Cryptococcosis in Asia

This chapter includes sections on aspects of the clinical epidemiology and features of cryptococcal infection particular to Asia and management practices and experience from Asia, especially where this differs in some respect from other regions. In Thailand, prior to the AIDS epidemic, Cryptococcus gattii was the most common cause of cryptococcosis and accounted for over half of all isolates that were recovered from human patients. The duration from onset of symptoms to diagnosis of cryptococcal meningitis in immunocompetent patients was longer than their predisposed counterparts. In immunocompetent patients, the cerebrospinal fluid (CSF) white cell count tended to be higher, and seizures, hydrocephalus, and shunt procedures were more frequent. Immunocompromised patients were more frequently found to have high fever and parenchymal lesions in cranial magnetic resonance imaging. A recent Cochrane review identified five randomized, controlled trials of antifungal therapy for primary prevention of cryptococcal disease in a total of 1, 316 HIV-infected patients who mostly had CD4 cell counts less than 150 cells/μl. A study from Thailand showed that the use of temporary external lumbar drainage can be a reasonably safe and effective management strategy for intractable elevated CSF pressure not responding to serial lumbar puncture in HIV-infected patients with cryptococcal meningitis, even in relatively resource-limited settings.