Diagnosis requires the demonstration of C. neoformans in normally sterile tissue (e.g., positive cultures of CSF or blood).
- India ink smear of CSF is a useful rapid diagnostic technique but may yield negative results in pts with a low fungal burden.
- Cryptococcal antigen testing of CSF and/or serum provides strong presumptive evidence for cryptococcosis; such testing often yields negative results in pulmonary cryptococcosis and is of limited utility in monitoring response to therapy.
Treatment: Cryptococcosis - Immunocompetent pts
- - Pulmonary cryptococcosis is treated with fluconazole (200-400 mg/d) for 3-6 months.
- - Severe extrapulmonary cryptococcosis may initially require AmB (0.5-1.0 mg/kg daily for 4-6 weeks).
- - CNS disease is treated with an induction phase of AmB (0.5-1.0 mg/kg qd) followed by prolonged consolidation therapy with fluconazole (400 mg/d).
- - Meningoencephalitis is treated with AmB (0.5-1.0 mg/kg) plus flucytosine (100 mg/kg) daily for 6-10 weeks or with the same drugs at the same dosages for 2 weeks followed by fluconazole (400 mg/d) for ≥10 weeks.
- Immunosuppressed pts are treated with the same initial regimens except that maintenance therapy with fluconazole is given for a prolonged period (sometimes throughout life) to prevent relapse.
- - HIV-infected pts with CNS involvement are typically treated with AmB (0.7-1.0 mg/kg daily) plus flucytosine (100 mg/kg qd) for at least 2 weeks followed by fluconazole (400 mg/d) for 10 weeks and then by lifelong maintenance therapy with fluconazole (200 mg/d).
- - An alternative regimen involves fluconazole (400-800 mg/d) plus flucytosine (100 mg/kg qd) for 6-10 weeks followed by fluconazole (200 mg/d) as maintenance therapy.
- Newer triazoles (e.g., voriconazole, posaconazole) appear effective, but clinical experience is still limited.
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