C. neoformans is a ubiquitous organism acquired by inhalation. Patients with meningitis may present acutely or insidiously over days or weeks with a headache, general malaise, confusion or seizures. The classical signs of meningism — neck stiffness, photophobia and Kernig's sign — are frequently absent.
Brain imaging is usually normal but MRI may reveal small abcesses — cryptococomas. The CSF cell count and protein may be normal and the diagnosis is confirmed by the presence of cryptococcal antigen in the CSF in 95% of cases. India ink staining is positive in 75%. 85% of cases are culture positive — the gold standard. Measurement of the serum cryptococccal antigen is a useful screening tool in patients presenting with headache or fever but should not be considered definitive.
Intracranial hypertension in the absence of mass lesions or hydrocephalus is an important cause of mortality and visual failure in approximately 20%. This is managed by repeated lumbar punctures or by the insertion of a lumbar or ventricular drain.
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