Steroids in Cryptococcosis
Corticosteroids should be avoided in cryptococcosis except for three specific situations: immune reconstitution inflammatory syndrome (IRIS) with major CNS complications, cerebral cryptococcomas with mass effect, and ARDS in the context of IRIS. 1
General Rule: Avoid Corticosteroids
Corticosteroids should be avoided to control increased intracranial pressure in cryptococcal meningitis (unless part of IRIS treatment). 1 This is a strong recommendation (A-II evidence) from the Infectious Diseases Society of America guidelines. 1
The rationale is critical: corticosteroids suppress immune function and can exacerbate fungal infections, reduce resistance to new infections, increase risk of disseminated infections, and mask signs of infection. 2 A landmark 2016 randomized controlled trial definitively demonstrated that dexamethasone in HIV-associated cryptococcal meningitis increased mortality (57% vs 49% at 6 months), caused more disability (only 13% vs 25% had good outcomes), slowed fungal clearance in CSF, and resulted in significantly more adverse events including grade 3-4 infections, renal events, and cardiac events. 3 The trial was stopped early for safety reasons. 3
Three Specific Exceptions Where Steroids Are Indicated
1. IRIS with Major CNS Complications
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 signs). 1
- Taper over 2-6 weeks as a reasonable starting point, adjusting based on clinical response. 1
- Always continue concomitant antifungal therapy—do not alter direct antifungal treatment. 1
- Minor IRIS manifestations resolve spontaneously in days to weeks and do not require corticosteroids. 1
2. Cerebral Cryptococcomas with Mass Effect
Use corticosteroids for cerebral cryptococcomas causing mass effect and surrounding edema. 1
- This is adjunctive to intensive antifungal therapy (amphotericin B plus flucytosine for at least 6 weeks). 1
- Consider surgical debulking for large (≥3 cm) accessible lesions with mass effect. 1
3. ARDS in Context of IRIS
Consider corticosteroids for ARDS occurring in the context of an inflammatory syndrome response in pulmonary cryptococcosis. 1
- This applies specifically to immunosuppressed patients with severe pneumonia or ARDS related to IRIS, not routine pulmonary cryptococcosis. 1
Critical Management Principles
For elevated intracranial pressure in cryptococcal meningitis, use CSF drainage via serial lumbar punctures—not corticosteroids. 1
- If opening pressure ≥25 cm CSF with symptoms, reduce pressure by 50% or to ≤20 cm CSF. 1
- Repeat daily until pressure stabilizes if persistently elevated. 1
- Consider temporary lumbar drains or ventriculostomy for patients requiring repeated daily punctures. 1
- VP shunts are reserved for refractory cases despite appropriate antifungal therapy and conservative measures. 1
Common Pitfalls to Avoid
Do not use corticosteroids reflexively for headache or elevated intracranial pressure in cryptococcal meningitis—this worsens outcomes. 1, 3 The evidence is unequivocal that steroids increase mortality and morbidity in standard cryptococcal meningitis management. 3
Recognize that corticosteroids themselves are a major risk factor for developing cryptococcosis. 2, 4, 5 Patients on chronic high-dose steroids are at increased risk for cryptococcal infections, creating a clinical dilemma when managing conditions requiring immunosuppression. 4, 5
Distinguish IRIS from treatment failure. 1 IRIS typically occurs after immune reconstitution (e.g., starting HAART in HIV patients) and presents with paradoxical worsening despite appropriate antifungal therapy and improving fungal burden. 1 This is when steroids may help, not during initial infection management. 1