RECOGNITION AND MANAGEMENT OF NEUROCRYPTOCOCCOSIS IN PATIENT WITH SIDA

GABRIELA JUNQUEIRA FILHEIRO, GABRIELLE CORRÊA ALVES DA SILVA, PAMELA REGINA HENNING, CARINA DA SILVEIRA MASSARO, CAROLINA DONAIRE SOUSA, DANIELLE APARECIDA JUSVIAK, ADRIANA NEGRI

Resumo


Introduction: There are about 37 million people living with HIV/AIDS (PLWH) in the world. In countries
which prevalence is high and the treatment suffers high dropout rates, arises more one challenge, the
high rates of opportunistic infection (OI)4. These, the cryptococcosis is considered the systemic mycosis
more frequent in PLWH and the third more common reason of OI of central nervous system (CNS)1. It is
caused mainly by Cryptococcus neoformans that present five serotypes, being the A and D the major
causative of human infection and 90% occurs in immunocompromised people3. Objective: To discuss
about the precocious recognition of neurocrytococcosis and its treatment in PLWH. Methodology: A
literature review was performed using the Pubmed, Scielo and Lillacs. Discussion: The cryptococcosis
has decreased after the beginning of antiretroviral treatment. However, it is still considered important
because of its morbidity and mortality (6). In immunocompromised patients, it causes meningoencephalitis, usually acute, with nonspecific manifestations, mainly, in males. The cryptococcal
meningitis has to be considered in PLWH with headache, unexplained fever, progressive dementia and
mental confusion. The initial management consists of clinical and accurate neurological exam (8). Of
laboratory tests, there are three methods for antigen detection: latex agglutination, enzyme
immunoassays and lateral flow test (CrAg), a rapid test that can be used with serum, CSF and urine -
now considered a useful screening in the diagnosis of cryptococcosis in PLWH. The cryptococcal antigen
in CSF has the best performance (97,8%). The cytochemical exam of CSF could show regular cellularity
associated with high fungal load. The urine culture, with 71,6% of yield, is easy to obtain, low biological
risk and cost (1). The culture is the ‘gold standard’ test to diagnostic with 90% of sensitivity, besides to
be a parameter for the treatment. The straight exam with China paint may be positive in 80% of PLWH
(6). The image exams are normal in a half of the cases, in the remainder the exam could reveal
hydrocephalus, atrophy and vasculitis(8). In Brazil, the neurocryptococcosis treatment is done with
Amphotericin B and Fluconazole and is compound by three phases: the induction phase, to reduce the
fungal load, for two to four weeks; the consolidation phase, to normalize clinical and laboratory
parameters; and the maintenance phase, to secondary prevention, for six months at least (6). The
Fluconazole has been better in this last phase. Furthermore, Amphotericin B deoxycholate may be
replaced by liposomal, this presents less side effects (7). The prophylaxis used with fluconazole may be
pointed as one of factors responsible for the increase of minimum inhibitory concentration in vivo,
though the proper penetration of this drug in the CSF support the good results noted in vivo (5).
Conclusion: Then, the cryptococcosis has been relevant because it is considered one of the main OI
associated with AIDS, as well as cause serious CNS injury resulting in high mortality. Therefore, it is
necessary to recognize its neurocryptococcosis way to establish diagnosis and early treatment to slow
the progression of the disease.

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