abstract. Etiologies range in severity from benign and self-limited to life-threatening with potentially severe morbidity. This guideline is part of a series of updated or new guidelines from the IDSA that will appear in CID. Symptoms are those of pneumonia, meningitis, or involvement of skin, bones, or viscera. They help us to know which pages are the most and least popular and see how visitors move around the site. This recommendation is extrapolated from the treatment experience of patients with HIV-associated cryptococcal meningitis [11, 13]. The desired outcome is continued absence of symptoms associated with cryptococcal meningitis and resolution or stabilization of cranial nerve abnormalities. Objectives. Your doctor will also perform a physical examination when trying to figure out if you have CM. Theyll look for the symptoms associated with this disease. Prompt recognition of a potential case of meningitis is essential so that empiric treatment may begin as soon as possible. Classic signs of meningeal irritation commonly are absent on physical examination, and routine laboratory assessment is rarely revealing. Classic symptoms of pneumonitis, including cough, fever, and sputum production, may be present, or pleural symptoms may predominate. Dexamethasone in Cryptococcal Meningitis N Engl J Med. Your doctor will insert a needle and collect a sample of your spinal fluid. If tuberculosis is unlikely and there are no AIIRs and/or respirators available, use Droplet Precautions instead of Airborne Precautions, Tuberculosis more likely in HIV-infected individual than in. Diagnosis of meningitis is mainly based on clinical presentation and cerebrospinal fluid analysis. Salmonella meningitis is a kind of bacterial meningitis that can be dangerous if not treated. The presentation of pulmonary cryptococcosis can range from asymptomatic nodular disease to severe acute respiratory distress syndrome (ARDS). Studies evaluating the effectiveness of amphotericin B, with or without flucytosine, have elucidated the optimal length of therapy for HIV-negative, immunocompromised and immunocompetent hosts. For both immunocompetent and immunocompromised patients with significant renal disease, lipid formulations of amphotericin B may be substituted for amphotericin B during the induction phase [12] (CIII). The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Improved access to antiretroviral therapy (ART) globally has helped improve the immune systems of many HIV patients so that they arent at increased risk of cryptococcal meningitis. Acetozolamide and mannitol have not been shown to provide any clear benefit in the management of elevated intracranial pressure resulting from cryptococcal meningitis (DIII). Regardless of the treatment chosen, it is imperative that all patients with pulmonary and extrapulmonary cryptococcal disease have a lumbar puncture performed to rule out concomitant CNS infection. A fungus called C. neoformans causes most cases of CM. Intravenous fluids may be beneficial within the first 48 hours, but further study is needed to determine the appropriate intravenous fluid management.35 A meta-analysis of studies with variable quality in children showed that fluids may decrease spasticity, seizures, and chronic severe neurologic sequelae.35 The next urgent requirement is initiating empiric antibiotics as soon as possible after blood cultures are drawn and the LP is performed. In cases where fluconazole is not an option, an acceptable alternative is itraconazole, 400 mg/d for life [9] (CII). Let's discuss when to get it and possible side effects: Learn how COVID-19 could lead to meningitis in rare cases and what it may mean for your treatment and outlook. We avoid using tertiary references. This approach has been shown to reduce the chance of a patient developing cryptococcal meningitis. Meningitis is an inflammatory process involving the meninges. Among patients with normal baseline opening pressure (<200 mm H2O), a repeat lumbar puncture should be performed 2 weeks after initiation of therapy to exclude elevated pressure and to evaluate culture status. Airborne Precautions if pulmonary infiltrate, Airborne Precautions plus Contact Precautions, if potentially infectious draining body fluid present, Petechial/ecchymotic with fever (general). Outcomes. So, if the disease is left untreated for a long time, it can cause some serious damage to your nervous system some of which can . Your Guide to Salmonella Meningitis and How to Spot It, Group B Streptococcal (GBS) Meningitis: Symptoms, Treatment, Outlook, and More. Microscopy of cerebrospinal fluid Meningitis can be caused by fungi, parasites, injury, or viral or bacterial infection. Copyright 2023 American Academy of Family Physicians. It is associated with a variety of complications including disseminated disease as well as neurologic complications . These patients, as well as those coinfected with human immunodeficiency virus, should be managed in consultation with an infectious disease subspecialist when available. Academic Pulmonary Sleep Medicine Physician Opportunity in Scenic Central Pennsylvania, MEDICAL MICROBIOLOGY AND CLINICAL LABORATORY MEDICINE PHYSICIAN, CLINICAL CHEMISTRY LABORATORY MEDICINE PHYSICIAN, Copyright 2023 Infectious Diseases Society of America. definitions. Specific recommendations for the treatment of non-HIV-associated cryptococcal meningitis are summarized in table 1. (2005). At approximately the same time, the incidence of cryptococcal infections rose dramatically, due in large part to the explosion of the AIDS epidemic around the world and the use of more potent immunosuppressive agents by increasing numbers of solid organ transplant recipients [4]. In addition, anemia occurs frequently and thrombocytemia occurs occasionally (possibly as a result of exposure to heparin). Several treatment options exist for managing elevated intracranial pressure (table 3) including intermittent CSF drainage by means of sequential lumbar punctures, insertion of a lumbar drain, or placement of a ventriculoperitoneal shunt. More Information. Surgery should be considered for patients with persistent or refractory pulmonary or bone lesions. The Bacterial Meningitis Score has a sensitivity of 99% to 100% and a specificity of 52% to 62%, and appears to be the most specific tool available currently, although it is not widely used.2527 The score can be calculated online at http://reference.medscape.com/calculator/bacterial-meningitis-score-child. Recently, lipid formulations of amphotericin B have been tested in cryptococcal meningitis and may have some toxicity profile advantages over the conventional amphotericin B formulation when used alone or possibly with flucytosine [12, 29]. Please check for further notifications by email. Early, appropriate treatment of non-CNS pulmonary and extrapulmonary cryptococcosis reduces morbidity and prevents progression to potentially life-threatening CNS disease. Immunocompetent patients who are asymptomatic and who have a culture of the lung that is positive for C. neoformans may be observed carefully or treated with fluconazole, 200400 mg/d for 36 months [3, 4, 6, 7] (AIII; see article by Sobel [8] for definitions of categories reflecting the strength of each recommendation for or against its use and grades reflecting the quality of evidence on which recommendations are based).