Cryptococcal meningitis in an immunocompetent child

Abstract

An immunocompetent child infected with cryptococcal meningitis was cured without any sequelae or relapse with six months of antifungal treatment. An 11-year old Japanese boy who presented with headache and vomiting without high fever was admitted to a local hospital with a diagnosis of aseptic meningitis and discharged after symptomatic relief. Cryptococcus neoformans was later detected in the cerebrospinal fluid (CSF) culture and he was referred to our hospital. His physical and neurological examination was unremarkable except for a mild stiff neck. Cryptococcus neoformans was detected in an India ink stain and culture of the CSF upon admission (Fig. 1), and the cryptococcal antigen with latex agglutination was positive. CSF revealed leukocytosis, increased protein and high opening pressure with normal glucose (53 mg/dl) (Fig. 2). Blood leukocyte count was 7600/ll. Although chest Xray was normal, CT revealed mild peribronchial inflammation in the left lower lobe (S7). An enhanced head MR imaging was negative. The initial treatment with intravenous amphotericin B (AMPH-B) and oral flucytocin (FC) was discontinued after ten days due to fever and skin rash: fluconazole (FLCZ) was administered orally for six months thereafter (Fig 2). No relapses or sequelae have been observed. A detailed developmental and medical history was unremarkable except that he had a history of repeated hospitalizations for asthma until eight years of age. It is noteworthy that he had occasionally been exposed to guano of wild pigeons. His humoral and cellular immunological parameters (CD4 900/ll, CD4/8 2.25), complement and neutrophil functions were normal. Anti-HIV antibody was negative. Although cryptococcal meningitis is uncommon among HIV-negative patients [1, 2, 6, 7, 8], severe pediatric cases have been reported [3, 4]. We infer that, in the case reported here, a pulmonary cryptococcal infection was the primary lesion preceding meningitis because of the exposure to guano of pigeons, repeated