Cryptococcal Meningitis

Cryptococcal meningitis is a serious fungal infection of the membranes covering the brain and spinal cord, caused by Cryptococcus fungi. It occurs almost exclusively in people with significantly weakened immunity, most often advanced, untreated HIV infection, and is a medical emergency.

• Headache, often severe and gradually worsening over days to weeks
• Fever
• Neck stiffness may be present but is sometimes mild or absent, unlike in bacterial meningitis
• Confusion or altered behaviour
• Visual disturbance or, in more advanced cases, seizures or reduced consciousness

• Caused by Cryptococcus fungi, acquired through inhalation, which can then spread to the brain and its lining in people with significantly weakened immunity.
• Occurs almost exclusively in people with advanced immune suppression, most commonly untreated or late-diagnosed HIV infection with a very low CD4 count.

• Suspected in anyone with advanced HIV infection presenting with headache, especially if gradual and worsening, with or without fever or neck stiffness.
• Lumbar puncture with cerebrospinal fluid (CSF) analysis is essential for diagnosis; measuring and recording the opening pressure is especially important, as raised pressure requires specific additional management.
• A rapid cryptococcal antigen test on blood or CSF, where available, can support prompt diagnosis; India ink staining or fungal culture of CSF can also confirm the diagnosis.

Cryptococcal meningitis is a medical emergency managed at hospital level with antifungal treatment, typically starting with an induction course (such as amphotericin B combined with flucytosine, where available, or fluconazole where these are not accessible) for the first couple of weeks, followed by a longer consolidation and then maintenance course of fluconazole.

Repeated lumbar punctures to relieve raised pressure in the fluid around the brain are an important part of management when pressure is elevated, as this significantly improves survival.

Antiretroviral therapy for HIV is typically started after a short delay following the start of antifungal treatment, following national guidance, to reduce the risk of a dangerous inflammatory reaction as the immune system recovers.

Long-term maintenance antifungal treatment (fluconazole) continues for a prolonged period after the acute infection is controlled, until the immune system has recovered sufficiently on antiretroviral therapy.

• Early HIV diagnosis and prompt initiation of antiretroviral therapy is the most effective way to prevent cryptococcal meningitis, since it prevents the severe immune suppression that allows this infection to occur.
• Routine screening for cryptococcal infection in the blood may be recommended for people newly diagnosed with advanced HIV in some settings, allowing pre-emptive treatment before meningitis develops.
• Seek prompt medical assessment for persistent or worsening headache in anyone with known advanced HIV infection.