Cryptococcal meningitis: a review for emergency clinicians

Fisher, Kathryn; Montrief, Tim; Ramzy, Mark; Koyfman, Alex; Long, Brit

doi:10.1007/s11739-020-02619-2

Cited by 30 publications

(23 citation statements)

References 77 publications

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“…Very similar findings in CSF corresponding to mononuclear or lymphocytic pleiocytosis, hyperproteinorhachia, hypoglycorhachia and hyperlactatorhachia have been described in patients with neurotuberculosis, neurolisteriosis and cryptococcal meningitis [ 10 , 19 , 32 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. In contrary, Bicanic and Harrison (2004) reported normal CSF white cell counts in HIV-associated cryptococcal meningitis, probably reflecting inability to mount protective immune response in these patients [ 49 ].…”

Section: Introductionsupporting

confidence: 64%

Basic Analysis of the Cerebrospinal Fluid: An Important Framework for Laboratory Diagnostics of the Impairment of the Central Nervous System

Kelbich

Hrach

Spicka³

et al. 2022

CIMB

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Laboratory analysis of basic cerebrospinal fluid (CSF) parameters is considered as essential for any CSF evaluation. It can provide rapidly very valuable information about the status of the central nervous system (CNS). Our retrospective study evaluated parameters of basic CSF analysis in cases of either infectious or non-infectious CNS involvement. Neutrophils are effector cells of innate immunity. Predominance of neutrophils was found in 98.2% of patients with purulent inflammation in CNS. Lymphocytes are cellular substrate of adaptive immunity. We found their predominance in 94.8% of patients with multiple sclerosis (MS), 66.7% of patients with tick-borne encephalitis (TBE), 92.2% of patients with neuroborreliosis, 83.3% of patients with inflammatory response with oxidative burst of macrophages in CNS and 75.0% of patients with malignant infiltration of meninges (MIM). The simultaneous assessment of aerobic and anaerobic metabolism in CSF using the coefficient of energy balance (KEB) allows us to specify the type of inflammation in CNS. We found predominantly aerobic metabolism (KEB > 28.0) in 100.0% CSF of patients with normal CSF findings and in 92.8% CSF of patients with MS. Predominant faintly anaerobic metabolism (28.0 > KEB > 20.0) in CSF was found in 71.8% patients with TBE and in 64.7% patients with neuroborreliosis. Strong anaerobic metabolism (KEB < 10.0) was found in the CSF of 99.1% patients with purulent inflammation, 100.0% patients with inflammatory response with oxidative burst of macrophages and in 80.6% patients with MIM. Joint evaluation of basic CSF parameters provides sufficient information about the immune response in the CSF compartment for rapid and reliable diagnosis of CNS involvement.

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Section: Introductionsupporting

confidence: 64%

Basic Analysis of the Cerebrospinal Fluid: An Important Framework for Laboratory Diagnostics of the Impairment of the Central Nervous System

Kelbich

Hrach

Spicka³

et al. 2022

CIMB

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“…11 Note that specific recommendations vary for specific populations, such as HIV-infected individuals, organ transplant recipients, children, and pregnant women. 14 A comprehensive treatment of cryptococcal meningitis management for ED clinicians can be found in Fisher et al 5 Patients with cryptococcal meningitis who are not presenting with classic signs and symptoms of meningitis and who do not have the main risk factors (immunosuppression), often have poor outcomes because diagnosis and treatment are delayed. 11 The most important prognostic factors are the nature of the underlying immunosuppression and the concurrent disease processes.…”

Section: Discussionmentioning

confidence: 99%

“…Immunocompetent patients may have a longer time from the onset of illness to presentation, a more evident inflammatory response (leading to elevated intracranial pressure), and various comorbidities that may also contribute to poor prognosis. 3,5,6,7 The purpose of this case report is to illustrate how patients with cryptococcal meningitis may not have the risk factors, patient history, or physical exam findings that are commonly seen in meningitis. Additionally, we emphasize that immunocompetent patients are likely to develop cryptococcal meningitis in the absence of a classic meningitis presentation, thus, the disease should be considered in every patient who presents to the emergency department (ED) with headache, altered mental status, or behavioral change.…”

