Wednesday, May 02, 2007

Cryptococcus/fungals/meningoencephalitis pearls (Dr Perfect AAN 2007 lecture)

1.  Cryptococcus neoformans serotype A and D (grubii and neofomans) and serotype B and C (Cr. gattii) are major serotypes.  Gattii affects more normal hosts and has more torulomas. 
2.  Consider IRIS (immune reconstition syndrome) in HIV patients starting HAART or with any CHANGE in immunosuppressive regiment.  If patient seems to be getting worse in spite of treatment, this may be one of the few times to pay attention to the Crypto antigen titer.  If it is dropping the patient may have IRIS and may not be failing therapy. 
3.  Don't put a shunt in until the patient is already on treatment-- you'll just have to replace it later.  Increased ICP can occur on presentation chronic and indolent, acutely during early therapy, or classic hydrocephalus with therapy.  Consider increased ICP if frequent and severe headaches, pappilledema, hearing loss, or pathologic reflexes present.  Consider repeat LP's as a treatment modality.  Shunts don't work often in comatose patients.
4. Indications for surgery include diagnostic biopsy, toruloma greater than 3 mm, zygomycetes and infarcted tissue, phaeohyphomycosis, shunt placement.
5.  Diagnosis of other fungi clues: neutrophilic meningitis (aspergillus, scedosporium, blastomyces, zygomycetes), large volume CSF cultures (Blasto/histo/coccidio).  Histoplasmosis antigen, sporotrix CSF antibodies, cocciiodes CFA, aspergillus galactomannan.
6.  Wangiella (Exophiala) dermatitidis meningitis occurs due to injectable steroids that are contaminated, with a 1-11 month incubation period.  Therapy with voriconazole. 
7.  Hyalohyphomycosis-- occurs in near fresh water drownings, due to steroids, and diabetes, usually from sinus disease,  causes abscesses, surgery is critical for diagnosis and debulking. 
8.  Drug resistance is rare but it occurs.

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