What is the role of corticoids (corticosteroids) in the treatment of cryptococcosis?

Use of Corticosteroids in Cryptococcosis

Corticosteroids should generally be avoided in cryptococcosis except for specific, limited indications: severe IRIS with CNS inflammation, cerebral cryptococcomas with mass effect, and ARDS in the context of IRIS. 1

When Corticosteroids Are NOT Recommended

Routine Management of Increased Intracranial Pressure

• Corticosteroids should be avoided for controlling elevated intracranial pressure in cryptococcal meningitis 1
• Serial lumbar punctures to reduce CSF pressure by 50% (or to <20 cm H₂O) are the primary management strategy for elevated ICP 1, 2
• Mannitol has no proven benefit and is not routinely recommended 1
• Acetazolamide should also be avoided for ICP control 1

Transplant Recipients

• In transplant recipients with cryptococcosis who are already receiving corticosteroids (80-90% at disease onset), reduce corticosteroids gradually before reducing calcineurin inhibitors, as the latter have direct anticryptococcal activity 1
• Abrupt withdrawal of immunosuppression risks triggering IRIS or organ rejection 1
• Use a step-wise elimination approach, spacing reductions over time after initiating antifungal therapy 1

When Corticosteroids ARE Indicated

Immune Reconstitution Inflammatory Syndrome (IRIS)

• For major IRIS complications with CNS inflammation and increased intracranial pressure, use prednisone 0.5-1.0 mg/kg/day (or dexamethasone at higher doses for severe CNS symptoms) 1, 2
• Duration: 2-6 weeks with gradual taper, empirically chosen based on patient response 1
• Continue antifungal therapy and antiretroviral therapy during corticosteroid treatment 2
• Minor IRIS manifestations resolve spontaneously in days to weeks and do not require corticosteroid treatment 1

Cerebral Cryptococcomas

• Use corticosteroids for mass effect and surrounding edema associated with cryptococcomas 1
• This is an adjunctive therapy alongside amphotericin B plus flucytosine induction for at least 6 weeks 1
• Corticosteroids reduce cryptococcoma-associated edema 3

Severe Pulmonary Disease

• Consider corticosteroids if ARDS is present in the context of IRIS 1
• This applies to both immunosuppressed and non-immunosuppressed patients with severe pulmonary cryptococcosis 1

Critical Pitfalls to Avoid

Risk of Dissemination

• Corticosteroid use is a known risk factor for developing cryptococcosis in the first place 1, 4, 5
• Historical data show that patients receiving steroids or with connective tissue diseases represented a significant proportion of cryptococcal meningitis cases 1

IRIS Paradox in Transplant Recipients

• Transplant recipients who develop IRIS are more likely to have received potent immunosuppressive regimens 1
• Renal transplant recipients with cryptococcosis may experience allograft loss related to IRIS through Th1 upregulation 1
• Overall allograft survival is significantly lower in patients who develop IRIS 1

Timing Considerations

• When corticosteroids are indicated for IRIS, they must be given with a concomitant antifungal regimen 1
• Never use corticosteroids as monotherapy or before establishing adequate antifungal coverage 1

Alternative Anti-Inflammatory Agents

• Nonsteroidal anti-inflammatory drugs and thalidomide have been used for IRIS but have insufficient evidence to make recommendations 1