History

Fact Explanation
Duration of the symptoms Meninges are the lining that covers the brain and spinal cord.Meningitis is inflammation of the meninges around the brain and spinal cord. It is usually caused by an infectious pathogens such as bacteria, virus, fungi and parasites. Chronic meningitis is different from acute meningitis as it is an uncommon disease with a gradual onset over 2 weeks or more. Fungal infections are the common cause for chronic meningitis.Yeast pathogens (Cryptococcus neoformans and Candida albicans), dimorphic fungi (Histoplasmacapsulatum, Coccidioidesimmitis, Paracoccidioides brasiliensis and Blastomyces dermatitidis), filamentous fungi (Aspergillus species and Zygomycetes) and several dematiaceous molds (Bipolarisspicifera, Exophialajeanselmei, Cladophialophorabantiana, Ochroconisgallopavum and Ramichloridiummackenziei) are the fungal causes of meningitis. [5] Cryptococcal meningitis is one of the commonest fungal form of the disease.Cryptococcus neoformans is an encapsulated yeast causingopportunistic life-threatening infections, particularly in immuno-compromised patients. [1]
Headache [2] Pathogens may cross the BBB transcellularly (through human brain microvascular endothelial cells), paracellularly(penetration between barrier cells with and/or without disruption of tight junctions) and “Trojan horse” mechanism(penetration of the barrier cells using transmigration within infected phagocyte) . [3] Once the organism entered through the blood brain barrier, immune system of the body gets activated to release various cytokines and chemikines. Further it releases reactive oxygen radicals to cause more endothelial and nearby tissue damage. These can cause meningeal irritation, increased intracranial damage and cerebral edema.
Fever In chronic meningitis the inflammation of the meninges and endothelium releases pyrogens causing fever. This inflammation will be there for at least 1 month. [8]
Vomiting [2] Vomiting is a common finding in the meningitis. [2]
Sensitivity to light (photophobia) Inability to tolerate light [2]
Pain during retraction of the neck Due to the meningeal irritation. [6]
Seizures [2] Altered cerebral perfusion pressure can cause reduction of the cerebral blood flow and ischaemia. [2,6]
Decreased alertness and drowsiness There can be increased intracranial pressure which may be due to the increased blood brain barrier permeability, swelling of the cellular elements of the brain, interstitial edema results from obstruction of flow in normal CSF pathways etc. Neuronal cell death and cerebral edema may also contribute to the drowsiness. [6]
Excessive crying, refusing the feeds Infants and young children present with nonspecific features. [9]
Hearing loss [4] Inflammation can extends to the cranial nerves, when the 8th nerve is involved that causes sensorineural type hearing loss. [2]
Visual problems Visual problems Involvement of the optic and other cranial nerves related to the vision can be the cause. [2]
History of immunodeficiency People with immune deficiency like malignancy, chemotherapy, long term steroid use, organ transplant , diabetes mellitus, and HIV AIDS are particularly vulnerable for the disease. [8]
Long term history of ear pain Chronic otitis media can be a source for the meningitis. [7]
Involvement of the other organs Inhaled Cryptococcus can lodge in the lungs and disseminate hematogenously causing systemic infection when host immunity is compromised. Cryptococcus can infect and spread to the any part of the body, including the skin, eyes, myocardium, bones, joints, lungs, prostate gland, or urinary tract. [3]
References
  1. LEE CH, CHANG TY, LIU JW, CHEN FJ, CHIEN CC, TANG YF, LU CH. Correlation of anti-fungal susceptibility with clinical outcomes in patients with cryptococcal meningitis BMC Infect Dis [online] :361 [viewed 11 August 2014] Available from: doi:10.1186/1471-2334-12-361
  2. GUPTA V, SHARMA AK, SUREKA RK, BHUYAN SK, SINGH PK. Chronic meningitis with multiple cranial neuropathies: A rare initial presentation of Wegener's granulomatosis Ann Indian Acad Neurol [online] 2013, 16(3):411-413 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.116920
  3. VERWEIJ PE, BRINKMAN K, KREMER HP, KULLBERG BJ, MEIS JF. Aspergillus Meningitis: Diagnosis by Non-Culture-Based Microbiological Methods and Management J Clin Microbiol [online] 1999 Apr, 37(4):1186-1189 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88672
  4. LIDOVE O, CHAUVEHEID M, BENOIST L, ALEXANDRA J, KLEIN I, PAPO T. Chronic meningitis and thalamic involvement in a woman: Fabry disease expanding phenotype J Neurol Neurosurg Psychiatry [online] 2007 Sep, 78(9):1007 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2006.108464
  5. LIU TB, PERLIN D, XUE C. Molecular mechanisms of cryptococcal meningitis Virulence [online] 2012 Mar 1, 3(2):173-181 [viewed 11 August 2014] Available from: doi:10.4161/viru.18685
  6. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  7. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  8. BOOS C, DANESHVAR C, HINTON A, DAWES M. An unusual case of chronic meningitis BMC Fam Pract [online] :21 [viewed 22 September 2014] Available from: doi:10.1186/1471-2296-5-21
  9. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260

