What is included in the maintenance therapy for CNS cryptococcosis in HIV infection?

Updated: Jan 08, 2020
  • Author: Felicia J Gliksman, DO, MPH; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Answer

Maintenance therapy should be continued with fluconazole 200 mg/day for at least one year. Amphotericin B (1 mg/kg/wk) is less effective than fluconazole, but it is an alternative for patients who experience relapse on fluconazole or for those who cannot tolerate it. Itraconazole 200 mg/day can be an alternative to fluconazole, but it is less effective. There is limited data for use of the newer triazoles, voriconazole, and posaconazole as most data is reported for refractory cases, with success rate in 50%. [14, 15]

Lifelong secondary prevention may be required. Relapses occur if secondary prevention is stopped or becomes ineffectual. Relapse rates without prevention range from 15–27%; and from 0–7% with antifungal prophylaxis.

Discontinuing secondary antifungal prophylaxis may be considered in selected patients who have responded well to highly active antiretroviral therapy (HAART), with 12–18 months of successful suppression of HIV viral replication. This remains controversial.

Criteria for discontinuing antifungal suppressive therapy during HAART, according to IDSA guidelines, are maintenance of a CD4+ cell count above 100 cells/µL and an undetectable or very low HIV RNA level for 3 months or longer (minimum of 12 months of antifungal therapy). [12] The guidelines advise considering reinstitution of maintenance therapy if the CD4+ cell count falls below 100 cells/µL.

Patients with cryptococcal disease who initiate HAART are at risk for cryptococcal immune reconstitution inflammatory syndrome (IRIS). Boulware et al found that in HAART-naive patients with AIDS and prior cryptococcal meningitis who developed IRIS after starting HAART, the cerebrospinal fluid tended to show less inflammation, with decreased CSF leukocytes (25 cells/mL or fewer), protein (50 mg/dL or less), interferon-gamma, interleukin-6, interleukin-8, and tumor necrosis factor-alpha, compared with patients who did not develop IRIS. [16]


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