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% Document Info
\author{Bernard Karani (Bernard Karani)}
\pdfinfo{
  /Title (cryptococcal-disease.pdf)
  /Creator (Cheatography)
  /Author (Bernard Karani (Bernard Karani))
  /Subject (Cryptococcal disease Cheat Sheet)
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\noindent
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    {\parbox{\dimexpr\textwidth-2\fboxsep\relax}{\noindent
        \hspace*{-6pt}\includegraphics[width=5.8cm]{/web/www.cheatography.com/public/images/cheatography_logo.pdf}}
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\begin{tabulary}{11cm}{L}
    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{Cryptococcal disease Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{Bernard Karani (Bernard Karani)} via \textcolor{DarkBackground}{\uline{cheatography.com/123206/cs/23346/}}}
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  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}Bernard Karani (Bernard Karani) \\
  \uline{cheatography.com/bernard-karani} \\
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  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Published 16th July, 2020.\\
   Updated 16th July, 2020.\\
   Page {\thepage} of \pageref{LastPage}.
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  %\includegraphics[width=48px,height=48px]{dave.jpeg}
  Measure your website readability!\\
  www.readability-score.com
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\begin{document}
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\begin{multicols*}{3}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{Definition}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{Infection of the brain and spinal column caused by {\emph{Cryptococcus neoformans}}% Row Count 2 (+ 2)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{Diagnosis}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{For adults, adolescents and children living with HIV suspected of having a first episode of cryptococcal meningitis, prompt lumbar puncture with measurement of cerebrospinal fluid (CSF) opening pressure and rapid cryptococcal antigen assay is recommended} \tn 
% Row Count 6 (+ 6)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{In settings with ready access to and no contraindication for lumbar puncture: Do a lumbar puncture to obtain CSF for CrAg ,India Ink and Gene Xpert and VDRL} \tn 
% Row Count 10 (+ 4)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{CSF CRAG positive, India Ink Positive or culture growth confirmed (any one positive):} \tn 
% Row Count 12 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{Contraindications include: \newline Significant coagulopathy or suspected space-occupying lesion based on focal nervous system signs (excluding cranial nerve VI palsy) or recurrent seizures and, where possible, confirmed by computed tomography \newline Other contraindications include major spinal deformity and patient refusal after fully informed consent was sought.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{Treatment and Management}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{5.377cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/bernard-karani_1592480777_WHO-2018-guidelines-for-management-of-cryptococcal-disease-in-HIV-infected-adults-20.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{Routine use of adjunctive corticosteroid therapy during the induction phase is not recommended in treating HIV-associated cryptococcal meningitis among adults, adolescents and children}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{Treatment for pregnant women}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{Amphotericin B therapy can be given to pregnant women with meningeal and non-meningeal \newline % Row Count 2 (+ 2)
disease. Exposure to flucytosine and fluconazole during pregnancy has been associated with an \newline % Row Count 4 (+ 2)
increased risk of birth defects in animal studies and some uncontrolled human studies.% Row Count 6 (+ 2)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{The use of flucytosine and fluconazole for treating cryptococcal disease in pregnant women should be \newline evaluated on an individual basis, considering the benefits and potential harm.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{x{1.74195 cm} x{3.23505 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Prevention, monitoring and management of toxicity}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Pre-emptive hydration and electrolyte supplementation} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
Adults and adolescents & 1L of normal saline solution with 20 mEq of potassium chloride (KCl) over two hours before each controlled infusion of amphotericin B \tn 
% Row Count 8 (+ 6)
% Row 2
\SetRowColor{LightBackground}
 & If available, magnesium supplementation should also be provided (two 250-mg tablets of magnesium trisilicate or glycerophosphate twice daily, or magnesium chloride 4 mEq twice daily). \tn 
% Row Count 16 (+ 8)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Monitoring} \tn 
% Row Count 17 (+ 1)
% Row 4
\SetRowColor{LightBackground}
Serum potassium & Baseline and 2–3 times weekly (especially in the second week of amphotericin B administration) \tn 
% Row Count 21 (+ 4)
% Row 5
\SetRowColor{white}
Serum creatinine & Baseline and 2–3 times weekly (especially in the second week of amphotericin B administration) \tn 
% Row Count 25 (+ 4)
% Row 6
\SetRowColor{LightBackground}
Haemoglobin & Baseline and weekly \tn 
% Row Count 26 (+ 1)
% Row 7
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Management} \tn 
% Row Count 27 (+ 1)
% Row 8
\SetRowColor{LightBackground}
Hypokalaemia & If hypokalaemia is significant (K \textless{}3.3 mol/l), increase potassium supplementation to 40 mEq KCl by intravenous infusion and/or one to two 8-mEq KCl tablets orally three times daily. Monitor potassium daily. \tn 
% Row Count 35 (+ 8)
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\vfill
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\begin{tabularx}{5.377cm}{x{1.74195 cm} x{3.23505 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Prevention, monitoring and management of toxicity (cont)}}  \tn
% Row 9
\SetRowColor{LightBackground}
Elevated creatinine & ≥2 fold from the baseline value, increase pre-hydration to 1 L every eight hours and consider temporarily omitting a dose of amphotericin B. Once creatinine improves, restart amphotericin B at 0.7 mg/ kg/day and consider alternate-day amphotericin B. If creatinine continues to rise, consider discontinuing amphotericin B and continuing with fluconazole at 1200 mg/ day. \tn 
