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