Chronic Headache

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 🇺🇸 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 🇺🇸& 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

Originally tweeted by Indiana University Infectious Diseases Fellowship (@IUIDfellowship) on 2 December, 2020.

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