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Abstract
Discussion Forum (0)
Abstract number: 2271

Session Type: ePosters

Session Title: ePosters

Authors(s): T. Siripongboonsitti (1), K. Ponglikitmongkol (2), M. Harnphadungkit (3)

Authors Affiliations(s): (1) Division of Infectious Diseases, Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand, (2) Division of Neurology, Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand, (3) Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand

Background:

Cryptococcal meningitis is an opportunistic mycosis in HIV patients. Neurological complications are hydrocephalus and increase intracranial pressure (ICP). Immune reconstitution syndrome (IRS) is well recognized, especially in early HAART patients. However, IRS in HAART-naïve patients after antifungal therapy is not well established. Brain edema without hydrocephalus is also rare after antifungal treatment.

Case:

A 31-year-old Thai male, the HAART-naïve HIV patient with CD4 count 7 cell/µl, had a severe headache and tonic seizure without neurological deficit. Initial computed tomography (CT) of the brain showed unremarkably. The lumbar puncture (LP) for cerebrospinal fluid (CSF) drainage and analysis revealed open pressure 31 cmH2O,  white blood cells (WBC) count of 2 cell/µl, numerous encapsulated yeast cells demonstrated in all stains. (Figure 1) CSF cryptococcal antigen titer was 1:256. According to fungal culture results, disseminated Cryptococcus neoformans infection is diagnosed by fungemia, meningitis, and bone marrow involvement. Prompt intravenous deoxycholate amphotericin B (DAmB) therapy was initiated, and the patient had dramatically symptom-free after treatment. Twelve days later, he developed a headache again. MRI brain showed unremarkably. Repeated LP demonstrated high intracranial pressure without pleocytosis. CSF was serial LP drained twice daily, and intravenous fluconazole was adjunct to combine with DAmB. On the 15th day, He had increasing CSF pleocytosis with a WBC count of 26 cell/µl and rapidly developed consciousness deterioration. The emergency CT brain demonstrated rapidly diffuse brain edema with tonsillar herniation in the absence of hydrocephalus 6 hours later. (Figure 2 and 3) The patient had failed treatment and demise from severe brain edema, although the high dose dexamethasone and mannitol therapy were applied for cryptococcal IRS.

Discussion:

Cryptococcal meningitis IRS with cerebral edema after antifungal therapy in HAART-naïve patients is a rare and high fatality. Although cryptococcal meningitis IRS after antifungal therapy is hard to differentiate from persistent infection, a high index of suspicion in case of a deterioration of consciousness, developed CSF pleocytosis, brain edema, and prolong uncontrolled ICP after antifungal therapy are needed to prompt evaluation, anti-inflammatory treatment, awareness of brain herniation, and difficulty managing with CSF drainage alone. The pathogenesis is still unclear and needs further study.

Keyword(s): Immune reconstitution syndrome, Cryptococcal meningitis, Cryptococcus

COI Institutional Grants: Yes
Abstract number: 2271

Session Type: ePosters

Session Title: ePosters

Authors(s): T. Siripongboonsitti (1), K. Ponglikitmongkol (2), M. Harnphadungkit (3)

Authors Affiliations(s): (1) Division of Infectious Diseases, Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand, (2) Division of Neurology, Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand, (3) Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand

Background:

Cryptococcal meningitis is an opportunistic mycosis in HIV patients. Neurological complications are hydrocephalus and increase intracranial pressure (ICP). Immune reconstitution syndrome (IRS) is well recognized, especially in early HAART patients. However, IRS in HAART-naïve patients after antifungal therapy is not well established. Brain edema without hydrocephalus is also rare after antifungal treatment.

