Management of Cryptococcal Meningitis in the Antiretroviral Therapy Era: More than Just Antifungals

Overview CME Credit Available: 2 AMA PRA Category 1 CreditsTM Release Date: November 25, 2008 Date of Last Review/Update: November 25, 2008 Expiration Date: November 25, 2009 This Cases on the Web activity introduces a case and presents 6 clinical decision points, each focusing on an aspect of HIV patient care in the setting of cryptococcal infections. At each clinical decision point, learners should select the option that they believe is most sound and then read the presenters’ explanation of that option. Choosing the best option links the learner to an extended discussion of related medical findings, research-based evidence, and case management considerations. To advance from one clinical decision point to the next, learners should click on the NEXT arrow at the base of each page that discusses the best clinical option. After reviewing the case, learners may link to the continuing medical education (CME) posttest questions and the course evaluation, both of which must be completed and submitted to receive credit. Please see the posttest form and the evaluation form for further instructions. Activity Objectives On completion of this activity, the learner will be able to: Describe the epidemiology and major clinical manifestations of cryptococcal infections in HIV-infected patients. Explain the optimal approach to the diagnosis of cryptococcal infections. Discuss preferred treatment strategies for cryptococcal infections using amphotericin B, flucytosine, and azole antifungal drugs. Describe the management of intracranial hypertension. List indicators of poor prognosis for cryptococcosis. Identify risk factors for immune reconstitution inflammatory syndrome (IRIS). Distinguish Cryptococcus-related IRIS from active cryptococcal infection. Assessment of Needs The International AIDS Society–USA offers this state-of-the-art activity as part of a nationwide CME effort for HIV physicians on the evolving challenges of HIV disease. This activity examines issues relevant to managing HIV-infected patients in the setting of active cryptococcal infection or Cryptococcus-related IRIS. Intended Audience This online CME activity is designed for physicians who are actively involved in HIV and AIDS care. Specifically, these activities have been designed for physicians who: Have a solid, working knowledge of HIV disease management. Provide comprehensive or specialty care for at least 10 patients with HIV and AIDS or are involved in HIV and AIDS clinical trials or investigations. Have completed at least 10 hours of CME in the area of HIV and AIDS medicine in the past 2 years. This activity is also relevant to nurse practitioners, physician assistants, nurses, and other health professionals who provide care for people with HIV disease. CME Accreditation The International AIDS Society–USA is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The International AIDS Society–USA designates this educational activity for a maximum of 2 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. This CME activity is offered from November 25, 2008 to November 25, 2009. Participants who successfully complete the activity posttest and submit the evaluation and registration forms are eligible to receive CME credit. Physicians (MDs, DOs, and international equivalents) may receive CME credit for completing this activity. Nonphysician health care practitioners will receive a certificate of attendance. Faculty Authors Anuradha Ganesan, MD Dr Ganesan is an Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and a Staff Physician in the Infectious Disease Clinical Research Program at the National Naval Medical Center, Bethesda. Her research interests include the host immune response to HIV infection and metabolic complications of HIV infection. Henry Masur, MD Dr Masur is the Chief of the Critical Care Medicine Department at the National Institutes of Health Clinical Center in Bethesda, Maryland, a Clinical Professor of Medicine at the George Washington University School of Medicine and Health Sciences in Washington, DC, and immediate Past President of the Infectious Diseases Society of America. He has published widely on HIV-related opportunistic infections and has conducted research on ICU-related infections and emerging infections. Editor Paul E. Sax, MD Dr Sax is Associate Professor of Medicine at Harvard Medical School and is Clinical Director of the Division of Infectious Diseases at Brigham and Women’s Hospital in Boston. He is site Principal Investigator for the Harvard Medical School AIDS Clinical Trials Unit and is a member of the Cost Effectiveness of Preventing AIDS Complications (CEPAC) group at the Harvard School of Public Health. Dr Sax maintains an active clinical practice in infectious diseases that focuses on HIV infection. Disclosure of Financial Interests In the interest of maintaining the independence of its continuing medical education activities, and in accordance with the policies of the Accreditation Council for Continuing Medical Education, the International AIDS Society-USA requires all persons with control of content (ie; authors, reviewers, Editorial Board members, and the staff of the Cases on the Web [COW] program) to disclose any financial