Meningoencephalitis in an African woman
58 year old woman from Tanzania presented with fever and altered sensorium. She had been previously diagnosed with HIV infection, however adherence with anti-retroviral therapy was poor. She had been started on a protease inhibitor based antiretroviral regimen approximately 1 month prior to presentation.
MRI brain was normal. A CSF study showed no pleocytosis and normal glucose and protein levels. CSF cryptococcal antigen was positive. Cryptococcus was isolated from CSF cultures. The HIV viral load was less than 10 copies/ml. CD4 count was 16 cells/ul.
The patient was started on liposomal amphotericin B and 5-flucytosine. The patient developed an ESBL producing klebsiella bacteremia during ICU stay. Sensorium remained poor despite 2 weeks of amphotericin B. A followup lumbar puncture showed persistent positive cryptoccal antigen and negative cryptococcal cultures.
The patient improved over the next few weeks, however with significant neurological disability.
Important features:
- Cryptococcal meningitis can present with a normal CSF, reflecting poor immunological response against the cryptococci
- Low HIV viral load with a low CD4 count in context of recent initiation of antiretroviral therapy.
- Unmasking cryptococcal immune reconstitution syndrome few weeks after starting antiretroviral therapy, especially with CD4 count less than 50 cells/ul.
- Persistent positive crypococcal antigen does not necessarily indicate treatment failure. Cryptococcal cultures are a more useful indicator.
Unmasking IRIS / cryptococcal meningitis after initiation of antiretroviral therapy