CRYPTOCOCCOSIS AT THE UNIVERSITY-HOSPITAL, KUALA-LUMPUR

We review our experience with 27 cases of pulmonary and meningeal cryp tococcosis at the University Hospital, (Kuala Lumpar, Malaysia) where this is the most common cause of adult meningitis in patients without debilitating illnesses. Of the 27 cases analysed, six presented primar ily with pulmonary symptomatology which usually were mainly cough, che st pain and low grade fever. The rest presented with primarily central nervous system (CNS) symptomatology of which headaches and fever were the most consistent symptoms although a third of these patients also had pulmonary lesions noted on chest radiographs. Treatment in all cas es was with amphotericin B and 5-fluorocytosine and usually till a tot al cumulative dose of 1.5 g of amphotericin had been reached (an avera ge of 10 weeks). Primary pulmonary presentations, if symptomatic, were treated as per CNS cryptococcosis due to the high likelihood of CNS d issemination. Incidental pulmonary cryptococcoma found on routine ches t radiographs were confirmed by biopsy under ultrasound or fluoroscopy guidance and booked for surgical resection. Death usually occurred ea rly in patients who presented late. Once patients responded to therapy , mortality was usually avoided. The only cause of morbidity in surviv ors was visual impairment or blindness, and this was attributed mainly to intracranial hypertension with residual deficits determined by the measures taken to lower intracranial pressures. Our experience sugges ts that: (i) symptomatic patients should have combination therapy with 5-fluorocytosine and amphotericin B till at least a cumulative dose o f 1.5 g amphotericin B is reached irrespective of whether they have pr imary CNS or pulmonary symptomatology; (ii) non-symptomatic pulmonary cryptococcoma could be treated primarily by surgical resection; (iii) visual failure or papilloedema should be treated aggressively; and (iv ) prognosis is good with adequate therapy and early presentation.