Case:

A 31-year-old Thai male, the HAART-naïve HIV patient with CD4 count 7 cell/µl, had a severe headache and tonic seizure without neurological deficit. Initial computed tomography (CT) of the brain showed unremarkably. The lumbar puncture (LP) for cerebrospinal fluid (CSF) drainage and analysis revealed open pressure 31 cmH2O,  white blood cells (WBC) count of 2 cell/µl, numerous encapsulated yeast cells demonstrated in all stains. (Figure 1) CSF cryptococcal antigen titer was 1:256. According to fungal culture results, disseminated Cryptococcus neoformans infection is diagnosed by fungemia, meningitis, and bone marrow involvement. Prompt intravenous deoxycholate amphotericin B (DAmB) therapy was initiated, and the patient had dramatically symptom-free after treatment. Twelve days later, he developed a headache again. MRI brain showed unremarkably. Repeated LP demonstrated high intracranial pressure without pleocytosis. CSF was serial LP drained twice daily, and intravenous fluconazole was adjunct to combine with DAmB. On the 15th day, He had increasing CSF pleocytosis with a WBC count of 26 cell/µl and rapidly developed consciousness deterioration. The emergency CT brain demonstrated rapidly diffuse brain edema with tonsillar herniation in the absence of hydrocephalus 6 hours later. (Figure 2 and 3) The patient had failed treatment and demise from severe brain edema, although the high dose dexamethasone and mannitol therapy were applied for cryptococcal IRS.

Discussion:

Cryptococcal meningitis IRS with cerebral edema after antifungal therapy in HAART-naïve patients is a rare and high fatality. Although cryptococcal meningitis IRS after antifungal therapy is hard to differentiate from persistent infection, a high index of suspicion in case of a deterioration of consciousness, developed CSF pleocytosis, brain edema, and prolong uncontrolled ICP after antifungal therapy are needed to prompt evaluation, anti-inflammatory treatment, awareness of brain herniation, and difficulty managing with CSF drainage alone. The pathogenesis is still unclear and needs further study.

Keyword(s): Immune reconstitution syndrome, Cryptococcal meningitis, Cryptococcus

COI Institutional Grants: Yes
Immune reconstitution syndrome with rapidly fatal cerebral oedema after antifungal therapy in Cryptococcus neoformans meningitis in a HAART-naïve HIV patient: a case report
Dr. Taweegrit Siripongboonsitti
Dr. Taweegrit Siripongboonsitti
ESCMID eAcademy. Siripongboonsitti T. 07/09/2021; 328646; 2271;
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Dr. Taweegrit Siripongboonsitti
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Abstract
Discussion Forum (0)
Abstract number: 2271

Session Type: ePosters

Session Title: ePosters

Authors(s): T. Siripongboonsitti (1), K. Ponglikitmongkol (2), M. Harnphadungkit (3)

Authors Affiliations(s): (1) Division of Infectious Diseases, Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand, (2) Division of Neurology, Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand, (3) Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand

Background:

Cryptococcal meningitis is an opportunistic mycosis in HIV patients. Neurological complications are hydrocephalus and increase intracranial pressure (ICP). Immune reconstitution syndrome (IRS) is well recognized, especially in early HAART patients. However, IRS in HAART-naïve patients after antifungal therapy is not well established. Brain edema without hydrocephalus is also rare after antifungal treatment.

Case:

A 31-year-old Thai male, the HAART-naïve HIV patient with CD4 count 7 cell/µl, had a severe headache and tonic seizure without neurological deficit. Initial computed tomography (CT) of the brain showed unremarkably. The lumbar puncture (LP) for cerebrospinal fluid (CSF) drainage and analysis revealed open pressure 31 cmH2O,  white blood cells (WBC) count of 2 cell/µl, numerous encapsulated yeast cells demonstrated in all stains. (Figure 1) CSF cryptococcal antigen titer was 1:256. According to fungal culture results, disseminated Cryptococcus neoformans infection is diagnosed by fungemia, meningitis, and bone marrow involvement. Prompt intravenous deoxycholate amphotericin B (DAmB) therapy was initiated, and the patient had dramatically symptom-free after treatment. Twelve days later, he developed a headache again. MRI brain showed unremarkably. Repeated LP demonstrated high intracranial pressure without pleocytosis. CSF was serial LP drained twice daily, and intravenous fluconazole was adjunct to combine with DAmB. On the 15th day, He had increasing CSF pleocytosis with a WBC count of 26 cell/µl and rapidly developed consciousness deterioration. The emergency CT brain demonstrated rapidly diffuse brain edema with tonsillar herniation in the absence of hydrocephalus 6 hours later. (Figure 2 and 3) The patient had failed treatment and demise from severe brain edema, although the high dose dexamethasone and mannitol therapy were applied for cryptococcal IRS.

