How is it treated?

The standard recommended treatment for all forms of cryptococcal meningitis involves two drugs. The first, amphotericin B (Fungizone), is given every day through an IV line. The second, flucytosine (Ancobon), is taken orally.

Amphotericin B can cause side effects, some of them serious. Side effects include nausea, fever, chills, muscle pain, low potassium levels, damage to the bone marrow and its ability to produce red blood cells and white blood cells, and kidney damage. Tip: Take a regular dose of acetaminophen (e.g., Tylenol), ibuprofen (e.g., Advil), naproxen (e.g., Aleve), or diphenhydramine (e.g., Benadryl) approximately half an hour before receiving amphotericin B—this can help prevent/reduce some side effects during and after receiving the infusion.

Liposomal amphotericin B—a drug involving microscopic spheres of lipids (fats) that contain amphotericin B—may be prescribed for patients who become very ill while taking Fungizone or develop kidney problems. If liposomal amphotericin B is used, experts recommend a dose between 4 and 6 milligrams per kilogram of body weight per day.

After two weeks of taking amphotericin B and flucytosine, you will need to have another blood test and/or spinal tap to check for Cryptococcus neoformans. If the test is positive, combination treatment will be continued. If the tests are negative, both drugs are stopped and another drug, fluconazole (Diflucan), is immediately started. This is necessary to help prevent the cryptococcal meningitis from recurring. Fluconazole is taken by mouth, every day, at a dose of 400 mg.

Fluconazole treatment may be stopped if the patient sees his or her CD4 cell count increase to levels above 200 for at least six months in response to ARV drug treatment. However, some specialists recommend a spinal tap before discontinuing fluconazole treatment, to make sure that there is no detectable Cryptococcus neoformans infection in the CSF. Fluconazole treatment should be restarted if the CD4 cell count falls below 200 again.

Because cryptococcal meningitis can cause the brain to swell, which can lead to debilitating symptoms and brain damage, it is often necessary to drain CSF from the spinal column to reduce the amount of pressure in the brain. These spinal taps may need to be repeated daily during the first few weeks of treatment to keep CSF pressure low.

A syndrome—called immune reconstitution inflammatory syndrome (IRIS)—where initiating antiretroviral treatment can actually exacerbate the symptoms of an opportunistic infection due to a strengthened immune response, has been reported in up to 30 percent of people diagnosed with cryptococcal meningitis. For this reason, some experts recommend waiting to start ARV therapy until people have been on treatment for cryptococcal meningitis for two weeks.

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