Cryptococcal meningitis on T2 MRI 30 M from sub-Saharan Africa presents w/ progressive Headache x1 mo, +neck pain, photophobia, vomiting. Csf opening pressure 25cm, wbc<5, normal protein/glucose. Diagnosis? Cryptococcal meningitis, hiv+ Given prolonged headache, high csf opening pressure, csf wbc<5, normal gluc/protein: crypto meningitis is most likely. DDX Tb meningitis (pleocytosis & low glucose) CNS involvement is due to hematogenous spread & results from reactivation of prior silent pulmonary infection. meningeal infection along base of skull may extend perivascular & dilate with mucoid gelatinous cyst produced by capsule of organism (soap bubble sign on mri) HIV-infected pts w/ with #crypto meningitis are usually severely immunocompromised CD4<100 & often present w/ subacute-to-chronic headaches x days-wks. Nausea & vomiting are common but fever is present in only half. absence of fever does not rule out. Seizure/FND can be seen 40% have a normal CSF profile. CSF wbc is generally low w/ lymph predominant (median count is 20) 25% have csf wbc>100 (higher in pts on ART). CSF glucose level may be low or normal, and the CSF protein level is sometimes elevated. Standard treatment in the US includes induction therapy with amphotericin B (typically liposomal amphotericin B) plus flucytosine for 14 days, consolidation therapy with high-dose fluconazole, and maintenance therapy and secondary prophylaxis with a lower dose of fluconazole. Flucytosine costs >$2,000 per day in the US & is unavailable in resource-limited countries. In resource-limited countries, recommended therapy consists of amphotericin B deoxycholate plus high-dose fluconazole amphotericin: Severe AKI is rare (<5%)but severe K+ deficiency is common & can be life-threatening. After 5 days of amphotericin B deoxycholate, massive losses of K+ & Mg in urine are common. In resource-limited settings, electrolyte replacement ↑ 30d survival by 25% ↑ ICP is common 65%. median amount of CSF that needs to be drained at time of diagnosis to normalize ICP is typically 20 ml. If a second LP is performed, relative risk of death during the first 10 days is decreased by 70% Early initiation of ART w/ crypto meningitis results in an approximately 15% ↑ in rate of death occurring during the first 30 days, which is most likely due to IRIS. Crypto with a very low CSF wbc<5 have a higher risk of death if ART is started w/in 10 days after initiation of antifungal therapy. Guidelines recommend deferring ART until 4 to 6 weeks after initiation of antifungal therapy. Indiana University Infectious Diseases Fellowship @IUIDfellowship #Cryptococcal #meningitis #T2 #MRI #Brain #clinical #radiology
