Cryptococcal meningitis: a review for emergency clinicians

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

Research output: Contribution to journalReview articlepeer-review

Abstract

Introduction: Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization. Objective: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM. Discussion: This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS). Conclusions: CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.

Original languageEnglish (US)
Pages (from-to)1031-1042
Number of pages12
JournalInternal and Emergency Medicine
Volume16
Issue number4
DOIs
StatePublished - Jun 2021

Keywords

  • Antifungal therapy
  • Antiretroviral therapy
  • Cryptococcosis
  • HIV
  • Immunosuppression
  • Meningitis

ASJC Scopus subject areas

  • Internal Medicine
  • Emergency Medicine

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