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Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Ali AA, Maaliki N, Oye M, Isache CL. Cryptococcal meningitis presenting with acute hearing loss. BMJ Case Rep 2021; 14:e242059. [PMID: 33947677 PMCID: PMC8098921 DOI: 10.1136/bcr-2021-242059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/04/2022] Open
Abstract
Reversible sensorineural hearing loss is a recognised complication of cryptococcal meningitis. Cryptococcal meningitis typically presents with usual symptoms of fever, headache and neck stiffness. This case highlights acute, profound, bilateral hearing loss as the initial symptom and presentation of cryptococcal meningitis in a young woman, who was later diagnosed with AIDS.
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Affiliation(s)
- Aleem Azal Ali
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Naji Maaliki
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Monique Oye
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Carmen Liliana Isache
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
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Gong S, Sivabalan P, Eisen DP. Hearing impairment as an unusual presenting sign of Cryptococcus gattii meningoencephalitis. BMJ Case Rep 2021; 14:14/4/e239040. [PMID: 33863766 PMCID: PMC8055112 DOI: 10.1136/bcr-2020-239040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hearing loss is an unusual presenting feature of Cryptococcus gattii meningoencephalitis. Two cases of HIV-negative patients who presented with hearing loss are discussed and a literature review of published cases was conducted. Possible mechanisms for hearing loss with C. gattii infection are explored. This case series aims to raise awareness among clinicians that hearing loss can be a concerning feature in patients with persistent headache necessitating further investigation.
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Affiliation(s)
- Sophie Gong
- Internal Medicine, Queensland Health, Brisbane, Queensland, Australia .,Infectious Diseases, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Pirathaban Sivabalan
- Infectious Diseases, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Damon P Eisen
- Infectious Diseases, Townsville Hospital and Health Service, Townsville, Queensland, Australia.,Division of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
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Zhu Y, Zhao Z, Dong C, Jiang H. Cryptococcal meningitis presented as sudden hearing loss: A case study. J Mycol Med 2020; 31:101084. [PMID: 33276295 DOI: 10.1016/j.mycmed.2020.101084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND This case report emphasizes that cryptococcal meningitis could be uncommonly presented to otolaryngologists as sudden onset of hearing loss, especially in patients with underlying diseases that could cause immunocompromise, and highlights the importance of differentiated diagnosis on sudden hearing loss before steroid therapy. It also demonstrates that prompt and sufficient fungicidal therapy with appropriate supportive treatment is crucial for a good prognosis on cryptococcal meningitis. CASE PRESENTATION A diabetic adult with untreated chronic hepatitis B was admitted complaining of sudden onset of left-sided hearing loss, following unexpected aggravating headache with meningeal signs after hospitalization with days of intratympanic steroid therapy. Cryptococcal meningitis was confirmed through lumbar puncture showing positive India ink staining and microbial culture of the cerebrospinal fluid (CSF). Fortunately, the patient recovered after prompt and adequate fungicidal therapy plus appropriate supportive treatment at last, though persistent hearing loss remained. CONCLUSIONS Cryptococcal meningitis could be presented in a very concealed way as sudden hearing loss, especially in patients with underlying diseases that could cause immunosuppression. Differentiated diagnosis on sudden hearing loss before steroid therapy is important.
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Affiliation(s)
- Y Zhu
- Otolaryngology-Head and Neck Surgery Hospital of Hainan Province, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, 19, Xiuhua Road, Haikou, 570311 Hainan, China
| | - Z Zhao
- Otolaryngology-Head and Neck Surgery Hospital of Hainan Province, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, 19, Xiuhua Road, Haikou, 570311 Hainan, China
| | - C Dong
- Otolaryngology-Head and Neck Surgery Hospital of Hainan Province, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, 19, Xiuhua Road, Haikou, 570311 Hainan, China
| | - H Jiang
- Otolaryngology-Head and Neck Surgery Hospital of Hainan Province, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, 19, Xiuhua Road, Haikou, 570311 Hainan, China.
