Weltermann B M, Röttgers H R, Lüdemann P, Evers S, Reichelt D, Husstedt I W
Klinik und Poliklinik für Neurologie, Westfälische Wilhelms-Universität Münster.
Nervenarzt. 1999 Aug;70(8):732-7. doi: 10.1007/s001150050502.
Cryptococcal meningitis is one of the most frequent forms of meningoencephalitis in AIDS patients. Before the introduction of triazole antibiotics like difluconazole, the frequency of this meningitis among AIDS patients was 5-10%, yet declined during the last years. Clinically, nonspecific signs of a meningeal inflammation predominate while focal neurological signs are rare. Rapid institution of high-dose antimycotic therapy is the keystone to improve prognosis and decrease mortality. Antimycotics of choice are amphotericin B, fluconazole, and flucytosin. Diagnosis is established by detection of cryptococcal antigen in cerebrospinal fluid, microscopic demonstration of cryptococci using India-ink, and cryptococcal cultures. Recent developments aim to improve antimycotic therapies. During the last years, lifelong secondary prevention with difluconazole was established. Cryptococci which are resistant against fluconazole and amphotericin B are a special challenge, yet fortunately are rare. Longterm outcome of patients is determined by the progression of the underlying immunosuppression. Therefore, combination of secondary prophylaxis with modern antiviral substances is important. Clinical decision analysis in patients with suspected cryptococcal meningitis is presented using methods from evidence-based medicine.
隐球菌性脑膜炎是艾滋病患者中最常见的脑膜脑炎形式之一。在引入氟康唑等三唑类抗生素之前，艾滋病患者中这种脑膜炎的发生率为5% - 10%，但在过去几年有所下降。临床上，脑膜炎症的非特异性体征占主导，而局灶性神经体征罕见。迅速开始高剂量抗真菌治疗是改善预后和降低死亡率的关键。首选的抗真菌药物是两性霉素B、氟康唑和氟胞嘧啶。通过检测脑脊液中的隐球菌抗原、使用印度墨汁显微镜下显示隐球菌以及进行隐球菌培养来确诊。近期的进展旨在改进抗真菌治疗。在过去几年中，确立了使用氟康唑进行终身二级预防。对氟康唑和两性霉素B耐药的隐球菌是一个特殊挑战，但幸运的是较为罕见。患者的长期预后取决于潜在免疫抑制的进展情况。因此，将二级预防与现代抗病毒药物联合使用很重要。运用循证医学方法对疑似隐球菌性脑膜炎患者进行临床决策分析。
