[Cryptococcal meningoencephalitis related to HIV infection with resistance to fluconazole, relapse, and IRIS]

A 24-year-old HIV-positive patient was admitted to hospital on account of increasing headache.

On admission, a patient with severe headache, nausea and vomiting but without neurologic deficiencies was seen. The diagnosis of a cryptococcal meningoencephalitis could be confirmed by direct detection of cryptococci in the liquor.

The patient was treated with a combination of fluconazole, flucytosine and amphotericin B, and an antiretroviral therapy (ART) was started on account of the severe immunodeficiency. The patient improved during the following weeks, and fluconazole was administered as maintainance therapy. About 2 months later, the patient presented again with severe headache. On lumbar puncture, a great amount of cryptococci could be detected, and the antimycotic combination therapy was restarted. An antimycotic testing of the cryptococci revealed a partial resistance to fluconazole. Therefore, fluconazole was replaced by voriconazole which has been continued ever since. Cryptococci could not be detected on further investigations of the liquor. The patient's condition worsened again 8 months after initiation of the ART. MR scan showed a slight cerebral edema. There was no hint of an opportunistic infection nor of a lymphoma. The complaints were supposed to be due to an immune restoration inflammatory syndrome (IRIS), and administration of high steroid dosages was started. The complaints resolved within 48 h, and the patient's condition has been stable ever since (19 months).

Cryptococcal meningoencephalitis is an opportunistic infection in AIDS. Therapeutically, various regimens containing two to three different antimycotic drugs show good efficacy but resistance to antimycotics has to be considered. As in other HIV associated infections, an IRIS has to be taken into account.