Last reviewed: November 2017
Last updated: November  2017

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • progressive headache
  • severe headache
  • meningismus
  • symptoms of hydrocephalus (impaired cognitive function, confusion, coordination and gait disturbances, and urinary incontinence)
  • behavioural or personality change
  • reduced visual acuity and papilloedema

Other diagnostic factors

  • nausea or vomiting
  • fever
  • reduced conscious level
  • cranial nerve palsies
  • seizures
  • weight loss
  • mouth ulcers
  • focal neurological signs
  • lymphadenopathy, hepatosplenomegaly
  • dyspnoea
  • papular umbilicated skin lesions
  • retinal defects
  • nasal or palatal eschar

Risk factors

  • HIV infection
  • corticosteroid use
  • underlying chronic disease (e.g., malignancy, organ failure, autoimmune disease, organ transplant)
  • residing in or visiting northern Australia, Papua New Guinea, or Vancouver Island, Canada
  • exposure to disturbed soil, chicken guano, or bat caves
  • impaired cell-mediated immunity
  • Filipinos and African Americans
  • neutropenia or impaired phagocytic function
  • neurosurgery
  • infants and neonates
  • central vascular catheters
  • sinonasal disease
  • antibacterial usage
  • prior surgery
  • hyperalimentation
  • intravenous drug abuse

Diagnostic investigations

1st investigations to order

  • CT and/or MRI head scan
  • fungal blood cultures (3 sets)
  • serum cryptococcal antigen test
  • serum + urine Histoplasma antigen
  • immunodiffusion tests (IgM and IgG) and complement fixation test (IgG) for coccidioidomycosis
  • CSF opening pressure
  • CSF WBC and differential
  • CSF protein
  • CSF glucose
  • CSF India ink stain
  • CSF culture
  • CSF cryptococcal polysaccharide antigen test
  • CSF Histoplasma antigen
  • CSF Histoplasma antibodies
  • CSF coccidioidal IgG antibodies
  • CSF galactomannan antigen test
Full details

Investigations to consider

  • histopathology and culture of biopsies: meningeal, brain, extraneural sites of involvement
  • PCR
Full details

Emerging tests

  • 18F-FDG PET/CT
  • CSF (1-3)-beta-D-glucan
Full details

Treatment algorithm

Contributors

Authors VIEW ALL

Consultant Neurologist

Clinical Lead of Neuroinflammation

Department of Neurology

Queen's Hospital

Romford

UK

Disclosures

AC has received honoraria, speaker fees, and sponsorship for attending meetings from the following pharmaceutical companies during the past 3 years: Novartis, Biogen Idec, Eisai, Terumo BCT, Genzyme. Financial compensations received from his pharmaceutical consultancy have been publicly declared in the UK disclosure website of the Association of the British Pharmaceutical Industry (ABPI). AC declares that these interests do not influence or compromise his role as a contributor.

Dr Abhijit Chaudhuri would like to gratefully acknowledge Dr Thomas S. Harrison and Dr Angela Loyse, previous contributors to this monograph. TSH and AL declare that they have no competing interests.

Peer reviewers VIEW ALL

Associate Professor of Medicine

University of Southern California

Keck School of Medicine

Los Angeles

CA

Disclosures

RAL declares that he has no competing interests.

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