Cryptococcus neoformans is an encapsulated yeastlike fungus. Infection is acquired through direct exposure to bird droppings. The infection is initially characterized by a localized pneumonitis, but when dissemination occurs the CNS is a preferential site for disease presumably because the CSF is a good culture media for cryptococci. The most common symptoms of cryptococcal meningitis are headache, fever, and malaise. Cryptococcal skin lesions may precede the development of meningitis, and when they are present, are an indication for lumbar puncture, even in the absence of signs and symptoms of meningitis.  Diagnosis is made by the examination of the CSF, and the following are typical abnormalities: (1) normal or slightly elevated opening pressure; (2) lymphocytic pleocytosis (usually of less than 100 cells/mm3 ); (3) elevated protein concentration; (4) decreased glucose concentration; and (5) positive cryptococcal antigen. The cryptococcal antigen is a highly sensitive and specific test and should be performed on all CSF specimens. A reactive CSF cryptococcal antigen test establishes the diagnosis. C. neoformans can also be grown in culture of CSF.
The treatment of cryptococcal meningitis in immunocompetent patients includes a combination of intravenous amphotericin B (0.5 mg/kg/d) plus oral flucytosine (25 mg/ kg four times daily) for 6 weeks. The therapy of cryptococcal meningitis in patients with AIDS includes a combination of intravenous amphotericin B (0.5 to 0.8 mg/kg/d) for at least 2 weeks followed by fluconazole (400 mg/d) for 10 to 12 weeks at which point the CSF should be recultured. When the CSF culture is sterile, the patient is switched to maintenance fluconazole therapy for life. The dose is 200 mg/d.
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