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Hughes CM, Lennon D, Davis JS. CRyptOcoccosis in Newcastle and the hUnTer (CRONUT) – An epidemiological study. Infect Dis Health 2020; 25:34-42. [DOI: 10.1016/j.idh.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 11/15/2022]
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King KA, Ansari G, Panackal AA, Zalewski C, Anjum S, Bennett JE, Beri A, Kim HJ, Hammoud D, Brewer CC, Williamson PR. Audiologic and Otologic Complications of Cryptococcal Meningoencephalitis in Non-HIV Previously Healthy Patients. Otol Neurotol 2019; 40:e657-e664. [PMID: 31157723 PMCID: PMC6565454 DOI: 10.1097/mao.0000000000002242] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To identify audiologic and otologic outcomes in previously healthy non-HIV patients with cryptococcal meningoencephalitis (CM). STUDY DESIGN Retrospective case review of a subset of patients recruited in a prospective observational study following previously healthy individuals who developed CM. SETTING Tertiary referral center, National Institutes of Health Clinical Center. PATIENTS Previously healthy adult patients with CM without immune suppressive therapy before disease onset. INTERVENTIONS Diagnostic evaluations included audiometry, acoustic immittance, otoacoustic emissions, and auditory brainstem response studies, in addition to neurotologic assessment. RESULTS Twenty-nine patients (58 years) underwent audiologic evaluation between 6 months and 3.5 years after CM diagnosis; 21 patients were seen for longitudinal assessment with an average duration of follow up of 20.3 months. Nearly three-quarters (73%) of the cohort presented with hearing loss, most commonly (90%) sensorineural in origin. The most frequent degree of loss was mild and then moderate, although some patients had severe or profound impairment. Hearing loss improved (43%) or remained stable (38%) in most cases. Ears with internal auditory canal enhancement on magnetic resonance imaging (MRI) had significantly more hearing loss than those without enhancement, although a similar finding was not observed with gyral enhancement or the presence of ependymitis or ventricular volume expansion. Hearing loss was not associated with reduced cerebrospinal fluid (CSF) glucose, CSF total protein, cryptococcal antigen, or total cell count. CONCLUSIONS Hearing loss is a common manifestation of cryptococcal meningitis in previously healthy patients and may involve a cochlear or neural site of lesion, or both. Routine surveillance of hearing in patients is recommended, regardless of symptomatology, to ensure early and appropriate intervention and care.
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Affiliation(s)
- Kelly A King
- National Institute on Deafness and Other Communication Disorders
| | | | - Anil A Panackal
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health
| | - Chris Zalewski
- National Institute on Deafness and Other Communication Disorders
| | - Seher Anjum
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health
| | - John E Bennett
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health
| | - Andrea Beri
- Biomedical Translational Research Information System
| | - Hung Jeff Kim
- National Institute on Deafness and Other Communication Disorders
- Department of Otolaryngology-Head and Neck Surgery, Georgetown University Hospital, Washington, DC
| | - Dima Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Carmen C Brewer
- National Institute on Deafness and Other Communication Disorders
| | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health
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Risk factors and outcomes of cerebrospinal fluid overdrainage in HIV-negative patients with cryptococcal meningitis after the ventriculoperitoneal shunting procedure. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 51:545-551. [DOI: 10.1016/j.jmii.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 05/16/2017] [Accepted: 06/06/2017] [Indexed: 11/20/2022]
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Reversible hearing loss following cryptococcal meningitis: case study. The Journal of Laryngology & Otology 2016; 130:691-5. [DOI: 10.1017/s002221511600801x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackground:Sensorineural hearing loss is a recognised complication of cryptococcal meningitis. The mechanism of hearing loss in patients with cryptococcal meningitis is different from that in bacterial meningitis.Case report:An immune-competent man with cryptococcal meningitis presented with sudden onset, bilateral, severe to profound sensorineural hearing loss and vestibular dysfunction. He was initially evaluated for cochlear implantation. However, he had a significant recovery; he no longer required surgery and was able to cope without a hearing aid.Conclusion:Typically, cochlear implantation is performed with some urgency in patients with hearing loss post-bacterial meningitis, because of the risk of labyrinthitis ossificans. However, this process has not been described in patients with cryptococcal meningitis. Furthermore, patients with hearing loss associated with cryptococcal meningitis have shown varying degrees of reversibility. In this case report, hearing loss from cryptococcal meningitis is compared with that from bacterial meningitis, and the need for cochlear implantation in patients with cryptococcal meningitis is discussed.
