Burden of cryptococcal meningitis in Malawi

Recent advances in management of cryptococcal meningitis: commentary

Cryptococcal meningitis remains a substantial health burden with high morbidity, particularly in developing countries. Antifungal treatment regimens are guided by host factors, severity of illness (including presence of complications), and causative cryptococcal species. Recent clinical studies indicate the need for rapidly fungicidal induction therapy regimens using amphotericin B in combination with flucytosine for optimal outcomes. Maintenance therapy with fluconazole is necessary until recovery of immune function. Cryptococcus gattii meningitis requires prolonged induction/eradication therapy. Prompt control of raised intracranial pressure or hydrocephalus is essential. Clinicians should be vigilant for immune restoration-like features. Adjuvant surgery, corticosteroids, and/or recombinant interferon-gamma may be required for large cryptococcomas, cerebral edema, or refractory infection.

Treatment of cryptococcal meningitis in resource limited settings

PURPOSE OF REVIEW

Cryptococcal meningitis most commonly occurs in advanced HIV. Although diminishing in the developed world with antiretroviral therapy (ART), it remains a major problem in resource-limited settings. ART rollout will improve long-term HIV survival if opportunistic infections are effectively treated. Considering cryptococcal meningitis in that context, this review addresses excess morbidity and mortality in developing countries, treatment in areas of limited drug availability and challenges posed by combined anticryptococcal and HIV therapy.

RECENT FINDINGS

From Early Fungicidal Activity (EFA) studies, amphotericin B-flucytosine is best induction therapy but often unavailable; high dose amphotericin B monotherapy may be feasible in some settings. Where fluconazole is the only option, higher doses are more fungicidal. Serum cryptococcal antigen testing may identify patients at highest disease risk and primary prophylaxis is effective; the clinical role of such interventions needs to be established. Timing of ART introduction remains controversial; early initiation risks Immune Reconstitution Disease (IRD) delays may increase mortality.

SUMMARY

Amphotericin B based treatment is appropriate where possible. More studies are needed to optimize fluconazole monotherapy doses. Other research priorities include management of raised intracranial pressure, appropriate ART initiation and IRD treatment. Studies should focus on developing countries where problems are greatest.