Cryptococcal Meningitis: Treatment, Procedure, Cost and Side Effects

Cryptococcal meningitis is associated with brain infection caused by encapsulated yeast which can directly colonize the airways, and can also lead to disseminated disease. People with defective cell-mediated immunity are likely to get affected by it. It is a highly dangerous and life-threatening fungal infection found especially in HIV patients and can also make organ transplantation complicated. Furthermore, it complicates sarcoidosis, reticuloendothelial malignancy, and even corticosteroid treatment.

In most immunocompetent patients, pulmonary cryptococcosis is seen to have been revolving without any specific therapy. In cases of pulmonary cryptococcosis in immunosuppressed hosts, CNS cryptococcosis and disseminated nonpulmonary non-CNS cryptococcosis, anti-fungal therapy is recommended by doctors. Patients with AIDS undergoing cryptococcal meningistis are given Amphotericin B deoxycholate, 0.7-1 mg/kg/day for 2 weeks. Amphotericin B is a serious side effect causing drug. Therefore, the administration of amphotericin involves impatient hospitalization, a substantial nursing commitment and proper intravenous administration.

Flucytosine, another antifungal drug, is given in 100 mg/kg/day for 2 weeks and 4 divided doses. After 2 weeks, the dosage will increase to 400 mg/day for a minimum of 10 weeks. Voriconazole drug can be used an alternative for flucytosine in the induction therapy. This therapy has been properly examined and found to have the same EFA to flucytosine and amphotericin.

Along with the multiple ways of treating the disease, antifungal drug therapy is the most beneficial one. It is available as an intravenous (IV) drug or a pill form. Fluconazole is known to be easily tolerable and fairly effective. Patients who cannot take fluconazole are given itraconazole. Some health care providers use a combination of flucytosine casules and amphotericin B. Amphotericin B is quite a strong drug. It is given as a slow intravenous (IV) infusion or an injection. Both of these drugs are known to cause serious side effects. Advil or Tylenol intake half an hour before taking the drug can reduce the side effects to a great extent. There is a new method of amphotericin found, in which the medication is enclosed in fat bubbles (liposomes). There are fewer side effects in this method.

In about 50% of the people who get cryptococcal meningitis, there is a usual relapse. The repetition is reduced only if people maintain a proper and regular antifungal drug intake routine. However, people who underwent an increase of CD4 to more than 100 and had an undetectable viral heap for a period of 3-4 months, found to have no relapse of meningitis, according to a recent study. For some people, daily spinal fluid drainage for reduced pressure on the brain is also part of the treatment.

The eligibility criteria of cryptococcal meningitis depends on the CD4 count. If the CD4 count is 350 cells or lower, the person is eligible for the treatment. Patients who haven’t undergone treatment for acute cryptococcal meningitis before are eligible for radiation therapy. It is a must that a patient must have a baseline cerebrospinal fluid (CSF) culture-positive for Cryptococcus neoformans. Written and detailed consent must be obtained from either the legal guardians or from the patient himself. The treatment is started as soon as the patient starts showing signs related to the disease.

In case of co-existing conditions patients are excluded. These include evidence of chronic or acute meningitis based upon an etiology and not cryptococcosis. Severe or moderate liver disease is also a criteria of non-eligibility. History of intolerance or allergy to azoles or imidazoles excludes you from receiving the treatment.

Amphotericin B has multiple side effects including low blood pressure, high fever, kidney damage, decreased number of either red blood cells or white blood cells, vomiting, nausea and chills. A newly found formula of the drug, which is the enclosure of active compound, is being studied and may happen to have fewer side effects. However, there needs to be more study and analysis of amphotericin B to find out the effectiveness and safety of this new form of drug. Flucytosine may also result in serious side effects, including diarrhea, abdominal discomfort, seizures, liver damage or rash.

The post-treatment guidelines of cryptococcal meningitis, is to take fluconazole daily in order to prevent reoccurrence of the disease. Most doctors also recommend taking intravenous amphotericin B weekly or once every two weeks. Amphotericin is a known cause of infusion related reactions like rigors, nausea and fever. For the symptomatic management of these reactions, doctors give the patients adjunctive acetaminophen with hydrocortisone. Acute kidney injury occurs when the dosage of amphotericin is in accumulation. This can be reversed with discontinuation. Hence, the administration of ample amounts of IV fluids while receiving this treatment can prevent renal insufficiency.

In case of a patient without AIDS, it may take 6-10 weeks for recovery. This usually results through the initial amphotericin B therapy either alone or with the combination of flucytosine. Administration of amphotericin B alone for 6-8 weeks can prove beneficial. Combination treatment with flucytosine for 2 weeks may also be effective. In most cases, this method has resulted in patients having a normal cell count and CSF glucose. CFS cultures need to remain negative throughout during the antifungal therapy. Patients showing signs of positive CSF cultures need to extend therapy until it turns negative.

Each vial of intravenous drugs, infused in a patient’s veins, amounts to Rs. 1,080. This treatment therapy has to go on for 6-10 weeks for a noticeable change. The total amount of drugs used in a couple of week amount to Rs. 3,465. A week of short-intrathecal treatment is Rs. 2,932. The total cost of the treatment varies according to the time period of recovery of a patient.

Cryptococcal meningitis is a prevalent opportunistic fungal infection with high morbidity and mortality rate. It can be controlled, but permanent recovery is not guaranteed. The results of the treatment depend upon the dosage of drug intake each week. There are always strong chances of reoccurrence of cryptococcal meningitis in patients. With the discontinuation of antifungal drugs, the disease is more likely to come back and affect the person.

There are alternate therapies for patients who have a major fungal disease, are at a high risk for renal dysfunction, or have failed therapy. Liposomal amphotericin B 3-4 mg/kg/day continued for at least a couple of weeks will definitely help. In case the patient shows signs of a significant clinical improvement by the CSF culture being negative, means that the initial therapy has proven to be successful.