Cryptococcosis

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Click here to access the Primary Health Care - PHC Chapter 11: Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV and AIDS) - 26 February 2026

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Description

Investigations

Medicine Treatment

Referral

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B20.5 + B45.0-3/B45.7-9

DESCRIPTION

A life-threatening fungal infection caused by the fungus Cryptococcus. The fungi remain inactive unless a person’s immune system is weakened, such as in transplant recipients or persons with untreated HIV.

INVESTIGATIONS

• All ART-naïve adults and adolescents with CD4 < 200 cells/mm³ should have a serum cryptococcal antigen (CrAg) test done (unless confirmed diagnosis of cryptococcal infection). This is performed as a reflex test on the patient’s CD4 sample if it is <100 cells/mm³ . If the CD4 cell count is between 100 and 199, a separate sample should be sent for CrAg testing.
• All patients with a positive serum CrAg test should have a lumbar puncture (LP) to exclude cryptococcal meningitis. The CSF is tested for cryptococcal meningitis by CSF CrAg.

LoE:IIa³⁵

MEDICINE TREATMENT

If CSF CrAg positive:

Refer for liposomal amphotericin B, IV (induction phase) and monitoring of intracranial pressure symptoms - See: Cryptococcosis.

Patients may be down referred for consolidation and maintenance phase therapy; see below.

If there is any delay in performing LP, start oral fluconazole therapy:

• Adults: Fluconazole, oral, 1200 mg immediately.
• Children: 12 mg/kg to a maximum dose of 800 mg immediately.

LoE:IVb³⁶

No symptoms present and CSF CrAg negative (LP):

Induction phase

• Fluconazole, oral 1200 mg daily for 14 days.

LoE:IIIb³⁷

Consolidation phase

Follow with:

• Fluconazole, oral, 800 mg daily for 8 weeks.

Maintenance phase

•  Fluconazole, oral, 200 mg daily. 
  • Continue for at least 1 year provided that the CD4 count increases to >200 cells/mm³ on ART. If the CD4 count does not increase continue treatment indefinitely.

LoE:IIIb³⁸

•  Commence ART: See: Antiretroviral therapy 
  • Cryptococcal meningitis: After 4–6 weeks after starting antifungal therapy.
  • Asymptomatic cryptococcosis: No need to delay ART. ART can be started immediately.

LoE:IIIb³⁹

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CAUTION
- Fluconazole is potentially teratogenic when used during the 1st trimester, but pregnant women should be counselled that the benefits of fluconazole likely outweigh the risks in the management of cryptococcosis.
- All pregnant women <20 weeks gestation exposed to fluconazole should have an ultrasound scan to detect congenital abnormalities.
LoE:IIIb⁴⁰
- Although fluconazole is excreted into breast milk at concentrations similar to maternal plasma concentrations, the dose that the infant is exposed to with doses <400 mg is similar to the dose used in systemic treatment in infants. Even for higher doses, the benefits will likely outweigh the risks, though this can be discussed with a specialist.
LoE:IVb⁴¹

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REFERRAL 

• If LP unavailable: Refer all serum CrAg positive patients to a facility where LP is available.
• If LP available:
  • Refer all patients that are CSF CrAg positive (cryptococcal meningitis).
  • Refer all symptomatic patients that are CSF CrAg negative (non-meningeal cryptococcosis).
• All patients with complications.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 2.1_09 December 2024

Chapter 11: Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV AND AIDS)_11.3 Opportunistic Infections, Treatment in Adults_11.3.4 Cryptococcosis