My brother has multiple myeloma and recently was hospitalized again. A spinal tap showed that he had cryptococcal meningitis. Would you please tell me any thing you know about this illness? The doctors and the multiple myeloma association seem to know little or nothing about it. I would also like to know if there are any aftereffects of this disease.

B.J.H.

Multiple myeloma is a malignancy (cancer) of a type of white blood cell. It can cause a variety of problems, including bone loss, the destruction of other types of white blood cells and a high risk of infection. In addition, the drugs used to treat myeloma can suppress the immune system. One infection that can result in such cases is cryptococcal meningitis. Cryptococcus neoformans, the causative organism, is a fungus found worldwide. Most infections are in patients with AIDS and in those with weakened immune systems, such as your brother.

Cryptococcus can cause pneumonia, but the most important infection it causes is meningitis. Unlike bacterial meningitis, the cryptococcal form of the disease usually progresses slowly, over weeks or even months. Patients usually complain of headache and fever, and later there can be drowsiness and other mental changes. Cryptococcal meningitis should be suspected in anyone with an underlying illness who has these symptoms. To confirm the diagnosis, a spinal tap is performed to remove cerebrospinal fluid for testing.

Unless the infection is treated, it is usually fatal. Typically, doctors first prescribe amphotericin B (Amphotec). This is an intravenous drug that can be toxic (poisonous). If the patient does not have AIDS, and sometimes if he or she does, another agent, flucytosine (Ancobon) is added. Although this drug helps, it can increase the toxicity of the treatment.

If the treatment is discontinued, many patients will relapse, sometimes months later. Relapse is almost a certainty in AIDS patients. Because of the possibility of relapse, at some point doctors switch from the first medications to one designed to chronically suppress the fungus, usually the oral drug fluconazole (Diflucan). This agent is well tolerated with few side effects. Because it is considerably less toxic than amphotericin B and flucytosine, some physicians use this drug from the beginning, especially if the patient is not very ill. I almost always start with amphotericin B and flucytosine, if the patient can tolerate them. However, it is certainly not incorrect to start with fluconazole in some circumstances.

The prognosis of this disease is not that great. About 65 to 70 percent of patients will survive. Unfortunately, of these, up to 40 percent will be left with some neurologic abnormality, including vision loss, weakness or personality changes.