This document summarizes cryptococcal meningitis, a fungal infection of the membranes surrounding the brain and spinal cord that is common in people with HIV/AIDS. It describes the causative organism, Cryptococcus neoformans, and outlines the clinical presentation, diagnosis, and treatment of cryptococcal meningitis. The treatment involves amphotericin B and flucytosine initially, followed by long-term fluconazole therapy and antiretroviral treatment once the patient's CD4 count recovers. Prevention strategies include screening high-risk HIV patients and treating asymptomatic cryptococcal infections before starting antiretroviral therapy.
This presentation focuses on Acute Bacterial Meningitis.
Viral and fungal cause is mentioned but focus is on bacterial meningitis in Pediatrics Patient.
Feel free to correct if there is any error.
Refer to other reference books for clarity.
Acute meningoencephalitis Powerpoint presentation.
It comprises of acute meningitis and acute encephalitis, their clinical features, physical assesment, diagnosis and treatment.
is an upper respiratory tract bacterial infection associated with a characteristic rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin) -producing GAS in individuals who do not have antitoxin antibodies In the past.
scarlet fever was thought to reflect infection of an individual lacking toxin-specific immunity with a toxin-producing strain of GAS.
Subsequent studies have suggested that development of the scarlet fever rash may reflect a hypersensitivity reaction requiring prior exposure to the toxin.
Now a days TBM is super most disease in Indian children.
Tuberculous meningitis (TBM) is difficult to diagnose, and a high index of suspicion is needed to make an early diagnosis.
This presentation focuses on Acute Bacterial Meningitis.
Viral and fungal cause is mentioned but focus is on bacterial meningitis in Pediatrics Patient.
Feel free to correct if there is any error.
Refer to other reference books for clarity.
Acute meningoencephalitis Powerpoint presentation.
It comprises of acute meningitis and acute encephalitis, their clinical features, physical assesment, diagnosis and treatment.
is an upper respiratory tract bacterial infection associated with a characteristic rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin) -producing GAS in individuals who do not have antitoxin antibodies In the past.
scarlet fever was thought to reflect infection of an individual lacking toxin-specific immunity with a toxin-producing strain of GAS.
Subsequent studies have suggested that development of the scarlet fever rash may reflect a hypersensitivity reaction requiring prior exposure to the toxin.
Now a days TBM is super most disease in Indian children.
Tuberculous meningitis (TBM) is difficult to diagnose, and a high index of suspicion is needed to make an early diagnosis.
go to www.medicaldump.com to download this medical powerpoint presentation. You can find medical templates, medical pdfs and medical powerpoints on all specialties
Apparently a lengthy presentation actually very good for junior physicians as it covers all aspects of assessment, diagnosis and treatment of pleural effusion
AIDS stands for: Acquired Immune Deficiency Syndrome
AIDS is a medical condition. A person is diagnosed with AIDS when their immune system is too weak to fight off infections.
Since AIDS was first identified in the early 1980s, an unprecedented number of people have been affected by the global AIDS epidemic. Today, there are an estimated 33.3 million people living with HIV and AIDS worldwide.
http://www.pediatricdentists.blogspot.com
For the students studying Medical Microbiology like MSC BSC MBBS DENTAL BPTH Nursing DMLT Pharmacy etc and also for those who are preparing for exams such as NEET
Cryptococcal meningitis is a serious opportunistic fungal infection which occur most in severe immunocompromised patients caused by pathogenic yeast species of the cryptococcus genus called Cryptococcus neoformans which spreads from the lungs to the brain
It is the most common central nervous system (CNS) fungal infection, affecting individual with weaken body immune system
The condition is rare in healthy person
Immunosupression resulting from HIV, places a patient at risk for infection from different organisms that are other wise relatively mildly hazardaus and that would normally be cleared by a competent immune system,
The other oppotunistics diseases includes,
-Pneumocystis jirovecii pneumonia
-Toxoplasmosis
-Cytomegalovirus infections
-Tuberculosis
-Disseminated mycobacterium avium complex
Globally, approximately 957,900 cases of cryptococcal meningitis occur annually, resulting in 624,700 deaths within 3 months of infection in HIV-infected adults and children.
