Cryptococcosis

Cryptococcosis is an infection caused by a fungus found in dirt. When it goes into the lining of the brain and the spinal cord, it’s called cryptococcal meningitis. (Meningitis is when the lining of the brain and the spinal cord swell and become inflamed.) Cryptococcal meningitis is the most common brain and spinal cord infection linked to HIV.

The cryptococcal fungus can also infect the skin, lungs, kidneys, bone marrow, urinary tract and lymph nodes. Cryptococcus infections in the lungs can lead to pneumonia. 

In people with weak immune systems, cryptococcosis can quickly cause coma and death without treatment. Once a person gets cryptococcal meningitis, he or she needs to be on drugs to keep it from coming back.

Symptoms

At first, signs of cryptococcosis may be like those of flu. The symptoms come on slowly. A person living with HIV may not be able to tell what is happening. Signs of cryptococcal meningitis may include:

• Severe Headache
• A high fever (over 100°)
• Confusion
• Nausea
• Pain from bright light
• Seizures
• Severe body aches
• Stiff neck
• Vomiting

A person who feels confusion, bad headache or seizures, should call his or her doctor right away or go to an emergency room. If fever, nausea, vomiting, body aches or pain from bright light go on for three or more days in a row, the doctor should be called.

If the infection spreads past the lungs, brain and spinal cord, it’s called disseminated (spread out) infection. This causes spots on the skin (lesions). The spots will look different from one person to another. Sometimes these spots look like other skin conditions. Sometimes these spots are the first sign that a person has cryptococcosis.

Causes

A fungus found in dirt and bird droppings causes cryptococcosis. Healthy people can keep the fungus in check before it spreads past the lungs. The risk of this condition is highest when CD4 counts are below 100. 

Prevention

Avoid breathing in dust. Stay away from places where birds roost or leave a lot of droppings.

Fluconazole (Diflucan®) can prevent cryptococcal meningitis. It also may lead to yeast infections like thrush or vaginitis that resist treatment with many drugs. When a resistant yeast-infection happens, it can only be treated with Amphotericin B. Fluconazole is usually given to people who have had cryptococcal meningitis once to prevent its returning.

Powerful anti-HIV therapy helps prevent infection by cryptococcosis.

Diagnosis

A doctor will take samples of blood and spinal fluid to analyze. One type of test looks for a protein (an antigen) that the cryptococcus makes.  This test can detect about 95% of the people who are ill with cryptococcal meningitis.  Sometimes a culture will be done.  This is where the blood or spinal fluid is used to try to grow a sample of the fungus in the lab. This test is slower than the first one.

To get a sample of spinal fluid, a doctor will insert a needle in the middle of the back just above the hips (a spinal tap). The area will be numbed first. The needle is used to remove spinal fluid. At the same time, the pressure of the fluid can also be measured. If the pressure is too high, the doctor may drain some of the fluid. Some people get headaches for a few days after having a spinal tap. Sometimes lying down for an hour or two right after the spinal tap can prevent the headache.

Treatment

The sooner cryptococcosis is found, the better it can be treated. Less toxic drugs can be used to treat the infection when it is found early.

Several types of anti-fungal drugs are used to treat cryptococcosis. Usually amphotericin B is given at first, followed by fluconazole. Itraconazole is sometimes given to people who cannot take fluconazole. Some health care providers use a combination of amphotericin B and flucytosine capsules.

Amphotericin B is a very strong drug that can cause kidney damage.  It can be given either as a shot or slowly through a vein (intravenous infusion). A newer form of the drug is wrapped in bubbles of fat (liposomes). This slows the process by which the body breaks down the drug.  Lower doses of the drug can be used as a result. This also means there are fewer side effects.

Because meningitis causes the linings of the brain and spinal cord to swell, pressure develops on the brain. For some people, removing some spinal fluid every day helps reduce the pressure.

Cryptococcal meningitis comes back in about half the people who get it the first time. Continuing to take antifungal drugs such as fluconazole for life help prevent this. (Federal guidelines for treating infections such as cryptococcal recommend that fluconazole be continued even when the patient is also on antiretroviral drugs.