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drug should be discontinued if the blood urea nitrogen reaches 40 mg/dL and resumed when it descends to normal levels Renal tubular acidosis also frequently complicates amphotericin B therapy The addition of ucytosine (150 mg/kg/day) to amphotericin B results in fewer failures or relapses, more rapid sterilization of the CSF, and less nephrotoxicity than the use of amphotericin B alone because it permits the reduction of the amphotericin dose to 03 to 05 mg/kg/day Both medications are usually continued for at least 6 weeks longer if CSF cultures remain positive However, this regimen, which has a success rate of 75 to 85 percent in immunocompetent patients, has proven to be much less effective in patients with AIDS Such patients are also extremely sensitive to ucytosine and about half of them are forced to discontinue this drug because of neutropenia Fluconazole, an oral triazole antifungal agent given in a dosage up to 400 mg daily, or oral itraconazole (up to 200 mg per day) are alternatives to ucytosine in AIDS patients and are considerably more effective in preventing relapse if given inde nitely (Saag et al; Powderly et al) The optimum use of these drugs has not been settled, and some trials have yielded ambiguous results in both AIDS and other patients A current perspective on treatment can be obtained in the reference of Tunkel and Scheld Mortality from cryptococcal meningoencephalitis, even in the absence of AIDS or other disease, is about 40 percent Candidiasis (Moniliasis) Candidiasis is probably the most frequent type of opportunistic fungus infection, but it is far less common then cryptococcosis The most notable antecedents of Candida sepsis are severe burns and the use of total parenteral nutrition, especially in children Urine, blood, skin, and particularly the heart (myocardium and valves) and lungs (alveolar proteinosis) are the usual sites of primary infection No special features distinguish this fungal infection from others; meningitis, meningoencephalitis, and cerebral abscess, usually multiple and small, are the main modes of clinical presentation Lipton and colleagues, who reviewed 2631 autopsy records at the Peter Bent Brigham Hospital (1973 to 1980), found evidence of Candida infection in 28 cases, in half of which the CNS was infected These infections took the form of scattered intraparenchymal microabscesses, noncaseating granulomas, large abscesses, and meningitis and ependymitis (in that order of frequency) In most of these cases, the diagnosis had not been made during life, possibly because of the dif culty of obtaining the organism from the CSF Generally the CSF contains several hundred (up to 2000) cells per cubic millimeter Yeast can be seen on direct microscopy in half the cases Even with treatment (intravenous amphotericin B), the prognosis is extremely grave Aspergillosis In most instances, this fungal infection has presented as a chronic sinusitis (particularly sphenoidal), with osteomyelitis at the base of the skull or as a complication of otitis and mastoiditis Cranial nerves adjacent to the infected bone or sinus may be involved We have also observed brain abscesses and cranial and spinal dural granulomas In one of our patients, the Aspergillus organisms had formed a granulomatous mass that compressed the cervical spinal cord Aspergillosis does not present as a meningitis but hyphal invasion of cerebral vessels may occur, with thrombosis, necrosis, and hemorrhage In some cases the infection is acquired in the hospital, and in most it is preceded by a pulmonary infection that is unresponsive to antibiotics Diagnosis can often be made by nding the organism in a biopsy specimen.

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