244.4 📌 章末速蚘

244.4.0.0.1 Cryptococcus
  • Encapsulated yeast (India ink halo)
  • C. neoformans (worldwide, immunocompromise, HIV) + C. gattii (tropical + Pacific NW; sometimes immunocompetent severe)
244.4.0.0.2 Cryptococcal Meningitis
  • HIV CD4 < 100 primary risk
  • Subacute headache + altered mental status + fever + meningismus + increased ICP
  • Diagnosis: serum CrAg (99% sens) + CSF analysis + CSF CrAg + India ink + culture
244.4.0.0.3 Treatment 3 Phases
  • Induction (2 wk): AmB lipo 4 mg/kg/d + flucytosine 100 mg/kg/d OR single-dose AmB 10 mg/kg (Ambition-cm)
  • Consolidation (8 wk): Fluconazole 800 mg/d
  • Maintenance: Fluconazole 200 mg/d until immune recovery
244.4.0.0.4 Critical Adjuncts
  • Repeated LP for high ICP — mortality reduction
  • Delay ART 4-6 wk in HIV (COAT trial)
  • VP shunt / lumbar drain for refractory ICP
  • NO routine steroid (no benefit)
244.4.0.0.5 Pre-Emptive
  • Serum CrAg screening when CD4 < 100
  • Positive asymptomatic + normal LP → fluconazole 800 × 14d then 200/d
  • WHO recommendation
244.4.0.0.6 C. gattii
  • Pacific NW USA + Vancouver Island 1999+
  • More immunocompetent + cryptococcomas + may need surgery
  • Same treatment regimen + longer course
244.4.0.0.7 Pulmonary
  • Asymptomatic immunocompetent: observation
  • Symptomatic: fluconazole 400 × 6-12 mo
  • Severe / immunocompromise: full Tx
244.4.0.0.8 Burden
  • #1 cause of HIV-related meningitis worldwide (especially Sub-Saharan Africa)
  • 180,000 deaths/yr
  • WHO 2024 priorities + access programs
244.4.0.0.9 盧醫垫 hint
  • HIV CD4 < 100 + chronic headache → urgent serum CrAg + LP
  • Cryptococcal meningitis high ICP → repeated LP + ICP management essential
  • Solid organ transplant + chronic headache → cryptococcal workup
  • Pacific NW USA traveler + chronic respiratory / neurologic sx → C. gattii consideration