How is increased intracranial pressure due to CNS cryptococcosis treated in HIV infection?

Answer

Opening pressure is elevated to greater than 25cm H20 in 60–80% of patients with AIDS and cryptococcal CNS infection.^{[8, 9]} This is probably due to obstruction of the basal meninges or impaired CSF absorption. Since increased intracranial pressure is a prognostic factor whose correction leads to symptomatic improvement, this must be managed aggressively.

In the absence of obstructive hydrocephalus or risk of herniation, increased pressure (>25cm H₂ O) can be relieved by serial lumbar punctures. For those who cannot tolerate repeated lumbar punctures, a lumbar drain or ventriculostomy should be considered. A lumbar-peritoneal shunt or ventriculoperitoneal shunt may be indicated as well. Decreasing intracranial pressure can rapidly improve headache, nausea, and vomiting. Mannitol and corticosteroids have no proven benefit and are not recommended.^[12] Acetazolamide should not be used for treatment of increased intracranial pressure as it may cause hyperchloremic acidosis.^[17]

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Media Gallery

Magnetic resonance imaging showing a cryptococcoma in the medulla.
Coronal section of brain showing a cryptococcoma in the basal ganglia.
This image shows meningeal enhancement in a patient with cryptococcal meningitis.

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Author

Felicia J Gliksman, DO, MPH Assistant Professor, Department of Pediatrics and Department of Neurology, Hackensack Meridian School of Medicine at Seton Hall University; Attending Physician, Division of Pediatric Neurology, Hackensack University Medical Center

Felicia J Gliksman, DO, MPH is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, Child Neurology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Florian P Thomas, MD, PhD, MA, MS Chair, Neuroscience Institute and Department of Neurology, Director, National MS Society Multiple Sclerosis Center and Hereditary Neuropathy Foundation Center of Excellence, Hackensack University Medical Center; Founding Chair and Professor, Department of Neurology, Hackensack Meridian School of Medicine at Seton Hall University; Professor Emeritus, Department of Neurology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM Adjunct Associate Professor of Neurology, University of Missouri-Columbia School of Medicine; Medical Director of St Mary's Stroke Program, SSM Neurosciences Institute, SSM Health

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Additional Contributors

Prityi Rani, MD General Neurologist, Headache, Stroke, and Neuromuscular, Jefferson City Medical Group

Prityi Rani, MD is a member of the following medical societies: American Academy of Neurology, Indian Medical Association, International Headache Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Vitor Pacheco, MD, to the development and writing of the source article.

How is increased intracranial pressure due to CNS cryptococcosis treated in HIV infection?

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