Treating cryptococcal meningitis depends on the severity of disease. Generally speaking, this can be broken down into two types: mild cryptococcal meningitis and moderate-to-severe cryptococcal meningitis.
Mild cryptococcal meningitis. Someone has mild cryptococcal meningitis if they have the following:
Blood or CSF sample that contains Cryptococcus neoformans.
"Constitutional" symptoms of an underlying infection (e.g., fever, fatigue, body aches).
No brain-related symptoms of disease (e.g., confusion, muddled thinking, severe headaches, vision problems).
No increase in CSF pressure found during the spinal tap.
To treat mild cryptococcal meningitis, fluconazole (Diflucan®) is prescribed. Fluconazole comes in a pill form and high doses of the drug – 400 mg to 800 mg – are taken by mouth every day for approximately three months. After two or three months of taking fluconazole, you will probably need to have another blood test and/or spinal tap to check for Cryptococcus neoformans. If the test is negative, therapy can be stopped. However, if your T-cell count is still below 50 to 100, you may be asked to take a lower dose of fluconazole – 200 mg – every day to prevent the fungus from returning.
Moderate-to-Severe cryptococcal meningitis. Someone has moderate-to-severe cryptococcal meningitis if they have the following:
Blood or CSF sample that contains Cryptococcus neoformans.
"Constitutional" symptoms of an underlying infection (e.g., fever, fatigue, body aches).
Brain-related symptoms of disease (e.g., confusion, muddled thinking, severe headaches, vision problems).
Increased CSF pressure found during the spinal tap.
It is important to treat mild-to-moderate cryptococcal meningitis aggressively. For the first two weeks of treatment, the drug amphotericin B (Fungizone®) is given every day through an IV line, along with a second drug taken by mouth: flucytosine (Ancobon®).
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.
There have been some reports suggesting the liposomal amphotericin B – a drug involving microscopic spheres of lipids (fats) that contain amphotericin B – is less toxic than the standard form of amphotericin B (Fungizone®). However, recent studies conclude that liposomal amphotericin B is equally toxic – and less effective – than Fungizone. Still, liposomal amphotericin B is sometimes prescribed for patients who become very ill while taking Fungizone or develop kidney problems. If liposomal amphotericin B is used, experts recommend using the brand AmBisome® over that of the brands Abelcet® or Amphotec®.
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 200 mg.
Fluconazole treatment may be stopped if the patient sees his or her T-cell count increase to levels above 100 to 200 for at least six months in response to anti-HIV 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 T-cell count falls below 100 to 200 again.
Because cryptococcal meningitis can cause the brain to swell, which can lead to debilitating symptoms and brain damage, it is sometimes 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 during the first few weeks of treatment to keep CSF pressure low. Drug treatments including acetazolamide (Diamox®) and corticosteroids (e.g., prednisone) are also prescribed to help manage these symptoms.
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