Meningitis, Cryptococcal

Description

Diagnostic criteria

General and supportive measures

Medicine treatment

Referral

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ICD-10 code: G02.1

DESCRIPTION

An uncommon childhood meningitis that may occur in older HIV-infected children with severe CD4 T-cell depletion. Pulmonary and skin involvement can occur.

DIAGNOSTIC CRITERIA

Clinical

• Acute or chronic headache in an older HIV-infected child. Meningism need not be present.
• Often presents with cranial nerve palsy.
• Can occur as result of Immune Reconstitution Inflammatory Syndrome (IRIS) after initiation of antiretroviral therapy.

Investigations

• Test all cerebrospinal fluid (CSF) specimens from HIV-infected children with suspected meningitis.
• CSF: India ink stain, and/or cryptococcal antigen test (more sensitive than India ink stain). Measure CSF opening pressure.
• Fungal culture – CSF, blood and urine.

If indicated:

• Chest X-ray.
• Ophthalmological assessment.

GENERAL AND SUPPORTIVE MEASURES

• Admit to a high or intensive care unit, if appropriate.
• Monitor, where indicated:
  • neurological status,
  • respiration,
  • heart rate,
  • body temperature,
  • blood pressure,
  • electrolytes,
  • haematocrit,
  • blood glucose,
  • acid-base status,
  • blood gases,
  • fluid balance, i.e. hydration,
  • serum and urine osmolality.
• Ensure adequate nutrition by enteral feeding where possible. Use a nasogastric tube if necessary. If enteral feeding is not possible, provide appropriate intravenous fluids.

MEDICINE TREATMENT

Treatment

Preferred initial treatment (2 weeks):

First week:

• Amphotericin B deoxycholate, IV, 1 mg/kg/day as a daily infusion in 5% dextrose water over 4 hours.
  • Adjust dosing interval in patients with renal impairment.
  • Check serum potassium and magnesium at least 3 times a week.
  • Do not use a bacterial filter with amphotericin B deoxycholate.

Prehydration before administering amphotericin B deoxycholate to prevent renal impairment:

• Sodium chloride 0.9%, IV, 15 mL/kg plus potassium chloride, 20 mmol/L infused over 2–4 hours.

PLUS 

• 5-Flucytosine 100 mg/kg/day in 4 divided doses.

Second week:

• Fluconazole, IV/oral, 12 mg/kg/day.
  • Maximum dose: 800 mg.

OR

Alternative initial treatment (2 weeks):

• Amphotericin B deoxycholate, IV, 1 mg/kg/day as a daily infusion in 5% dextrose water over 4 hours.

PLUS 

• Fluconazole, IV/oral, 12 mg/kg/day.
  • Maximum dose: 800 mg.

Prehydration before administering amphotericin B deoxycholate to prevent renal impairment:

• Sodium chloride 0.9%, IV, 15 mL/kg plus potassium chloride, 20 mmol/L infused over 2–4 hours.

OR

Additional alternative: Only if Amphotericin B deoxycholate is not available/not tolerated or contraindicated, as this regimen is associated with poorer outcomes.

Initial treatment (2 weeks):

First week:

• Fluconazole, IV/oral, 12 mg/kg/day.
  • Maximum dose: 800 mg.

PLUS

• 5-Flucytosine 100 mg/kg/day in 4 divided doses.

Second week: 

• Fluconazole, IV/oral, 12 mg/kg/day.
  • Maximum dose: 800 mg.

THEN

Consolidation treatment (8 weeks):

• Fluconazole, oral, 12 mg/kg/day for 8 weeks.
  • Maximum dose: 800 mg.

Secondary prophylaxis (maintenance treatment): 

• Fluconazole, oral, 6 mg/kg/day.
  • Maximum dose: 400 mg.

Discontinue secondary prophylaxis:

• Children < 6 years of age, on ART: CD4 count > 25% for at least 6 months.
• Children > 6 years of age, on ART: CD4 count > 200 for at least 6 months.
• Adolescents on ART: CD4 count increases to between 100– 200 cells/mm³ for at least 6 months.
• Re-start prophylaxis if CD4 count drops below thresholds above.

For continued raised intracranial pressure:

• Daily therapeutic lumbar puncture is indicated if initial LP manometric pressure > 25 cm of water in the lateral recumbent position.
• Continue until pressure stabilises below 25 cm of water.
• Remove 10–20 mL daily and obtain a closing pressure.
• Refer for neurosurgical intervention if pressure persistently high and/or above 40 cm water.

REFERRAL

• All cases not responding to initial treatment.
• All patients with IRIS.

Click here for the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa Paediatric Hospital _2023, 5th edition_Updated July 2024 

Chapter 8: Infective/Infectious Diseases,   8.12 Meningitis, Cryptococcal