Cryptococcal meningoencephalitis among HIV-infected immigrants. Diagnosticand therapeutic aspects in consideration of evidence-based medicine strategies - a review

Cryptococcal meningitis is one of the most frequent forms of meningoencepha litis in AIDS patients. Before the introduction of triazol 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 imp rove prognosis and decrease mortality. Antimycotics of choice are amphoteri cin B,fluconazole, and flucytosin. Diagnosis is established by detection of cryptococcal antigen in cerebrospinal flu-id, microscopic demonstration of cryptococci using India-ink, and cryptococcal cultures. Recent development s aim to improve antimycotic thera pies. During the last years, lifelong se condary prevention with difluconazole was established. Cryptococci which ar e resistent 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 immunsuppression. Therefore, combination of secondary prophylaxis with modern antiviral substances is important. Clinic al decision analysis in patients with suspected cryptococcal meningitis is presented using methods from evidence based medicine.