Bibliographic Info
Recommendation
The following diagnostic approach should be used for people with persistent or recurrent symptoms to establish potential underlying causes: a. Review the patient history for evidence suggesting underlying treatment failure from (1) inadequate drug regimen, dose and duration, (2) poor adherence to fluconazole consolidation and maintenance treatment or (3) underlying fluconazole drug resistance among people with previous prolonged fluconazole therapy. b. Perform a lumbar puncture with measurement of the opening pressure to establish the presence or absence of raised intracranial pressure and cerebrospinal fluid (CSF) examination with other relevant investigations to exclude concomitant illnesses.b c. Consider paradoxical cryptococcal immune reconstitution inflammatory syndrome after excluding other causes of recurrent symptoms among people who have started ART. d. Send or resend CSF for prolonged fungal culture (two weeks of incubation).
Notes and Remarks
Other diseases that can present with symptoms and signs similar to cryptococcal meningitis (such as viral, bacterial or tuberculous meningitis) should also be considered. Where possible, fluconazole susceptibility testing should be performed at a national reference laboratory when clinically suspected (culture-positive relapse despite fluconazole adherence).