Cryptococcal meningitis associated with HIV infection is responsible for more than 600,000 deaths per year worldwide
In sub-Saharan Africa, 15%-30% of all patients with AIDS develop cryptococcal disease
Mortality rate of is 20%, 55%, 70% in high income , low and middle income and sub- saharan africa countries respectively
In Tanzania it accounts btn 13%- 44% of death of HIV infected individual, it is more common in male children than female
Risk factors;
Advanced HIV /AIDS
Cirrhosis
Solid organ transplantation
Systemic lupus erythematous
Advanced Malignant eg leukemia, lyphoma
Sarcoidosis
Diabetes
Long term use of corticosteroid
Disseminated Cryptococcus neoformans infection begins in the lungs by inhalation of spores, which in nature are dry, minimally capsulated and easily aerosolized
Primary pulmonary infection is self limiting
In immunocompitent patients the isolated pulmonary lesion usually heal spontaneously without disseminating even without ant fungal therapy
In immunocompromised patients cryptococcus may disseminate frequently through blood stream to other parts of the body but preferentially the central nervous system (brain and meninges) causing cryptococcal meningoencephalitis where by typically manifestating as microscopic multifocal intra cerebral lesions may be evident
The infection is more properly characterized as "meningoencephalitis" rather than meningitis since the brain parenchyma is almost always involved on histologic examination
Although pulmonary involvement is rarely dangerous , cryptococcal meningitis is life threatening and requires aggressive therapy
Focal sites of dissemination may also occur in skin, end of long bone, joints, liver, spleen, kidney, prostate, and other tissues
All these cause few or no symptoms but rarely , pyelonephritis with renal pappillary necrosis
If tissue involved typically contain cystic masses of yeast with or without inflammatory changes
Drugs
Amphotericin B
Flucytosine and Fluconazole
1. Cryptococcal Meningitis with
HIV AIDS
SUKRARAJ TROPICAL AND INFECTIOUS HOSPITAL
By: Dr. Saurav Poudel
On :12.18.2013
At : Presentation Hall Of AHF, Teku.
2. Meningitis:
Inflammation of Meninges i.e Pia mater and
Arachnoid mater.
Layer of Meninges: a)dura mater
b)arachnoid mater
c)pia mater
Subarachnoid space:It is the space between
arachnoid and pia mater which is filled with
cerebrospinal fluid.
3.
4. Infective cause of meningitis:
1)Bacteria:- Nesseria meningitidis 80% cases
-Streptococcus pneumonia
-Haemophilus influenza
-Staphylococcus aureus
-streptococcus Group B
-Leisteria monocytogens
-E.coli
-Mycobacterium tuberculosis
-Treponema Pallidum
7. Micro-organism reaches the meninges either by
direct extension from the
ears,nasopharnyx,cranial injury or congenital
meningeal defect or blood stream
spread,immuno-compromised patient are risk
of infection……………..
8. TYPES OF MENINGITIS
• Pyogenic or bacterial meningitis
• Tubercular meningitis
• Viral meningitis or Aseptic meningitis
• Fungal meningitis
9.
10. Clinical Features:
• Fever: high fever
• Signs of Meningeal irritation: -neck rigidity
-Kernigs sign
-Brudzinski’s sign
*signs of raised ICP:-nausea,vomiting,headache
-Pappiloedema
-Bradycardia
*conciousness : present or not
*focal neurological sign :present or not
14. Investigation
• Cerebrospinal fluid study
• Blood culture
• Complete blood count
• Chest x-ray for tuberculosis and pneumonia
• Mountaux test
• CT scan
15.
16. Antibiotic in acute bacterial meningitis
antibiotic alternate
*Unknown -ceftotaxime Benzylpenicillin
pyogenic &chloramphenicol
*Meningococcus -Benzylpeniciilin –ceftotaxime
*Pneumococcus - ceftotaxime - Peniciilin
*Haemophilus – ceftotaxime - chloramphenicol
*** ceftotaxime: 2gm iv 6 hourly for 10-14 days.
benzylpeniciilin:2.4gm iv 4 hourly for 5-7 days.
17. CRYPTOCOCCOSIS
Chronic, subacute to acute pulmonary,systemic or
meningitic disease,initiated by the inhalation of
the fungus.Primary pulmonary infections have no
diagnostic symptoms and are usually
subclinical.on dissemination,the fungus usually
shows a predilection for the central nervous
system,however skin, bones and other visceral
organs may also become involved….
Distribution: worldwide
Aetiological Agent: Cryptococcus neoformans.
18. Cryptococcus Neoformans
*A capsulated Yeast.
*Sporadic disease in the past.
*Most common infection in
aids patient.
Morphology:
-A true Yeast
--round 4-10 microns
--60% of the infected prove
positive by India ink
preparation on examination
of CSF…..
19. Cryptococcus Neoformans Serotypes
• A true yeast
• 4 serotypes –A,B,C,D A:80% clinical cases.
• Many infections are caused by: C.neoformans
var neoformans.
