MANAGEMENT OF CRYPTOCOCCAL MENINGITIS IN PATIENTS WITH AIDS

A case of crypotoccal meningitis in a patient with the acquired immunodeficiency syndrome (AIDS) is described, as well as the epidemiology, pathogenesis, clinical manifestation diagnosis, and therapeutic management of the disease. In July 1987 a 38-year-old white man was admitted to the hospital because of confusion, disorientation, and headache. His medical history was notable for a positive human immunodeficiency virus test. Culture of the cerebrospinal fluid was positive for Cryptococcus neoformans. The patient was started on amphotericin B 16 mg/day (0.3 mg/kg/day) intravenously and flucytosine 2 g every six hours (150 mg/kg/day) orally. Despite premedication with diphenhydramine and acetaminophen, he experienced rigors that were treated with hydrocortisoine and meperidine. Three weeks later he was discharged on flucytosine 2 g orally every six hours and amphotericin B 50 mg intravenously every other day. One week later the patient developed fever and chills; blood cultures were positive for methicillin-sensitive Straphylococcus aureus, and his peripheral leucocyte count was 1.8 .times. 103 / cu mm. Flucytosine was discontinued, and he was treated with intravenous nafcillin while remining on amphotericin B. In October the patient complained of nausea, vomiting, weakness, and agitation. A CSF latex agglutination titer for cryptoccal antigen was 1:32. He was treated with amphotericn B 50 mg daily until symptoms resolved and then continued on amphotericin B 50 mg twice weekly. Cryptocococosis is the most common life-threatening fungal infection among AIDS patients. In contrast to immunocompetent hosts, this population invariably develops disseminated disease, with 85% having meningeal involvement. The most effective therapy for cryptococcal meningitis in patients with AIDS has not been established. Conventional therapy consists of amphortericin B and flucytosine. However, the bone-marrow-suppressive effects of flucytosine make administration of this drug difficult in AIDS patients. Because of the high relapse rates, maintenance therapy with amphotericin B is recommended. Relapse is associated with a mortality rate of 75-100%. Therapeutic management of cryptococcal meningitis in patients with AIDS is problematic. Although many patients improve clinically during initial therapy with antifungal agents, cryptococcosis is difficult to eradicate.