How is HIV-associated meningitis treated?

Updated: Aug 24, 2017
  • Author: Gulshan Uppal, MD; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Answer

Answer

Drugs of choice include ganciclovir for CMV ventriculoencephalitis and amphotericin B for cryptococcal meningitis. [4, 5, 6]

In cases of cryptococcal meningitis, initially treat patients with amphotericin B (0.7-1 mg/kg/day) with flucytosine for 2 weeks, followed by fluconazole 400 mg orally daily for 10 weeks. High-dose amphotericin B with flucytosine and high-dose fluconazole with flucytosine have been tried in patients with cryptococcal meningitis with promising results.

In a randomized study that compared 1 mg/kg versus 0.7 mg/kg of amphotericin B in HIV-infected patients with cryptococcal meningitis, the higher dose was more rapidly fungicidal; side effects were comparable. [7] Patients in both arms of the study also received flucytosine, 25 mg/kg 4 times daily. [7]

Because amphotericin B treatment is not available in many centers in developing countries, oral therapy is an important alternative. Results of a randomized trial suggest that a 2-week course of high-dose fluconazole (1200 mg/day) combined with flucytosine (100 mg/kg/day) is the optimal oral therapy for cryptococcal meningitis. The combination proved more fungicidal than fluconazole alone and had a tolerable side-effect profile. [8]

Secondary to the significant toxicity of the medications used, very close laboratory monitoring is needed for renal insufficiency, hematologic abnormalities, and electrolyte disturbances during therapy. 

Treatment should be administered in consultation with an infectious disease specialist.


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