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[Cryptococcal meningitis in AIDS: successful long-term prophylaxis with fluconazole]
T Glück1, P Weber, K H Wiedmann
1Abteilung Innere Medizin I, Medizinische Universitätsklinik Tübingen.
Abstract:
A 30-year-old, HIV-positive, man who had been repeatedly treated with amphotericin B for oral thrush, developed headaches, fever up to 38.5 degrees C, dizzy spells with falling tendency, as well as disorder of speech and word finding. Cerebrospinal fluid (CSF) contained 5700/3 cells, of which 90% were encapsulated yeast-fungus. Cryptococcal antigen titres were elevated both in serum (1:256) and CSF (1:1024), providing the diagnosis of cryptococcal meningitis. Intravenous treatment was started with amphotericin B, 0.3 mg/kg daily and flucytosine, 150 mg/kg daily. The clinical, microbiological and serological findings regressed after 4 weeks. After 8 weeks the creatinine concentration rose to 2.5 mg/dl. Because amphotericin B nephrotoxicity was suspected, further intravenous administration was stopped after a cumulative dosage of 2 g. He was placed on a prophylactic dosage of fluconazole, 100 mg by mouth twice daily. The cryptococcal antigen titre had fallen to normal within one year. The prophylactic regimen has been continued now for three years without recurrence or other fungal infection.
Insights
This case study highlights cryptococcal meningitis in an HIV-positive man, successfully treated with amphotericin B and flucytosine. Amphotericin B nephrotoxicity led to fluconazole prophylaxis, preventing recurrence.
Area of Science:
- Infectious Diseases
- Mycology
- Nephrology
Background:
- Cryptococcal meningitis is a serious opportunistic infection in immunocompromised individuals, particularly those with advanced HIV.
- Recurrent or refractory infections necessitate careful management of treatment toxicities.
Observation:
- A 30-year-old HIV-positive male presented with symptoms suggestive of cryptococcal meningitis after prior amphotericin B treatment for oral thrush.
- Cerebrospinal fluid analysis revealed a high cell count with 90% encapsulated yeast, and elevated cryptococcal antigen titers in serum and CSF confirmed the diagnosis.
Findings:
- Initial treatment with intravenous amphotericin B and flucytosine led to clinical and microbiological remission within 4 weeks.
- Amphotericin B-induced nephrotoxicity (creatinine 2.5 mg/dl) necessitated discontinuation of the drug after a cumulative dose of 2g.
- Prophylactic fluconazole (100 mg twice daily) was initiated, resulting in normalization of cryptococcal antigen titers within one year and no recurrence over three years.
Implications:
- This case underscores the importance of monitoring for and managing amphotericin B nephrotoxicity during cryptococcal meningitis treatment.
- Long-term fluconazole prophylaxis appears effective in preventing cryptococcal meningitis recurrence in HIV-positive patients.
- Optimal management strategies are crucial for improving outcomes in patients with complex fungal infections and comorbidities.