Neurological problems

When a HIV positive child presents with neurological problems, do LP (unless contraindicated), India ink/CRAG on CSF. Consider MRI, start empiric treatment for bacterial meningitis +/- toxoplasmosis, Cryptococcus (discuss with seniors)

Cryptococcal meningitis

(Treat if India Ink/ CRAG positive)

Presentation Differentials Investigations Treatment
Subacute headache
Often only mild neck stiffness
Change in mental Status
Bacterial meningitis
TB meningitis
LP - send sample for
India ink stain
Mainly lymphocytes, Glucose N or low Protein N or high
India ink positive (in < 60%) Ideally induction period of 12 days
with Amphotericin B (normally not available)
or Fluconazole 12-15mg/kg for 10 Weeks,
then 6-10 mg/kg ongoing.
Therapeutic lumbar punctures every 24-48 hours if any signs of raised ICP

Presentation	Differentials	Investigations	Treatment
Subacute headache Often only mild neck stiffness Change in mental Status	Bacterial meningitis TB meningitis	LP - send sample for India ink stain Mainly lymphocytes, Glucose N or low Protein N or high India ink positive (in < 60%)	Ideally induction period of 12 days with Amphotericin B (normally not available) or Fluconazole 12-15mg/kg for 10 Weeks, then 6-10 mg/kg ongoing. Therapeutic lumbar punctures every 24-48 hours if any signs of raised ICP

It has been suggested that the optimal time to start ART is >4 weeks on treatment

N.B. life long fluconazole prophylaxis is indicated after cryptococcal meningitis 6mg/kg (max 200mg) OD