Cryptococcal Meningitis and a New Diagnosis of AIDS

Today, we presented an interesting case of a young man with no past medical history who presented with two weeks of progressive headache and fever, now with nausea, vomiting, and an episode of transient blurred vision. CSF revealed an elevated white blood cell count with lymphocytic predominance, low glucose, and elevated protein. Serum and CSF CrAg subsequently came back positive and fungal blood cultures showed Cryptococcus Neoformans.

Illness script for Crypto Meningitis:
Epi: AIDS patients with CD4<100
Symptoms: Indolent onset 1-2 weeks for fever, malaise, and headache. Can develop meningeal signs, altered level of consciousness, and focal neuro deficits. Disseminated disease can include pulmonary symptoms and skin findings resembling molluscum contagiosum.
Diagnosis: Serum and CSF CrAg with 93-100% sensitivity and 93-98% specificity. Crypto can be isolated on India Ink stain of CSF 60-80% patients.
Treatment: Induction with 2 weeks of IV amphotericin B and PO flucytosine, consolidation for 8 weeks with high dose fluconazole, and maintenance for one year with low-dose fluconazole. Serial LPs for ICP control. Start ART 2-10 weeks after starting antifungal treatment (delayed due to risk of IRIS).

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