A case of cryptococcal meningitis successfully treated with miconazole and CSF drainage

Abstract

Cryptococcal meningitis is the most frequent fungal infection of the central nervous system, known readily to complicate with immuno-compromised patients. There are only a few cases of primary infection in healthy non-immuno-compromised patients. Amphotericin-B (AMPH-B) and 5-Fluorocytosine (5-FC) are effective agents against Cryptococcal meningitis, although, their toxicity and drug resistance are limiting factors. However, in recent years Miconazole has been widely used against fungal infections and it's effectiveness has been reported. This is a 68 y.o. male who was admitted to Toyohashi Municipal Hospital on March 15, 1987 because of headache, vomiting, diplopia and gait disturbance. Continuous lumbar drainage was performed since lumbar puncture revealed surprisingly high cerebrospinal fluid (CSF) pressure and presence of many Cryptococcus neoformans, i.v. AMPH-B and p.o. 5-FC was also administrated. A 7 day course of i.v. AMPH-B and p.o. 5-FC showed no improvement with side effects of macrohematuria and anorexia. Then Miconazole was administrated i.v. and intrathecal (i.t.). The clinical signs and CSF laboratory data improved after a 90 day course of Miconazole therapy and the patient was discharged on August 24. But the patient was readmitted from March 10 to April 30, 1988, because of a slight increase of C. neoformans in CSF (17/mm3) and improved by i.v. and i.t. Miconazole. The total Miconazole dosage was 90.6 g (i.t.: 505 mg) at the first admission and 36 g (i.t.: 50 mg) at the second admission, but no side effect was seen. The reduction of elevated CSF pressure with continuous CSF drainage was also important for the treatment of such cases with increased intracranial pressure.