Complications of cryptococcal meningitis
| Complication | Approximate incidence | Considerations |
| ART-associated Cryptococcosis/unmasking IRIS | HIV-CM 1% | Fulminant CM presentation days after initiation of ART with evidence of cryptococcus in CSF. Treat as HIV-CM (see Table) |
| Paradoxical IRIS | HIV-CM 10%–50% | Occurs 1–12 months after ART initiation. Clinically, resembles CM relapse, with sterile CSF. Expert consensus advocates steroid initiation (varied formulations and doses—discuss with local Infectious Diseases team) |
| PIIRS | Limited data | 20–35 days postinfection in immunocompetent patients. Repeat CSF culture shows no fungal growth. Case reports suggest improvement with steroids, with varied formulations and doses—discuss with local ID team |
| Cryptococcomas | NHNT up to 40% | 50% single lesion, 50% multifocal. 73% have perilesional oedema. Steroids and surgical resection on case by case basis IDSA recommend prolonged induction (6 weeks) and 6–18 months fluconazole |
| Seizures | HIV-CM 25%, Non-HIV CM 10–20% | Associated with raised ICP, predictor of increased mortality |
| Stroke | 10–30% | Ischaemic infarcts predominantly lacunar. Multiterritorial infarct could indicate CM-associated intracranial vasculitis |
| Neurocognitive impairment | HIV-CM 90% at 1 month 40% at 12 months | Data are confounded by advanced HIV, but this is likely to be under-recognised in survivors and contributes significantly to economic impact of CM on survivors and to wider society |
| Visual Impairment | HIV-CM 40–50% | Severity correlates with ICP>20 cmH2O |
| Hearing impairment | HIV-CM 30%–90% NHNT 30% | Severity correlated with ICP>20 cmH2O |
ART, antiretroviral therapy; CM, cryptococcal meningitis; CSF, cerebrospinal fluid; ICP, intracranial pressure; IDSA, Infectious Diseases Society of America; IRIS, immune reconstitution inflammatory syndrome; NHNT, non-HIV, non-transplant; PIIRS, postinfectious inflammatory response syndrome.