interests that they (or their spouses or partners) have with commercial companies within the past 12 months. Faculty Neither Dr Ganesan nor Dr Masur have any financial conflicts of interest to disclose related to this Cases on the Web activity. Dr Sax has been a consultant for Abbott Laboratories, Bristol-Myers Squibb, Gilead Sciences, and GlaxoSmithKline and has received grants and research support from Bristol-Myers Squibb, Merck & Co, Inc, and Pfizer, Inc. He as been on a paid lecturer for Abbott Laboratories, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck & Co, Inc, Tibotec Therapeutics, and Virco Lab, Inc. Cases on the Web Editorial Board The members of the COW Editorial Board are volunteers and are not compensated for their role in overseeing the online COW program. The dates of the most recent update of relationships with commercial entities are indicated in parentheses. Michael S. Saag, MD — Editor-in-Chief Professor of Medicine The University of Alabama at Birmingham Dr Saag has received grants and research support from, and has been a scientific advisor to, Boehringer Ingelheim Pharmaceuticals, Inc, Gilead Sciences, GlaxoSmithKline, Merck & Co, Inc, Monogram Biosciences, Panacos Pharmaceuticals, Inc, Pfizer, Inc, Progenics Pharmaceuticals, Inc, Roche Laboratories, Tibotec Therapeutics, and Virco Lab, Inc. (February, 2008) Meg D. Newman, MD — Coeditor Associate Professor of Medicine University of California San Francisco Dr Newman has no relevant financial affiliations to disclose. (December, 2007) Judith A. Aberg, MD Associate Professor of Medicine New York University School of Medicine Dr Aberg has served as a consultant for Abbott Laboratories, Boehringer Ingelheim Pharmaceuticals, Inc, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, and Tibotec Therapeutics. She has received grants and research support from Abbott Laboratories, Bristol-Myers Squibb, Merck & Co, Inc, and Pfizer, Inc and was a paid lecturer for Abbott Laboratories and Bristol-Myers Squibb. Dr Aberg has received fees for written enduring materials, internet activities, or audio activities from Abbott Laboratories and Bristol-Myers Squibb. (December, 2007) Roger J. Bedimo, MD, MS Director, Infectious Disease Fellowship Training University of Texas Southwestern Medical Center Dr Bedimo has received grants and research support from Abbott Laboratories, Bristol-Myers Squibb, Merck & Co, Inc, and Tibotec Therapeutics and has served as a scientific advisor to Abbott Laboratories and Gilead Sciences. (September, 2007) Marshall J. Glesby, MD, PhD Associate Professor of Medicine and Public Health Weill Medical College of Cornell University Dr Glesby has served as a consultant for Merck Serono and received grants and research support from EMD Serono. (December, 2007) Steven C. Johnson, MD Professor of Medicine University of Colorado Dr Johnson has been a consultant for Abbott Laboratories, Gilead Sciences, GlaxoSmithKline, Merck & Co, Inc, and Tibotec Therapeutics. He has been a paid lecturer for Abbott Laboratories and Merck & Co, Inc. (December, 2007) Harry W. Lampiris, MD Associate Professor of Clinical Medicine University of California San Francisco Dr Lampiris has been a scientific advisor to Abbott Laboratories and has received grants and research support from Gilead Sciences, Pfizer, Inc, and Roche Laboratories. He has been a paid lecturer for Boehringer Ingelheim Pharmaceuticals, Inc, Merck & Co, Inc, and Monogram Biosciences. (December, 2007) Paul E. Sax, MD Associate Professor of Medicine Harvard Medical School Dr Sax has been a consultant for Abbott Laboratories, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, and Tibotec Therapeutics and has received grants and research support from Bristol-Myers Squibb, Merck & Co, Inc, and Pfizer, Inc. He has been a paid lecturer for Abbott Laboratories, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck & Co, Inc, and Tibotec Therapeutics. (February, 2008) Staff Donna M. Jacobsen — Executive Director/President Ms. Jacobsen has no relevant financial affiliations to disclose. Mark F. Wales — Web Content Coordinator Mr. Wales has no relevant financial affiliations to disclose. Grant Support This Cases on the Web activity is sponsored by the International AIDS Society–USA and was made possible through educational grants from the following commercial companies. Substantial Grant Support Bristol-Myers Squibb Tibotec Therapeutics Abbott Laboratories Gilead Sciences Merck & Co, Inc Pfizer Global Pharmaceuticals Generous Grant Support GlaxoSmithKline Drug and Product Disclaimer This activity may contain information about the investigational uses of drugs or products that are not approved by the US Food and Drug Administration. Please consult full prescribing information before using any medication or product mentioned in Cases on the Web. The views and opinions expressed herein are those of the faculty and do not necessarily represent the opinions or recommendations of the International AIDS Society–USA. Contact Information If you have any questions about this Cases on the Web activity, please contact the International AIDS Society–USA: International AIDS Society–USA 425 California Street Suite 1450 San Francisco, CA 94104-2120 Telephone: 415-544-9400 Fax: 415-544-9401 E-mail: info2008"at"iasusa.org