% Row Count 15 (+ 15)
% Row 10
\SetRowColor{white}
Severe anaemia & Transfusion should be undertaken if possible for severe amphotericin B–related anaemia \tn 
% Row Count 19 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Fluconazole dose adjustment if significant renal impairment. \newline Anaemia may be a reason to discontinue amphotericin B prematurely in the second week of a planned two-week induction course of amphotericin B with fluconazole. \newline Monitor intake and output of fluid and daily weight, especially among children. \newline Flucytosine requires regular monitoring of full blood count}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{symptoms and signs of raised intracranial pressure}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{Symptoms \newline % Row Count 1 (+ 1)
• Headache \newline % Row Count 2 (+ 1)
• Nausea with or without vomiting \newline % Row Count 3 (+ 1)
• Changes in vision or hearing (such as double vision, blindness or deafness) \newline % Row Count 5 (+ 2)
Signs \newline % Row Count 6 (+ 1)
• Change in mental status (ranging from confusion to lethargy to coma) \newline % Row Count 8 (+ 2)
• Papilloedema \newline % Row Count 9 (+ 1)
• Seizures \newline % Row Count 10 (+ 1)
• Cranial nerve palsies (such as eye movement problems, particularly cranial nerve VI) \newline % Row Count 12 (+ 2)
• Other focal neurological nervous system deficits% Row Count 14 (+ 2)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{causes of persistent and recurrent symptoms}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{Persistent symptoms \newline % Row Count 1 (+ 1)
• Raised intracranial pressure \newline % Row Count 2 (+ 1)
• Treatment failure caused by suboptimal induction treatment \newline % Row Count 4 (+ 2)
• Inadequate drug regimen, dose or duration \newline % Row Count 5 (+ 1)
• Fluconazole drug resistance (rare) \newline % Row Count 6 (+ 1)
• Other concomitant illness (such as viral, bacterial, or tuberculous meningitis) \newline % Row Count 8 (+ 2)
Recurrent symptoms \newline % Row Count 9 (+ 1)
• Raised intracranial pressure \newline % Row Count 10 (+ 1)
• Treatment failure due to suboptimal induction, consolidation or maintenance treatment \newline % Row Count 12 (+ 2)
• Inadequate drug regimen, dose or duration \newline % Row Count 13 (+ 1)
• Failure to prescribe or to adhere to fluconazole consolidation or maintenance \newline % Row Count 15 (+ 2)
treatment \newline % Row Count 16 (+ 1)
• Fluconazole drug resistance (rare) \newline % Row Count 17 (+ 1)
• Cryptococcal immune reconstitution inflammatory syndrome (IRIS) following \newline % Row Count 19 (+ 2)
ART initiation \newline % Row Count 20 (+ 1)
• Other concomitant illness (such as viral, bacterial or tuberculous meningitis)% Row Count 22 (+ 2)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{managing cryptococcal IRIS}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{1. Continue ART. \newline % Row Count 1 (+ 1)
2. Promptly manage raised intracranial pressure. \newline % Row Count 2 (+ 1)
3. Optimize anti fungal therapy and consider restarting induction therapy \newline % Row Count 4 (+ 2)
4. Short-course oral steroid therapy may be considered if there is continued deterioration \newline % Row Count 6 (+ 2)
and/or the development of life-threatening complications (such as intracranial space-occupying \newline % Row Count 8 (+ 2)
lesions with mass effect or extra-cranial disease impinging on vital structures) despite the \newline % Row Count 10 (+ 2)
above measures.% Row Count 11 (+ 1)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{Immediate ART initiation is not recommended for adults, adolescents and children living \newline with HIV who have cryptococcal meningitis because of the risk of increased mortality \newline and should be deferred by 4–6 weeks from the initiation of anti-fungal treatment.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{Discontinuing fluconazole maintenance treatment}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{Is HIV viral load monitoring is available} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{If stable on and adherent to ART and antifungal maintenance treatment for at least one year and has a CD4 cell count ≥100 cells/mm3 and a fully suppressed viral load} \tn 
% Row Count 5 (+ 4)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{Is HIV viral load monitoring is not available} \tn 
% Row Count 6 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{If stable on and adherent to ART and antifungal maintenance treatment for at least one year and has a CD4 cell count ≥200 cells/mm3} \tn 
% Row Count 9 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{For children living with HIV who are 2–5 years old and have successfully treated cryptococcal \newline disease, discontinuing anti-fungal treatment maintenance is recommended if the child is stable on and adherent to ART and anti-fungal maintenance treatment for at least one year and has a CD4 cell count percentage greater than 25\% or an absolute count \newline \textgreater{}750 cells/mm3. \newline Maintenance treatment for cryptococcal disease should not be discontinued for children younger \newline than two years.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{References}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy. Geneva: World Health Organization; 2017 \seqsplit{(http://www.who.int/hiv/pub/guidelines/advanced-} HIV-disease/en, accessed 17 January 2018).} \tn 
% Row Count 5 (+ 5)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{Speed BR, Kaldor J. Rarity of cryptococcal infection in children. Pediatr Infect Dis J. 1997;16:536–7.} \tn 
% Row Count 8 (+ 3)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{Lightowler JV, Cooke GS, Mutevedzi P, Lessells RJ, Newell ML, Dedicoat M. Treatment of cryptococcal meningitis in KwaZulu-Natal, South Africa. PLoS One. 2010;5:e8630.} \tn 
% Row Count 12 (+ 4)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{5.377cm}}{Rapid advice: diagnosis, prevention and management of cryptococcal disease in HIVinfected adults, adolescents and children. Geneva: World Health Organization; 2011 (http:// \seqsplit{www.who.int/hiv/pub/cryptococcal\_disease2011/en/}, accessed 17 January 2018).} \tn 
% Row Count 17 (+ 5)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{5.377cm}}{Antifungal drug maps {[}website{]}. Geneva: Global Action Fund for Fungal Infections; 2018 \seqsplit{(http://www.gaffi.org/antifungal-drug-maps}, accessed 17 January 2018).} \tn 
% Row Count 21 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}


% That's all folks
\end{multicols*}

\end{document}