Table 1.
EQUAL Cryptococcus Score 2018
| Section | Intervention | Score | |||
|---|---|---|---|---|---|
| HIVa | Transplant | Non-HIV, Nontransplant | |||
| Diagnosis | In all patients irrespective of site | ||||
| Blood fungal culture | 3 | 3 | 3 | ||
| Serum CrAg | 3 | 3 | 3 | ||
| Other sites explored based on clinical presentationb - Tissue/fluid fungal culture not obtained if biopsy performed - Histology with fungal stains not obtained if biopsy performedc |
–1 –1 |
–1 –1 |
–1 –1 |
||
| Immunosuppressed or CNS symptomsd | |||||
| LP done and opening pressure measured | 3 | 3 | 3 | ||
| CSF fungal culture | 2 | 2 | 2 | ||
| CSF CrAg titers measured | 2 | 2 | 2 | ||
| CSF India ink performed in the absence of CrAg | 1 | 1 | 1 | ||
| Brain CT or MRI not performed before LP if focal neurological or immunosuppressed | –1 | –1 | –1 | ||
| Pulmonarye | |||||
| If bronchoscopy done, no BAL/biopsy sent for fungal culture | –1 | –1 | –1 | ||
| Antifungal treatment | Mild–moderate, non-CNS, or localized disease | Fluconazole for 6–12 mo | 3 | 3 | 3 |
| Another azole for 6–12 mof | 2 | 2 | 2 | ||
| Any azole for <6 mo | 1 | 1 | 1 | ||
| Moderately severe–severe, CNS, or disseminated diseaseg | Induction phase (1st choice only) | ||||
| LFAmB plus 5-FC for ≥2 wkh | 3 | 3 | 3 | ||
| AmBD plus 5-FC for ≥2 wk | 2 | 2 | 2 | ||
| LFAmB alone for 4–6 wk | 2 | 2 | 2 | ||
| LFAmB plus fluconazole for 2 wk | 2 | 2 | 2 | ||
| Fluconazole with or without 5-FC for 6 wk | 1 | 1 | 1 | ||
| Not extending for 4–6 wk when clinically indicatedi | –2 | –2 | -2 | ||
| Consolidation phase (1st choice only) | |||||
| Fluconazole for ≥8 wk | 3 | 3 | 3 | ||
| Itraconazole or any other azole for 10–12 wk | 1 | 1 | 1 | ||
| Maintenance phase (1st choice only) | |||||
| Fluconazole for ≥12 mo | 3 | 3 | 3 | ||
| Itraconazole for ≥12 mo | 1 | 1 | 1 | ||
| No TDM If itraconazole is used | –1 | –1 | -1 | ||
| AmBD 1 mg/Kg IV/wk | 1 | 1 | 1 | ||
| Nonpharmacological therapeutic interventions | Immunomodulation | ||||
| ART started within 2 wk of diagnosis or not started at month 4 | –3 | NA | NA | ||
| No decrease in net immunosuppression | NA | –1 | NA | ||
| Was immunosuppression ruled out? a. HIV test not done b. Full history and immunosuppressive drug not reviewed |
NA NA |
–2 NA |
–2 –1 |
||
| Antifungal treatment stopped if IRIS developed | –2 | –2 | –2 | ||
| Management of ICHj | |||||
| No decompression via LP or lumbar drain or ventriculostomy or VP shunt to maintain CSF pressure <20 cmH2O | –3 | –3 | –3 | ||
| Corticosteroids (if no parenchymal edema)k | –2 | –2 | –2 | ||
| Acetazolamide | –1 | –1 | –1 | ||
| Mannitol | –1 | –1 | –1 | ||
| Infectious diseases consultationl | 2 | 2 | 2 | ||
| Follow-up | Repeat serum CrAg to monitor response | –1 | –1 | –1 | |
| If CNS disease: not repeating CSF culture at day 14 | –1 | –1 | –1 | ||
| If CNS disease: repeat CSF CrAg to monitor response | –2 | –2 | –2 | ||
| If HIV-positive, fluconazole was not stopped after 1 y of treatment on those on ART with a CD4 count ≥100 cells/µL | –1 | –1 | –1 | ||
Abbreviations: 5-FC, flucytosine; AmBD, Amphotericin deoxycholate; ART, antiretroviral therapy; BAL, bronchoalveolar lavage; CNS, central nervous system; CrAg, cryptococcus antigen; CSF, cerebrospinal fluid; CT, computed tomography; ICH, intracranial hypertension; IRIS, immune reconstitution inflammatory syndrome; LFAmB, lipid formulations of Amphotericin B; LP, lumbar puncture; MRI, magnetic resonance imaging; NA, not applicable; TDM, therapeutic drug monitoring; VP, ventriculoperitoneal.
aHIV-infected individuals with CD4 ≤100 cells/µL should be screened with serum CrAg, regardless of clinical manifestations.
bSome examples of sites that can be sampled based on clinical presentation include skin lesions and prostate tissue.
cSpecific fungal dyes include mucicarmine, Grocott-Gomori Methenamine Silver, Periodic Acid Schiff, and Fontana-Masson.
dCNS disease symptoms include headache, neck stiffness, confusion, ataxia, urinary incontinency, vomiting, photophobia. In all patients with disseminated disease or an underlying immunosuppression and evidence of cryptococcal disease (ie, positive blood cultures, serum CrAg, or tissue biopsy), a lumbar puncture should be even if asymptomatic.
eRespiratory symptoms or pulmonary infiltrates or nodule on imaging.
fIn the case of itraconazole, liquid formulation or capsules can be used, although the former is recommended.
gIn each phase, treatment options are mutually exclusive.
hOne week of AmB plus 5-FC is acceptable in resource-limited settings.
iNontransplant, non-HIV patients and pregnant women may require at least 4 weeks. Extending to 6 weeks is recommended in the presence of cryptococcomas, neurological complications (eg, deterioration, persistent coma, or seizures), severe uncorrected immunosuppression, and positive fungal CSF culture at the end of 2 weeks of treatment.
jIf intracranial hypertension is present (≥20 cmH2O), this intervention to decrease it should be continued until the intracranial pressure remains <20 cmH2O for 2 days. There are no data on the maximum volume of CSF that can be safely drained during a lumbar puncture. CSF pressure should be rechecked periodically afterwards.
kUse of steroids for other indications specific to each individual patient should not penalized (eg, transplant patients, chronic steroid use, etc.)
lRecently published data not contained in the IDSA guidelines.