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Liao CH, Chi CY, Wang YJ, Tseng SW, Chou CH, Ho CM, Lin PC, Ho MW, Wang JH. Different presentations and outcomes between HIV-infected and HIV-uninfected patients with Cryptococcal meningitis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2012; 45:296-304. [PMID: 22608531 DOI: 10.1016/j.jmii.2011.12.005] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 07/13/2011] [Accepted: 08/22/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Cryptococcus species are the most common causative agents of fungal meningitis. Different populations may show different clinical manifestations and outcomes. In this retrospective study, we investigated these differences in patients with and without HIV infection. METHODS From 1995 to 2009, we collected data from HIV-infected or HIV-uninfected patients aged 18 years or over who had cryptococcal meningitis (CM) in a medical center in Taiwan. We reviewed and analyzed their demographic data, clinical manifestations, therapeutic strategies and outcomes. RESULTS Among the 72 patients with CM, 19 HIV-infected patients were predominantly younger males, and all of them had AIDS status when CM was diagnosed. In contrast, the 53 HIV-uninfected patients were mostly older males with underlying diseases. The time from initial symptoms to diagnosis was shorter in HIV-infected patients (median 10 vs. 18 days, p = 0.048). The HIV-infected patients presented with less pleocytosis (p = 0.003) and lower protein levels in the cerebrospinal fluid (CSF), but a higher proportion had positive results for cryptococci in the CSF (90% vs. 60%, p = 0.02) and blood (53% vs. 21%, p = 0.009) cultures. Surgical drains and repeated lumbar punctures for the management of increased intracranial pressure were performed in 47% of the HIV-infected patients and 38% of the HIV-uninfected patients. A lower mortality rate was observed in the HIV-infected patients (p = 0.038). On multivariate analysis, initial CD4 count ≤20/mm(3) was an indicator of death or relapse in HIV-infected patients. In the HIV-uninfected group, the initial high cryptococcal antigen titer in the CSF (≥1:512) and hydrocephalus were related to unsatisfactory outcomes. CONCLUSION In addition to well-known differences, we found a lower mortality in HIV-infected patients than in HIV-uninfected patients. Cryptococci and inflammation in the central nervous system may play important roles in the pathogenesis of CM. Low intensity of inflammation and effective surgical CSF drains for increased intracranial pressure and cryptococci removal may contribute to lower mortality in HIV-infected patients.
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Affiliation(s)
- Chia-Hung Liao
- Section of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan
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Miyashita T, Kobayashi Z, Numasawa Y, Akaza M, Ishihara S, Shintani S. Epstein-Barr virus-associated meningitis presenting with hearing impairment. Intern Med 2012; 51:1755-7. [PMID: 22790140 DOI: 10.2169/internalmedicine.51.7739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 42-year-old man presented with fever, headache and liver dysfunction, and was diagnosed as having aseptic meningitis by lumbar puncture. The PCR detected Epstein-Barr virus (EBV)-DNA in the peripheral blood and cerebrospinal fluid. About 20 days after onset, the patient presented with hearing impairment in the right ear, which was confirmed by a pure tone audiogram. The hearing acuity improved after the initiation of hydrocortisone sodium phosphate. We presume that the hearing impairment was due to auditory nerve neuritis related to extension of inflammation of the meninges. This is the first reported case of EBV-associated meningitis showing hearing impairment.
