Approach to the Critical Patient

Immediate priorities

Airway and mental status threats

Elevated intracranial pressure recognition

Circulatory support

Monitoring and targets

Continuous monitoring bundle

Escalation triggers

Immediate consults

Consultation triggers

History

Presenting symptoms

Core neurological syndrome

Meningeal symptoms

Cranial nerve symptoms

Systemic and constitutional history

Constitutional features

Pulmonary symptoms

Skin findings history

Risk factors

Immunodeficiency risk factors

Medication and iatrogenic risks

Epidemiologic exposures

Past medical history

Relevant prior conditions

Physical Exam

Vital signs

Hemodynamic and fever assessment

Neurological exam

Mental status

Cranial nerve examination

Meningeal signs

Systemic examination

Skin and lymph node exam

Pulmonary exam

General markers of immunosuppression

PITFALLS

Diagnostic pitfalls

Differential Diagnosis

Life-threatening mimics

Infectious meningitis spectrum

CNS mass lesions

Other fungal infections

Endemic mycoses

Other CNS infections

Non-infectious mimics

Inflammatory and neoplastic

Vascular causes

Laboratory Tests

CSF analysis

Lumbar puncture priority tests

Routine CSF studies

Serum diagnostics

Point-of-care serum testing

Baseline safety labs before antifungal therapy

Additional targeted labs

Infection and inflammation markers

Coagulation and toxicity monitoring

Diagnostic Tests

Scoring Systems

IDSA/ECMM risk stratification for CM

ICP monitoring thresholds

MRI

Brain MRI indications and findings

CT

CT head indications and interpretation

Ultrasound

Point-of-care ultrasound applications

Disposition

Admission criteria

All patients with confirmed or suspected CM require admission

Level of care and specialist consultation

Monitored ward vs ICU

Mandatory specialist consultation

Discharge criteria

Criteria for transition to outpatient consolidation

Treatment

ED stabilization

Immediate ED interventions

Induction antifungal therapy (2 weeks)

Preferred induction regimen

Alternative induction regimen

Consolidation therapy (8 weeks)

Fluconazole consolidation

Maintenance therapy (minimum 12 months)

Long-term suppressive therapy

ICP management

Therapeutic lumbar punctures

Medications not recommended for ICP

ART timing in HIV-positive patients

ART initiation timing

IRIS management

Antifungal toxicity management

Amphotericin B toxicity monitoring and mitigation

Flucytosine toxicity monitoring

Echinocandins are not active against Cryptococcus

Special Populations

Pregnancy

Maternal considerations

Antifungal safety in pregnancy

Fetal and neonatal considerations

Geriatric

Altered presentation in older adults

Treatment modifications in older adults

Pediatrics

Epidemiology in children

Pediatric antifungal dosing

Pediatric ICP management

Pediatric-specific guidelines

Background

Epidemiology

Global burden

Population distribution

Pathophysiology

Organism and infection pathway

CNS pathology

IRIS pathophysiology

Therapeutic Considerations

Antifungal mechanism and rationale

Evidence base

Treatment targets and monitoring

Patient Discharge Instructions

copy discharge instructions

Diagnosis and treatment explanation

Medication instructions

Activity and lifestyle

Follow-up instructions

Return to emergency department immediately for

References

Guidelines and key sources

Global and society guidelines

Key clinical trials

Systematic reviews and landmark publications