Discussion:

Cryptococcal meningitis IRS with cerebral edema after antifungal therapy in HAART-naïve patients is a rare and high fatality. Although cryptococcal meningitis IRS after antifungal therapy is hard to differentiate from persistent infection, a high index of suspicion in case of a deterioration of consciousness, developed CSF pleocytosis, brain edema, and prolong uncontrolled ICP after antifungal therapy are needed to prompt evaluation, anti-inflammatory treatment, awareness of brain herniation, and difficulty managing with CSF drainage alone. The pathogenesis is still unclear and needs further study.

Keyword(s): Immune reconstitution syndrome, Cryptococcal meningitis, Cryptococcus

COI Institutional Grants: Yes
Abstract number: 2271

Session Type: ePosters

Session Title: ePosters

Authors(s): T. Siripongboonsitti (1), K. Ponglikitmongkol (2), M. Harnphadungkit (3)

Authors Affiliations(s): (1) Division of Infectious Diseases, Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand, (2) Division of Neurology, Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand, (3) Department of Medicine, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Thailand

Background:

Cryptococcal meningitis is an opportunistic mycosis in HIV patients. Neurological complications are hydrocephalus and increase intracranial pressure (ICP). Immune reconstitution syndrome (IRS) is well recognized, especially in early HAART patients. However, IRS in HAART-naïve patients after antifungal therapy is not well established. Brain edema without hydrocephalus is also rare after antifungal treatment.

Case:

A 31-year-old Thai male, the HAART-naïve HIV patient with CD4 count 7 cell/µl, had a severe headache and tonic seizure without neurological deficit. Initial computed tomography (CT) of the brain showed unremarkably. The lumbar puncture (LP) for cerebrospinal fluid (CSF) drainage and analysis revealed open pressure 31 cmH2O,  white blood cells (WBC) count of 2 cell/µl, numerous encapsulated yeast cells demonstrated in all stains. (Figure 1) CSF cryptococcal antigen titer was 1:256. According to fungal culture results, disseminated Cryptococcus neoformans infection is diagnosed by fungemia, meningitis, and bone marrow involvement. Prompt intravenous deoxycholate amphotericin B (DAmB) therapy was initiated, and the patient had dramatically symptom-free after treatment. Twelve days later, he developed a headache again. MRI brain showed unremarkably. Repeated LP demonstrated high intracranial pressure without pleocytosis. CSF was serial LP drained twice daily, and intravenous fluconazole was adjunct to combine with DAmB. On the 15th day, He had increasing CSF pleocytosis with a WBC count of 26 cell/µl and rapidly developed consciousness deterioration. The emergency CT brain demonstrated rapidly diffuse brain edema with tonsillar herniation in the absence of hydrocephalus 6 hours later. (Figure 2 and 3) The patient had failed treatment and demise from severe brain edema, although the high dose dexamethasone and mannitol therapy were applied for cryptococcal IRS.

Discussion:

Cryptococcal meningitis IRS with cerebral edema after antifungal therapy in HAART-naïve patients is a rare and high fatality. Although cryptococcal meningitis IRS after antifungal therapy is hard to differentiate from persistent infection, a high index of suspicion in case of a deterioration of consciousness, developed CSF pleocytosis, brain edema, and prolong uncontrolled ICP after antifungal therapy are needed to prompt evaluation, anti-inflammatory treatment, awareness of brain herniation, and difficulty managing with CSF drainage alone. The pathogenesis is still unclear and needs further study.

Keyword(s): Immune reconstitution syndrome, Cryptococcal meningitis, Cryptococcus

COI Institutional Grants: Yes

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