Cryptococcal meningoencephalitis and pneumonia in a HIV positive patient: A case report

Early diagnosis of cryptococcal infection is the key to improving outcomes, any newly diagnosed HIV patient presenting with subacute or chronic headache, particularly those who are CD4-deplete, should be investigated for cryptococcal meningitis. We had some delay in our patient management, including delay in HIV diagnosis, delay in doing LP and delay in initiation of anti-cryptococcal treatment and also early start of ART before specific cryptococcal treatment exacerbated IRIS in the patient. So, paying attention to these points can improve the prognosis of such patients.

Cryptocccus is a fungal pathogen and the causative agent of Cryptococcosis among human immunodeficiency virus (HIV) positive people. Meningoencephalitis is the most common manifestation of cryptococcal infection, while pulmonary cryptococcosis is often neglected due to nonspecific clinical and radiological presentation leading to a delay in diagnosis and disseminated disease. Here, we reported a 67-year-old man with newly diagnosed HIV who presented with concurrent cryptococcal meningoencephalitis and pulmonary cryptococcosis that admitted with the complaint of dyspnea and productive cough for 1.5 months, worsening shortness of breath, fever and weight loss since 15 days prior to admission. He also had severe oral candidiasis. Lung computed tomography (CT) revealed ill-defined subpleural cavitary lesion in left lower zone with bilateral diffuse ground glass opacity and air bronchogram. His HIV PCR test was positive with absolute CD4 count less than 50 cells/mm³. After starting antiretroviral therapy (ART), he gradually developed a headache and decreased level of consciousness. Cerebrospinal fluid (CSF) analysis revealed 450 cells, predominantly lymphocytes, with protein of 343 mg/dL and glucose of 98 mg/dL (corresponding blood glucose 284 mg/dL). CSF India ink staining was positive for crypococcus spp. Liposomal amphotericin B in combination with fluconazole (due to the unavailability of flucytosin) was stated. He was intubated because of hypoxia and his bronchoalveolar lavage was positive for Cryptococcus spp. too. He died 2 weeks after starting antifungal therapy based on this study it should be mentioned that neurologic and respiratory symptoms may be the first presentation of acquired immunodeficiency syndrome.