Examination

Fact Explanation
Febrile Fever is one of the most commonest presenting features. [1]
Stiff neck Due to the meningeal irritation. [5]
Kernig sign This is a bedside diagnostic sign used to evaluate suspected cases of meningitis. Patient is kept in supine position, hip and knee are flexed, the knee is slowly extended by the examiner. It is positive if there is a resistance or pain during extension. [1]
Brudzinki sign Another sign of meningeal irritation. First one hand is kept behind the patient's head and the other on chest in order to prevent the patient from rising, passive flexion of the neck produces reflex flexion of the patient's hips and knees in a positive Brudzinski's sign. [1]
Tachycardia Fast heart rate is observed in hypotensive, confused patients. [4]
Mental status changes Alteration in mental status is a poor prognostic indicator. [2]
Focal neurological signs Subdural effusion or cerebral-space-occupying lesions such as abscess formation can cause these symptoms. [3]
Buldging of fontanelle Due to the increased intracranial pressure. [7]
Growth retardation Ischaemia can cause neuronal cell death and tissue damage, if the developing brain is affected child may ends up with poor growth. [6]
Sensorineural hearing loss [4] Cranial nerve palsies specially VIII the nerve palsy is the cause for this hearing loss. [4]
Hydrocephalus Inflamed areas "ventriculitis" [6] are gradually fibrosed with creating an obstruction to the cerebrospinal fluid outflow, leading to hydrocephalus.
Papilloedema This is due to the increased intracranial pressure. [5] Increased blood brain barrier permeability, swelling of the cellular elements of the brain, interstitial edema results from obstruction of flow in normal CSF pathways as in hydrocephalus are the possible causes for the raised intracranial pressure.
References
  1. MEHNDIRATTA M, NAYAK R, GARG H, KUMAR M, PANDEY S. Appraisal of Kernig's and Brudzinski's sign in meningitis Ann Indian Acad Neurol [online] 2012, 15(4):287-288 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.104337
  2. LEE CH, CHANG TY, LIU JW, CHEN FJ, CHIEN CC, TANG YF, LU CH. Correlation of anti-fungal susceptibility with clinical outcomes in patients with cryptococcal meningitis BMC Infect Dis [online] :361 [viewed 11 August 2014] Available from: doi:10.1186/1471-2334-12-361
  3. LIU TB, PERLIN D, XUE C. Molecular mechanisms of cryptococcal meningitis Virulence [online] 2012 Mar 1, 3(2):173-181 [viewed 11 August 2014] Available from: doi:10.4161/viru.18685
  4. LIDOVE O, CHAUVEHEID M, BENOIST L, ALEXANDRA J, KLEIN I, PAPO T. Chronic meningitis and thalamic involvement in a woman: Fabry disease expanding phenotype J Neurol Neurosurg Psychiatry [online] 2007 Sep, 78(9):1007 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2006.108464
  5. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  6. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  7. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260

