neurologic disorders
Subacute and Chronic Meningitis
Cryptococcal meningitis
 Cryptococcosis is the most common cause of chronic meningitis in the Western hemisphere and the most common opportunistic infection in patients with Cryptococcus neoformansvar.neoformans(serotype D strains) C. neoformansvar.grubii(serotype A strains) C. neoformansvar.grubiicauses 90% of cases of cryptococcal meningitis.C. neoformanscan be in soil, trees, and pigeon or other bird excreta. Meningitis due toC. neoformansusually develops in immunocompromised patients but occasionally develops in patients without apparent underlying disease. Another cryptococcal species,C. gattii, has caused meningitis in the Pacific region and Washington state; it may cause meningitis in people with a normal immune status. Cryptococci cause a basilar meningitis with hydrocephalus and cranial nerve deficits; vasculitis is less common. Meningeal symptoms usually begin insidiously, at times with protracted relapses and remissions. Cryptococcal meningitis may develop and persist over months or years. CSF findings typically include Lymphocytic pleocytosis Elevated protein Low glucose However, cellular response may be minimal or absent in patients with advanced AIDS or another severe immunocompromised state. Diagnosis of cryptococcal meningitis is based on cryptococcal antigen tests and fungal culture; diagnostic yield with these tests is 80 to 90%. India ink preparation, which has a sensitivity of 50%, may also be used. Occasionally, diagnosis is extremely difficult and may require examination of multiple large (20 to 30 mL) amounts of CSF over a period of time. Tests for cryptococcal antigen and fungal culture should be done each time. Patients who haveC. neoformansmeningitis but do not have AIDS are traditionally treated with the synergistic combination of 5-fluorocytosine andamphotericin B. Patients with cryptococcal meningitis and AIDS are treated withamphotericin Bplusflucytosine(if tolerated) followed byfluconazole. 