Contraindications include significant coagulopathy or suspected space-occupying lesion based on focal nervous system signs (excluding cranial nerve VI palsy) or recurrent seizures and, where possible, confirmed by computed tomography. Raised intracranial pressure does not contraindicate lumbar puncture in (suspected) cryptococcal meningitis. Other contraindications include major spinal deformity and refusal by the patient after fully informed consent was sought.

Note: Other diseases that can present with symptoms and signs similar to cryptococcal meningitis (such as viral, bacterial or tuberculous meningitis) should also be considered.

IMPLEMENTATION CONSIDERATIONS Diagnosis Diagnosis is key to improving mortality from cryptococcal disease, and national programmes need to give priority to reliable access to rapid diagnostic cryptococcal antigen assays, preferably lateral flow assays for use in CSF and serum or plasma. In addition, health-care professionals need to have a low threshold for suspecting cryptococcal meningitis. Countries should develop plans to improve access to rapid cryptococcal antigen assays, depending on the cryptococcal burden. Health-care infrastructure and available resources will determine the comprehensiveness of access. The relative advantage of various screening approaches should be considered according to context. Evidence from South Africa suggests that laboratory-based reflexive screening, in which cryptococcal antigen testing is routinely performed in the laboratory on any blood sample with a CD4 cell count threshold meeting the criteria for screening, can save time and resources when laboratory resources allow (69,70). In resource-limited settings with limited laboratory infrastructure, task sharing has been found to overcome human resource limitations. A study in Lesotho found that cryptococcal antigen screening by lay counsellors followed by pre-emptive fluconazole treatment for cryptococcal antigen–positive asymptomatic cases or referral to hospital for symptomatic cases was feasible (71). This may be the preferred approach, especially when point-of care CD4 cell count is available, enabling same-day initiation of fluconazole among those who screen cryptococcal antigen–positive.