• Found in wild/domesticated birds.
• Piegeons carry C.neoformans
• Birds do not get infected…
23. • Virulence factors
--polysaccharide capsule
:antiphagocytic,diminsh complement,
enhance hiv replication.
--melanin:
protects from antifungal agents
--ability to grow at high temperature
--production of phospolipase ,urease.
25. CRYPTOCOCCAL MENINGITIS & HIV
• Leading infectious cause of meningitis in HIV
Patients-7% HIV patients (Adams neurology)
• Usually in CD4<100 cells/ul;
• Presentation:
subacute course with
fever,nausea,vomiting,altered mental
status, headache, cranial nerve palsies.
• Seizures and focal neurological signs are rare..
26. • In HIV patients
burden of yeast is higher
higher antigen titers
slower CSF sterilization
• Greater likelihood of second CNS event
• Immune reconstitution syndrome in patients
on ART
27.
28. LAB DIAGNOSIS
• CSF Microscopic observation under india ink preparation.
• INDIA INK:
Cryptococcus neoformans, because of its large polysaccharide capsule, can be
visualized by the India stain. Organisms that possess a polysaccharide capsule
exhibit a halo around the cell against the black background created by the India
• Direct microscopy- gram staining
• Cultures on Sabouraud dextrose agar
• Serological tests for detection of capsular antigen
• CSF findings mimic like tuberculosis
• In CSF-latex test for detection of antigen
• Blood Cultures
• ELISA
29.
30. CRYPTOCOCCAL MENINGITIS & HIV
@ our hospital
• From 2070/01/01-2070/09/01
• Total no. of HIV +ve patient got admitted:320.
total no. of death:24
CAUSE:
PLHIV e C.meningitis:8
PLHIV e PTB:4
PLHIV e fever under evaluation:4
PLHIV e CLD:3
PLHIV e anaemia:1
PLHIV e chest infection:1
PLHIV e ARF:1
PLHIV e weakness:1
PLHIV e Spticaemia:1
34. INTRACRANIAL PRESSURE(ICP)
• ICP is normally 7–15 mm Hg
• Raised ICP means:20–25 mm Hg
• CAUSE:
• increased CSF production can occur in meningitis, subarachnoid
hemorrhage, or choroid plexus tumor
• obstruction to CSF flow and/or absorption can occur
in hydrocephalus.
• mass effect such as brain tumor, infarction with edema, contusions,
subdural or epidural hematoma, or abscesses.
• OSMOTIC DIURETIC MANNITOL (1.5-2 g per kg intravenously) has
been used to treat signs of acutely increased ICP
35. ART
• ART shouldnot be given during acute phase of cryptococcal
meningitis treatment because:
ART
RAPID INCREASE IN CD4
DEPLETION OF VIRAL LOAD
EXAGERRATED IMMUNE RESPONSE
(IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME)
36. • ART should be initiated after two months of
initiation for treatment of cryptococcal meningitis
and CD4 count >200/ul..
• BUT Once cryptococcal antigen has been
significantly reduced, antiretroviral therapy can
be initiated while the therapy for cryptococcal
infection continues. However, newer data
demonstrate improved clinical outcomes when
highly active antiretroviral therapy (HAART) is
initiated within 6 months of the diagnosis of
cryptococcal meningitis.
37. PREVENTION
• Primary prophylaxis
To give an antifungal medication to all HIV–infected patients with low
CD4+ T-cell counts (i.e., patients with advanced HIV) in order to
prevent them from getting cryptococcal meningitis.
• Targeted screening to prevent deaths
"targeted screening" Research suggests that Cryptococcus is able to live in
the body undetected, especially when a person's immune system is
weaker than normal. A targeted screening program would test HIV-
infected patients for cryptococcal antigen (an indicator of
cryptococcal infection) before they begin taking antiretroviral treatment
(ART). A patient who tests positive for cryptococcal antigen can take oral
fluconazole, to help the body fight the fungus before the patient starts
ART. This would prevent them from developing severe cryptococcal
infection.
• A new method for detecting cryptococcal antigen has recently been
developed. This test is a "dipstick" test, and is simple to use on a small
sample of serum (a component of blood ). The test accurately detects
silent, as well as active, cryptococcal infections 95% of the time. .
38. PIEGONS SHOULD BE AWAY FROM
IMMUNOCOMPETENT &
IMMUNOCOMPROMISED PATIENT
39. THANK YOU
Dr.saurav poudel (saurav7utd@hotmail.com)
Medical Officer @ Sukraraj Tropical & Infectious
Disease Hospital.
2013.12.18
