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Persistent Cryptococcal Brain Infection despite Prolonged Immunorecovery in an HIV-Positive Patient.

Tom Wingfield1, Jo Baxter2, Amit Herwadkar3

  • 1Section of Infectious Diseases & Immunity and Wellcome Trust, Imperial College Centre for Global Health Research, Imperial College London Hammersmith Hospital Campus, 150 Du Cane Road, London W12 0NN, UK ; The Monsall Infection Unit, Regional Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Delaunays Road, Manchester M8 5RB, UK.

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Summary
This summary is machine-generated.

Immune reconstitution syndrome in HIV patients can mimic relapsing cryptococcal meningitis. This case highlights challenges in diagnosis and optimal timing for antiretroviral therapy initiation in cryptococcosis.

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Area of Science:

  • Infectious Diseases
  • Immunology
  • Neurology

Background:

  • Combined antiretroviral therapy (cART) can trigger immune reconstitution inflammatory syndrome (IRIS) in HIV-positive individuals.
  • IRIS involving cerebral Cryptococcus is poorly understood and potentially fatal.
  • Differentiating cryptococcal meningitis relapse from IRIS is clinically challenging.

Purpose of the Study:

  • To present a protracted case of cryptococcal meningitis in an HIV-positive patient.
  • To highlight diagnostic challenges in distinguishing cryptococcal meningitis relapse from IRIS.
  • To raise questions about optimal cART initiation timing in cryptococcosis.

Main Methods:

  • Case report of a 33-year-old female with newly diagnosed HIV and cryptococcal meningitis.
  • Treatment with amphotericin and flucytosine, followed by cART initiation.
  • Clinical monitoring over 18 months, including brain biopsy for diagnosis.

Main Results:

  • Patient initially improved but experienced recurrent symptoms mimicking meningitis despite high CD4 counts (≥400 cells/μL).
  • Brain biopsy 17 months after initial presentation confirmed active budding Cryptococci.
  • The protracted course underscored diagnostic difficulties.

Conclusions:

  • This case illustrates the complexity of differentiating relapsing cryptococcal meningitis from IRIS.
  • Optimal timing for cART initiation in HIV patients with cryptococcosis requires further investigation.
  • Protracted IRIS can present with persistent fungal activity despite immune recovery.