Presentation Date
13-10-2022 12:00 AM
Description
A 35-year-old African American male with no significant past medical history presented with generalized weakness, fatigue, cough, progressive 50-pound weight loss in the last 2 months, frontal headache, neck stiffness, and blurry vision. Workup revealed fever, sinus tachycardia, positive HIV screening, and multiple electrolyte abnormalities. There were negative/insignificant results on chest, lumbar spine, and head imaging. HIV viral load was 784,000; CD4 count was 4. Blood cultures grew yeast. Lumbar puncture revealed an opening pressure of 50 mmHg, WBC 2, protein 18, glucose 22, and a CSF panel positive for cryptococcus. The patient was initiated on induction therapy with AmBisome and flucytosine for 14 days. Upon discharge, he was transitioned to consolidation therapy with fluconazole 800 mg for 8 weeks and given Bactrim prophylactically. 4 weeks later, the patient was started on antiretroviral therapy (ART) with Biktarvy. After 8 weeks of consolidation therapy, the patient was transitioned to maintenance therapy with fluconazole 400 mg. 8 months after ART initiation, the patient presented with headache, photophobia, ataxia, and gait instability. The patient reported adherence to ARTs and fluconazole, and the previous month’s labs revealed an undetectable HIV viral load and a CD4 count of 143. MRI revealed diffuse leptomeningeal enhancement consistent with cryptococcal meningitis. Lumbar puncture revealed an opening pressure of 44, WBC 56, protein 56, glucose 22, and positive cryptococcal antigen (1:160 titer). The patient was restarted on induction therapy with AmBisome and flucytosine due to concern for cryptococcal meningitis recurrence, and serial lumbar punctures were performed with persistently elevated opening pressure. Blood cultures remained negative, and multiple CSF cultures had no growth throughout the hospital admission. Due to persistent negative cultures, the patient was now thought to have immune reconstitution inflammatory syndrome (IRIS). He was started on prednisone, and serial lumbar punctures were continued to be performed to decrease his intracranial pressure. The last opening pressure was 20, and the patient was discharged on a prednisone taper. This case illustrates the importance of considering IRIS in patients who have undergone treatment for disseminated cryptococcus or cryptococcal meningitis and initiation of antiretroviral therapy, even beyond the classic timeframe. Furthermore, if IRIS is on the differential, following the CSF cultures is crucial to help distinguish IRIS from recurrence of cryptococcal meningitis.
Recommended Citation
Kawji, Yasmeen; Nelson, Jacob A.; Griffin, Carl J.; and Hosse, Alexander G., "Late Onset Immune Reconstitution Inflammatory Syndrome presentingas Infectious Meningitis" (2022). Medical Student Research Poster Symposium. 39.
https://digitalscholar.lsuhsc.edu/sommrd/2022MRD/Posters/39
Included in
Late Onset Immune Reconstitution Inflammatory Syndrome presentingas Infectious Meningitis
A 35-year-old African American male with no significant past medical history presented with generalized weakness, fatigue, cough, progressive 50-pound weight loss in the last 2 months, frontal headache, neck stiffness, and blurry vision. Workup revealed fever, sinus tachycardia, positive HIV screening, and multiple electrolyte abnormalities. There were negative/insignificant results on chest, lumbar spine, and head imaging. HIV viral load was 784,000; CD4 count was 4. Blood cultures grew yeast. Lumbar puncture revealed an opening pressure of 50 mmHg, WBC 2, protein 18, glucose 22, and a CSF panel positive for cryptococcus. The patient was initiated on induction therapy with AmBisome and flucytosine for 14 days. Upon discharge, he was transitioned to consolidation therapy with fluconazole 800 mg for 8 weeks and given Bactrim prophylactically. 4 weeks later, the patient was started on antiretroviral therapy (ART) with Biktarvy. After 8 weeks of consolidation therapy, the patient was transitioned to maintenance therapy with fluconazole 400 mg. 8 months after ART initiation, the patient presented with headache, photophobia, ataxia, and gait instability. The patient reported adherence to ARTs and fluconazole, and the previous month’s labs revealed an undetectable HIV viral load and a CD4 count of 143. MRI revealed diffuse leptomeningeal enhancement consistent with cryptococcal meningitis. Lumbar puncture revealed an opening pressure of 44, WBC 56, protein 56, glucose 22, and positive cryptococcal antigen (1:160 titer). The patient was restarted on induction therapy with AmBisome and flucytosine due to concern for cryptococcal meningitis recurrence, and serial lumbar punctures were performed with persistently elevated opening pressure. Blood cultures remained negative, and multiple CSF cultures had no growth throughout the hospital admission. Due to persistent negative cultures, the patient was now thought to have immune reconstitution inflammatory syndrome (IRIS). He was started on prednisone, and serial lumbar punctures were continued to be performed to decrease his intracranial pressure. The last opening pressure was 20, and the patient was discharged on a prednisone taper. This case illustrates the importance of considering IRIS in patients who have undergone treatment for disseminated cryptococcus or cryptococcal meningitis and initiation of antiretroviral therapy, even beyond the classic timeframe. Furthermore, if IRIS is on the differential, following the CSF cultures is crucial to help distinguish IRIS from recurrence of cryptococcal meningitis.
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