Differential Diagnoses

Fact Explanation
Encephalitis Encephalitis [4] is an acute, usually diffuse, inflammatory process of the brain. About 90% of cases are associated with herpes simplex virus (HSV-1). [3] They also present with the fever, headache, and clouding of consciousness which may be associated with seizures and focal neurology in some patients. Encephalitis associated with meningitis : meningoencephalitis may give the same picture as in meningitis making diagnosis difficult. [2]
Encephalopathy due to non infectious causes Same clinical features of encephalitis presents with a history of anoxic/ischaemic damage, nutritional deficiency, alcoholism, critical illness, malignant hypertension, traumatic brain injury or epileptic (non-convulsive status). [2] Fever, headache like features are uncommon in encephalopathy than in encephalitis/ meningitis. Depressed mental status is steadily deteriorating in encephalopathy rathe than that may be fluctuating in encephalitis/ meningitis. Focal neurologic signs are uncommon in encephalopathy. Types of seizures are usually generalised.
ADEM/postinfectious encephalomyelitis This usually follows a vaccination or an infection like measles, rubella or chickenpox. [2]
Wegener's granulomatosis This is a granulomatous disease that affects the upper and lower respiratory tract and kidney. There is small vessel vasculitis which is commonly presents with upper or lower airway symptoms or both. Headache, cerebritis, seizures, stroke, meningitis, diabetes insipidus, hydrocephalus, external ophthalmoplegia, myelopathy, and myopathy are the less common clinical features of the disease. Meningeal involvement is rare. [1]
References
  1. GUPTA V, SHARMA AK, SUREKA RK, BHUYAN SK, SINGH PK. Chronic meningitis with multiple cranial neuropathies: A rare initial presentation of Wegener's granulomatosis Ann Indian Acad Neurol [online] 2013, 16(3):411-413 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.116920
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280
  3. BANATVALA JANGU E. Herpes simplex encephalitis. The Lancet Infectious Diseases [online] 2011 February, 11(2):80-81 [viewed 16 August 2014] Available from: doi:10.1016/S1473-3099(11)70012-3
  4. JAKKA S, VEENA S, ATMAKURI R, EISENHUT M. Characteristic abnormalities in cerebrospinal fluid biochemistry in children with cerebral malaria compared to viral encephalitis Cerebrospinal Fluid Res [online] :8 [viewed 16 August 2014] Available from: doi:10.1186/1743-8454-3-8

Investigations - for Diagnosis

Fact Explanation
Lumbar puncture Opening pressure will be elevated. Predominantly mononuclear pleocytosis with elevated lymphocytes, an elevated CSF protein, reduced CSF glucose <40 mg/dL is seen. Fewer inflammatory cells are observed among AIDS patients due to the lack of a vigorous cellular immune response. [1]
Blood culture Is done if the patient seems to be septic or lumbar puncture can not be done safely due to the possibility of increased intracranial pressure before the antibiotics. [3]
Computer tomography(CT) scan of the head and Magnetic Resonance Imaging(MRI) CT scan will be even better as the first investigation specially to rule out the possibility of increased intracranial pressure before doing lumbar puncture. MRI will demonstrate the inflammatory dural meningeal process with enhanced uptake over the affected areas. This also show the complications like hydrocephalus. [2]
Antigen detection The presence of the Aspergillus antigen galactomannan can be measured measured in the serum and CSF with enzyme-linked immunosorbent assay ELISA. [3] High CSF cryptococcal antigen titer is factor for the poor prognosis.Histoplasmosis antigen is also checked. [4] Culture of the organism and cultures of the cerebrospinal fluid (CSF) are done for bacteria, fungus, and mycobacteria in suspected cases of chronic meningitis. .Aspergillus PCR.Aspergillus DNA was detected by genus-specific hot-start PCR, as described previously for bronchoalveolar lavage fluid PCRs for herpes simplex virus, varicella zoster virus, Epstein–Barr virus, cytomegalovirus, and West Nile virus ,mycobacteria, and herpesviruses. [4,5]
Zeihl Neelson Staining for Acid fast bacilli Tuberculosis can be a cause for the chronic meningitis. [6]
Full blood count There can be elevated lymphocytes, it is also important to exclude the other causes for the fever such as low platelets in viral infections, high white blood cells (leucocytosis) in bacterial infections. [7]
References
  1. LEE CH, CHANG TY, LIU JW, CHEN FJ, CHIEN CC, TANG YF, LU CH. Correlation of anti-fungal susceptibility with clinical outcomes in patients with cryptococcal meningitis BMC Infect Dis [online] :361 [viewed 11 August 2014] Available from: doi:10.1186/1471-2334-12-361
  2. GUPTA V, SHARMA AK, SUREKA RK, BHUYAN SK, SINGH PK. Chronic meningitis with multiple cranial neuropathies: A rare initial presentation of Wegener's granulomatosis Ann Indian Acad Neurol [online] 2013, 16(3):411-413 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.1169
  3. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  4. CRUM-CIANFLONE N, TRUETT A, WALLACE MR. Cryptococcal Meningitis Manifesting as a Large Abdominal Cyst in a HIV-Infected Patient with a Robust CD4 Count AIDS Patient Care STDS [online] 2008 May, 22(5):359-363 [viewed 11 August 2014] Available from: doi:10.1089/apc.2007.0085
  5. VERWEIJ PE, BRINKMAN K, KREMER HP, KULLBERG BJ, MEIS JF. Aspergillus Meningitis: Diagnosis by Non-Culture-Based Microbiological Methods and Management J Clin Microbiol [online] 1999 Apr, 37(4):1186-1189 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88672
  6. SELVAKUMAR N, RAHMAN F, RAJASEKARAN S, NARAYANAN PR, FRIEDEN TR. Inefficiency of 0.3% Carbol Fuchsin in Ziehl-Neelsen Staining for Detecting Acid-Fast Bacilli J Clin Microbiol [online] 2002 Aug, 40(8):3041-3043 [viewed 19 September 2014] Available from: doi:10.1128/JCM.40.8.3041-3043.2002
  7. BROWN L, SHAW T, WITTLAKE W. Does leucocytosis identify bacterial infections in febrile neonates presenting to the emergency department? Emerg Med J [online] 2005 Apr, 22(4):256-259 [viewed 18 September 2014] Available from: doi:10.1136/emj.2003.010850

