Department of Emergency Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace St., Pittsburgh, PA, 15261, USA.
Intern Emerg Med. 2021 Jun;16(4):1031-1042. doi: 10.1007/s11739-020-02619-2. Epub 2021 Jan 9.
Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization.
This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM.
This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS).
CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.
隐球菌性脑膜炎（CM）仍然是一种高风险的临床情况，许多患者需要在急诊科（ED）进行并发症管理和稳定治疗。
本叙述性综述提供了有关 CM 的急诊评估和管理的当前数据的循证总结。
该综述评估了 ED 中 CM 的诊断、管理和经验性治疗。CM 可能会以亚急性表现而轻易被误诊，因此，任何头痛、神经功能缺损或免疫功能低下的患者都应考虑 CM。由于在 ED 不会明确诊断出 CM，因此对疑似 CM 的患者的管理包括及时进行诊断性检查和开始经验性治疗。多种新型隐球菌抗原检测在血清和脑脊液（CSF）中均具有较高的敏感性和特异性。应根据经验对疑似 CM 的患者进行治疗，具体治疗药物包括两性霉素 B 和氟胞嘧啶。此外，应立即开始适当的复苏和支持性护理，包括高级气道管理、颅内压（ICP）升高的管理、退热、静脉补液和隔离。对于发现或已知 HIV 阳性的患者，不应在 ED 中启动抗逆转录病毒治疗（ART），以防发生免疫重建炎症综合征（IRIS）。
CM 仍然是一种罕见的临床表现，但会带来重大的发病率和死亡率。医生在评估其他疾病和并发症的同时，必须快速诊断出这些患者。早期咨询传染病专家至关重要，同时还需要开始对症治疗。
