Cryptococcosis clinical features and management

Cryptococcosis clinical features and management

Cryptococcosis (torulosis) is a systemic infection with theyeast-like fungus Cryptococcus neoformans. The organismis commonly found in soil contaminated by bird droppings,notably those of pigeons. Disease occurs following inhalationof the organism, but it is unusual in immunocompetentpeople and currently is seen most often in patientswith AIDS.Respiratory infection usually occurs in the absence of CNS involvement. It is more chronic and may regressspontaneously.

Clinical features CNS infection causes chronic meningitis with very lowgradesymptoms on presentation. Cranial nerve palsiesmay cause visual abnormalities, loss of acuity or diplopia,or facial weakness and numbness. The course is slow orrapidly progressive, depending on the patient's immunestatus. Corticosteroid therapy accelerates progression.Respiratory infection usually occurs in the absence ofCNS involvement. It is more chronic and may regressspontaneously.Skin lesions are found in 10% of patients. The face andscalp are the most common sites of the painless lesions,which are variable nodules, sometimes ulcerating.

Diagnosis Routine culture is often negative. In the CSF little abnormalityis found, apart from a few cells, mainly lymphocytes,mildly reduced glucose compared with the blood, andslightly raised protein. The organisms are shown by Indiaink preparations, but the most sensitive method of diagnosisis by detection of antigen in CSF and sometimes in blood.

Management Treatment is started with fluconazole 400 mg daily, by mouthif the patient is not vomiting, or intravenously at the samedose. If there is no response after 2 days amphotericin B issubstituted, giving up to 1-1.5 mg/kg/day until there is a clinicalresponse, and then reducing to three times weekly to atotal dose of 1-2.5g.

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