CD4<10 – A Major Headache

Today we reviewed a case of a patient with HIV and a last known CD4<10 who is intermittently on ARVs who presented with 2 weeks of a headache, neck stiffness and photobia

We first reviewed the general framework for headaches

  • Primary
    • migraine
    • tension
    • cluster
  • Secondary
    • Intracranial
      • Vascular
        • stroke
        • aneurysm
        • vasculitis
        • systemic HTN
        • hemorrhage
        • dissection
      • Infection
        • meningitis
        • encephalitis
        • abscess
        • septic emboli
        • toxoplasmosis
      • Tumor
        • metastasis
        • primary
      • CSF
        • pseudotumor cerebri
        • hydrocephalus
        • low-pressure (post-LP or leak)
      • Other
        • trigeminal neuralgia
        • post-traumatic
    • Extracranial
      • meds
      • alcohol withdrawal
      • TMJ
      • dental abscess
      • cervicogenic
      • GCA

We then discussed the specific bugs you must consider in a patient with HIV presenting with a headache

  • Cryptococcus
  • TB
  • Toxoplasmosis
  • HSV infection
  • Coccidiomycosis
  • CNS primary lymphoma (not a bug but a unique condition that must be considered in an HIV patient with a headache

CT Before LP? The IDSA Describes Six Scenarios Where You Must Do It

  • Immunocompromised state
  • History of CNS disease (eg, mass lesion, stroke, or focal infection)
  • Seizure within 1 week of presentation
  • Papilledema
  • Abnormal level of consciousness
  • Focal neurologic deficit (eg, dilated nonreactive pupil, gaze palsy, or arm or leg drift)

Empiric Antimicrobial Therapy In Suspected Meningitis in Immunocompromised Patients

  • Vancomycin/Cefepime/Ampicillin OR Vancomycin Meropenem (you must cover for pseudomonas and listeria in immunocompromised patients regardless of age or other risk factors
  • All immunocompromised patients should be covered empirically with Acyclovir for HSV

Our patient did not have Cryptococcal Meningitis, but his clinical presentation is classic for it

  • The cryptococcal antigen (serum or CSF) is 95% sensitive and specific for the presence of cryptococcus (AKA a really good test). If you don’t find it in the CSF, it’s not crypto meningitis!
  • India Ink is at best 80% sensitive (expertise + high fungal load needed for direct visualization)
  • If it were cryptococcal meningitis, treatment is as follows:
    • Induction:Ampho B + flucyotosine for minimum of 2 weeks.
    • Consolidation:Fluconazole 200-400mg daily x 8 weeks
    • Maintenancetherapy is continued for at least 1 year.
    • Intracranial pressure control:Cryptococcal meningoencephalitis patients might need daily LPs to relief ICP, might require VP shunt. Do not use mannitol or acetazolamide.
    • Steroids not shown to be helpful.
  • In cryptococcal meningitis, wait 4-6 weeks to initiate ARVs to prevent the risk of IRIS

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