Page 20 - Delaware Medical Journal - September 2017
P. 20
FIGURE 1
T2 weighted MRI images, without contrast. Both show abnormal foci of T2 hyperintensity in the bilateral basal ganglia and thalami, corresponding to gelatinous pseudocysts. The second image shows increased number and size of these lesions, which could indicate disease progression or IRIS. Without contrast, leptomeningeal enhancement cannot be described.
Keeping Complicated Cryptococcal
Meningitis on the Radar
Pamela Bailey, DO; Chad Duffalo, MD, MPH
CASE REPORT
A 63-year old male with history of polymyalgia rheumatica and rheumatoid arthritis on daily prednisone, hydroxychloroquine,
and methotrexate therapy presented to the emergency department with a four month history of right sided headaches with associated nausea, vomiting, and photophobia. Due to concern for meningitis, a lumbar puncture was performed. India ink staining from the with Cryptococcus; CSF and blood cultures were positive for Cryptococcus neoformans. A CSF cryptooccal antigen titer was enhancement in the posterior fossa, but no noted enhancement in the supratentorial region or intraparenchymally. There was T2/ FLAIR hyperintensity noted in the basal ganglia and thalami bilaterally, suggesting gelatinous pseudocysts. He was started continued positive CSF cultures at two weeks, induction therapy improvement, including negative CSF cultures, he was discharged
He was seen in the outpatient setting on several occasions. Three months after initial presentation, he developed recurrent headache.
Cryptococcal meningitis can lead to significant morbidity and mortality in those individuals
who are infected with it. The highest risk
patient population, those infected with HIV,
has seen a significant decline in incidence due
to better management of HIV itself. However, cryptococcal disease occurs in the non-HIV immunocompromised patient population as well, and it may not only be underappreciated, but its relative contribution toward the overall burden of disease has increased. The complications seen
in those with HIV can also occur in the non-HIV patient population, such as increased intracranial pressure, seizures, and immune reconstitution inflammatory syndrome (IRIS). In the following, we report a case of a 63-year-old HIV-negative, immunocompromised patient who developed complicated cryptococcal meningitis, involving immune reconstitution inflammatory syndrome (IRIS) who required high dose steroids in addition to standard antifungal therapy.
Keywords: immune reconstitution, cryptococcal meningitis, immunocompromised
Abstract
