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1、AntifungalTreatmentforCryptococcalMeningitisLi-PingZhu,Xin-HuaWengHuashanHospital,FudanUniversityShanghaiChinaChallengeforCryptococcalMeningitisCryptococcusneoformansisthemostcommoncauseoffungalmeningitisinHIVandnon-HIV-infectedpatientsFoundin7%-10%patie
2、ntswithAIDSRemainhighmortalityrate(10%-44%),especiallyinimmunocompromisedpatientsCaseStudyPresentHistoryA46-year-oldmanwasadmittedtoourhospitalbecauseoffeversandheadacheforover2monthsLumbarpunctureshowedaWBCcountof58×106/Lwith0.94monocytes,proteinwas176m
3、g/dL,andglucosewas1.5mmol/LFailedfortreatingwithbroadspectrumantibioticsincludingceftazidime,levofloxacin,etc.Histemperaturecontinuedtoclimbupto39˚C,andhisheadachedevelopedintoanintolerableone.HewasthentransferredtoourhospitalLabExaminationsCSF:WBC28×106
4、/L，multinucleatedcells15/28，monocytes13/28，protein1169mg/L，glucose1.3mmol/LCSFsmearforfungiwasnegativeCSFculturewaspositiveforCryptococcusneoformansCSFcryptococcalantigentitres1:160CranialMRIPastHistoryofHepatitisBIn2002hewasdiagnosedwithdecompensatedhep
5、atitisBcirrhosis,presentingwithfatigue,anorexiaandbloatingHBVM:HBsAg(+),HBeAg(+),HBcAB(+)HBVDNAwas2.2×107copies/mLPastHistoryofHepatitisBHetookLamivudine100mg/d，andwitnessedareductionofviralloadto3.8×103copies/mL.15monthslaterhedevelopedYMDDmutationandvi
6、ralloadreboundedto1.0×107copies/mLSincethenhehadseveralepisodesofjaundice,liverenzymeelevation,ascitesandspontaneousbacterialperitonitis.Symptomswererelievedeachtimeafteranti-infectiveandsupportivetherapyHBVDNAwas6.19×108copies/mLinJuly2005.Adefovir10mg/
7、dwasaddedtolamivudineLiverCTHowcanIinitiallytreatthispatient?AmBL-AmBFluconazoleItraconazolePosaconazoleFlucytosineRoadmapClinicalstudiesinthepre-HIVEraClinicalstudiesintheAIDSEraRecentstudiesforcryptococcalmeningitisClinicalstudies inthepre-HIVEraAmBPri
8、ortotheavailabilityofAmB,cryptococcalmeningitiswasconsideredtobeuniformlyfatalWhenAmBbecameavailableinthelate1950s,itbecamethedrugofchoiceforcrypotococcalmeningitiswithsuccessratesofupto60%Successfultherapywasoftenlimitedb