Section: Introductionmentioning

confidence: 99%

An Uncommon Presentation of Cryptococcal Meningitis in an Immunocompetent Patient: A Case Report

Correa¹,

Craver

Sandhu

2021

Clinical Practice and Cases in Emergency Medicine

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Introduction: Meningitis is a serious and potentially life-threatening infection of the central nervous system. Cryptococcus neoformans is a rare fungal cause of meningitis that commonly presents with atypical symptoms. Although this infection is most common in immunocompromised patients, it also occurs in immunocompetent patients. This case report describes an atypical presentation of cryptococcal meningitis in a seemingly immunocompetent patient. Case Report: A 40-year-old immunocompetent patient with no significant past medical history had visited the emergency department (ED) five times within a span of 30 days reporting dental pain and headache. Throughout each of the visits, no clear symptoms signaling the need for a meningitis workup were observed, as the patient had been afebrile, displayed no nuchal rigidity, and his presenting symptoms subsided within the ED after treatment. A lumbar puncture was performed after emergency medical services brought the patient in for his sixth ED visit, initially for stroke-like symptoms and altered mental status. Spinal fluid was indicative of cryptococcal meningitis. Conclusion: This case highlights the challenge of identifying cryptococcal meningitis in the ED, particularly in immunocompetent patients who do not display classic meningitis symptoms. It also highlights the importance of keeping a broad differential and carefully ruling out diagnoses when patients return to the ED multiple times for the same complaint.

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“…Cryptococcal meningoencephalitis (CM) is accountable for more than 220,000 infections and 181,000 deaths each year, including approximately 15% of AIDS-associated deaths worldwide [ 1 , 2 , 3 ]. Although advanced HIV infection is an important risk factor for CM, other risk factors are also crucial to consider, including—but not limited to—transplant, sarcoidosis, immunoglobulin disorders, cell-mediated immunodeficiencies, diabetes mellitus, use of several biologicals, immunosuppressive agents, including corticosteroids, and several hematologic malignancies [ 4 , 5 ].…”

Section: Introductionmentioning

confidence: 99%

Elevated Intracranial Pressure in Cryptococcal Meningoencephalitis: Examining Old, New, and Promising Drug Therapies

et al. 2022

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Despite the availability of effective antifungal therapy, cryptococcal meningoencephalitis (CM) remains associated with elevated mortality. The spectrum of symptoms associated with the central nervous system (CNS) cryptococcosis is directly caused by the high fungal burden in the subarachnoid space and the peri-endothelial space of the CNS vasculature, which results in intracranial hypertension (ICH). Management of intracranial pressure (ICP) through aggressive drainage of cerebrospinal fluid by lumbar puncture is associated with increased survival. Unfortunately, these procedures are invasive and require specialized skills and supplies that are not readily available in resource-limited settings that carry the highest burden of CM. The institution of pharmacologic therapies to reduce the production or increase the resorption of cerebrospinal fluid would likely improve clinical outcomes associated with ICH in patients with CM. Here, we discuss the potential role of multiple pharmacologic drug classes such as diuretics, corticosteroids, and antiepileptic agents used to decrease ICP in various neurological conditions as potential future therapies for CM.

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Cryptococcal meningitis: a review for emergency clinicians

Cited by 30 publications

References 77 publications

Basic Analysis of the Cerebrospinal Fluid: An Important Framework for Laboratory Diagnostics of the Impairment of the Central Nervous System

Basic Analysis of the Cerebrospinal Fluid: An Important Framework for Laboratory Diagnostics of the Impairment of the Central Nervous System

An Uncommon Presentation of Cryptococcal Meningitis in an Immunocompetent Patient: A Case Report

Elevated Intracranial Pressure in Cryptococcal Meningoencephalitis: Examining Old, New, and Promising Drug Therapies

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