Investigations - Fitness for Management

Fact Explanation
Erythrocyte sedimentation rate(ESR) and C Reactive protein(CRP) Is elevated due to the inflammation. [1,2]
Renal functions and serum electrolytes [1] Syndrome of inappropriate Antidiuretic Hormone secretion is a complication of meningitis. [2] This can cause hyponatraemia. Reduced intake of fluids can cause electrolyte imbalances. Medications may alter the renal functions and therefore baseline value is also needed.
Liver function tests Medications may alter the liver functions and therefore baseline value is needed before the treatment. [3]
Random blood sugar Should be done immediately especially if the patient is drowsy, to rule out the hypoglycaemia as cause for drowsiness. [4]
References
  1. GUPTA V, SHARMA AK, SUREKA RK, BHUYAN SK, SINGH PK. Chronic meningitis with multiple cranial neuropathies: A rare initial presentation of Wegener's granulomatosis Ann Indian Acad Neurol [online] 2013, 16(3):411-413 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.116920
  2. KLEIN NJ, HEYDERMAN RS, LEVIN M. Antibiotic choices for meningitis beyond the neonatal period. Arch Dis Child [online] 1992 Feb, 67(2):157-159 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793401
  3. ELWIR SM, SHAFFER CC, ARVAN SW, KUPERMAN EF. Disseminated Varicella Zoster Virus Infection with Encephalitis in a UC Patient Receiving Infliximab Gastroenterol Hepatol (N Y) [online] 2013 Jan, 9(1):54-56 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975981
  4. BRACKENRIDGE A, WALLBANK H, LAWRENSON RA, RUSSELL‐JONES D. Emergency management of diabetes and hypoglycaemia Emerg Med J [online] 2006 Mar, 23(3):183-185 [viewed 18 September 2014] Available from: doi:10.1136/emj.2005.026252 Investigations - Followup

Investigations - Followup

Fact Explanation
Lumbar puncture Lumbar puncture Is done during the follow up and when the response is poor to the current treatment. [1]
References
  1. CRUM-CIANFLONE N, TRUETT A, WALLACE MR. Cryptococcal Meningitis Manifesting as a Large Abdominal Cyst in a HIV-Infected Patient with a Robust CD4 Count AIDS Patient Care STDS [online] 2008 May, 22(5):359-363 [viewed 11 August 2014] Available from: doi:10.1089/apc.2007.0085

Investigations - Screening/Staging

Fact Explanation
HIV screening Those who accept HIV screening should have the antibody check up as these infections are common in people infected with HIV. [1]
MRI/CT brain Increased intracranial pressure is evident on MRI by severe sulcal effacement and midline shift on brain imaging. [2]
References
  1. LEE CH, CHANG TY, LIU JW, CHEN FJ, CHIEN CC, TANG YF, LU CH. Correlation of anti-fungal susceptibility with clinical outcomes in patients with cryptococcal meningitis BMC Infect Dis [online] :361 [viewed 11 August 2014] Available from: doi:10.1186/1471-2334-12-361
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280