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Cryptococcal meningitis with isolated otologic symptoms. Am J Otolaryngol 2010; 31:49-53. [PMID: 19944900 DOI: 10.1016/j.amjoto.2008.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Accepted: 08/03/2008] [Indexed: 02/03/2023]
Abstract
Sensorineural hearing loss (SNHL) is a known complication of cryptococcal meningitis; however, it is unusual for a patient to present with isolated otologic symptoms. We review the case of a patient who is not immunocompromised and who presented with progressive gait instability and sudden onset of left-sided SNHL followed by progression to bilateral SNHL within a 3-week period. Cryptococcal meningitis was confirmed by lumbar puncture with positive cryptococcus antigen in the cerebrospinal fluid. The patient was treated with systemic antifungals, and the hearing loss persisted. The presented report outlines this patient's unusual presentation and his treatment course and reviews the literature on the otologic manifestations of cryptococcal meningitis.
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Chang WN, Lu CH, Chang HW, Lui CC, Tsai NW, Huang CR, Wang HC, Chuang YC, Chen SF, Chang CC. Time course of cerebral hemodynamics in cryptococcal meningitis in HIV-negative adults. Eur J Neurol 2007; 14:770-6. [PMID: 17594333 DOI: 10.1111/j.1468-1331.2007.01852.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To evaluate the cerebral hemodynamics in cryptococcal meningitis (CM) patients using non-invasive studies. Serial trans-cranial color-coded sonography (TCCS) and magnetic resonance angiography (MRA) studies were performed to measure the cerebral vasculopathy of 12 HIV-negative CM patients. With TCCS, 8 of the 22 middle cerebral arteries (MCAs) showed stenotic velocities, whereas the time-mean velocity (V(mean)) of the 20 anterior cerebral arteries (ACAs), 22 posterior cerebral arteries (PCAs), and 12 basilar arteries (BAs) did not. In total, five patients had stenotic velocities, three of whom had bilateral M1 stenosis (<50%), whilst two had unilateral M1 stenosis (<50%). The V(mean) of MCA increased from day 1 to day 35 and substantially decreased thereafter. The mean Pulsatility Index (PI) in the studied vessels was higher during the study period. A mismatch of the findings between TCCS and MRA studies were also demonstrated. There was a high incidence and a longer time-period of disturbed cerebral hemodynamics during the clinical course of CM. However, because of the limited case numbers for this study, further large-scale studies are needed to delineate the clinical characteristics and therapeutic influence of cerebrovascular insults in HIV-negative CM patients.
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MESH Headings
- Adult
- Aged
- Blood Flow Velocity
- Cerebral Angiography
- Cerebral Infarction/epidemiology
- Cerebral Infarction/etiology
- Cerebral Infarction/physiopathology
- Cerebrovascular Circulation
- Constriction, Pathologic
- Female
- Humans
- Incidence
- Infarction, Middle Cerebral Artery/epidemiology
- Infarction, Middle Cerebral Artery/etiology
- Infarction, Middle Cerebral Artery/physiopathology
- Infarction, Posterior Cerebral Artery/epidemiology
- Infarction, Posterior Cerebral Artery/etiology
- Infarction, Posterior Cerebral Artery/physiopathology
- Magnetic Resonance Angiography
- Male
- Meningitis, Cryptococcal/complications
- Meningitis, Cryptococcal/mortality
- Meningitis, Cryptococcal/physiopathology
- Middle Aged
- Middle Cerebral Artery/physiopathology
- Posterior Cerebral Artery/physiopathology
- Prospective Studies
- Taiwan/epidemiology
- Treatment Outcome
- Ultrasonography, Doppler, Transcranial
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Affiliation(s)
- W-N Chang
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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