Management - General Measures

Fact Explanation
Immediate management This is particularly important if the patient presents with confusion and drowsiness. Airway, breathing, circulation, disability and environment need to be attended. Random blood sugar is done to exclude hypoglycaemia. [3] Lumbar puncture needs to be done before the antifungals or any other treatment. [4] ( if the possibility of increased intracranial pressure can be rule out) If it is not safe to do the LP blood culture is done and anti fungals are started as soon as possible without delay.
Supportive management Antipyretics (acetaminophen), and antiemetics,(promethazine), may be given. Hydration should be checked and due to the possibility of syndrome of inappropriate Antidiuretic hormone, 2/3 of maintenance is preferable. Monitoring of the vital parameters should be done during the initial period.
Management of the complications Ventriculoperitoneal (VP) shunt is placed for the symptomatic improvement in hydrocephalus. [1] If there are seizures, anticonvulsants should be continued and close follow-up should be done. If there is of rapidly increasing intracranial pressure with clinical deterioration where medical treatment failed, surgical decompression has to be considered as a life saving measure. [2]
Follow up As they are vulnerable for complications such as hearing loss, vision problems, growth retardation, learning disability they need to be followed up with hearing, vision and growth assessment. [5]
References
  1. CRUM-CIANFLONE N, TRUETT A, WALLACE MR. Cryptococcal Meningitis Manifesting as a Large Abdominal Cyst in a HIV-Infected Patient with a Robust CD4 Count AIDS Patient Care STDS [online] 2008 May, 22(5):359-363 [viewed 11 August 2014] Available from: doi:10.1089/apc.2007.0085
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280
  3. BRACKENRIDGE A, WALLBANK H, LAWRENSON RA, RUSSELL‐JONES D. Emergency management of diabetes and hypoglycaemia Emerg Med J [online] 2006 Mar, 23(3):183-185 [viewed 18 September 2014] Available from: doi:10.1136/emj.2005.026252
  4. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  5. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260
  6. FLORET D. [Suppurative meningitis in infants and in children: adjuvant treatments and treatments of neurological forms]. Pediatrie [online] 1993, 48(1):21-7 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8392687

Management - Specific Treatments

Fact Explanation
Antifungal therapy Aims of the therapy would be to treat the infection and prevention of long-term central nervous system sequelae. Treatment for the cryptococccus is with amphotericin B(0.7-1.0 mg/kg daily), with or without flucytosine(100 mg/kg in four divided doses daily) for 14 days, followed by maintenance therapy with fluconazole 400 mg daily for eight weeks or until the cerebro spinal fluid (CSF) is sterile. PMCID: PMC3546060. If there is a renal dysfunction, a lipid formulation of amphotericin B (AmBisome 4 mg/kg daily)is used. If the person is not tolerating the amphotericin B fluconazole 400-800 mg daily is used. [1] There is no standard therapy for aspergillus meningitis. Intravenous amphotericin B desoxycholateor combination therapy :intravenous amphotericin B with flucytosine and rifampin is used. Combination therapy is to overcome the difficulty in achieving high drug levels in CSF. Amphotericin B-induced myelopathy is an uncommon side effect of treatment.Itraconazole Is used to treat the patients with Aspergillus brain abscesses, Voriconazole is a new antifungal azole that penetrates into the CSF and used for the treatment of brain abscess due to Aspergillus. [2]
Anti tuberculosis treatment When chronic meningitis is suspected, empirically treated with isoniazid, rifabutin, ethambutol, pyrazinamide, streptomycin. [1]
Steroids Dexamethasone (4 mg every six hours)is given to reduce the inflammatory response occur during the anti microbial treatment. [1]
Acyclovir If there are features of meningoencephalitis, acyclovir, 10 mg/kg three times daily,is added as soon as possible and once the diagnosis is confirmed acyclovir is continued for 14 days. [3]
Further management in HIV positive patients Discontinuation of secondary prophylaxis is done after 12-18 months of suppression if they achieve a CD4 count >100 cells/mm3 while receiving “highly active antiretroviral therapy” (HAART). [1]
References
  1. CRUM-CIANFLONE N, TRUETT A, WALLACE MR. Cryptococcal Meningitis Manifesting as a Large Abdominal Cyst in a HIV-Infected Patient with a Robust CD4 Count AIDS Patient Care STDS [online] 2008 May, 22(5):359-363 [viewed 11 August 2014] Available from: doi:10.1089/apc.2007.0085
  2. VERWEIJ PE, BRINKMAN K, KREMER HP, KULLBERG BJ, MEIS JF. Aspergillus Meningitis: Diagnosis by Non-Culture-Based Microbiological Methods and Management J Clin Microbiol [online] 1999 Apr, 37(4):1186-1189 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88672
  3. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280