CRYPTOCOCCOSIS OF THE NERVOUS SYSTEM.

Abstract

Case Report A male, age 45 years, resident in Colombo, was admitted to hospital on 7.9.6I complaining of headache, fever and vomiting of 14 days' duration. The headache preceded the fever and vomiting by ten days. Three years previously he was treated at the Chest Hospital for one month. No details of this illness are available. There were no other illnesses of note. On Examination: Temp. IooGF., the tongue was dry and coated, and the throat and tonsils normal. There were no carious teeth. There was no cedema of the feet. There were a few patches of tinea versicolor on the left upper arm. The skin was otherwise healthy. There were no enlarged lymph glands. The cardiovascular, respiratory and gastrointestinal systems were clinically normal. The ocular fundi were normal and the nervous system was apparently normal. Investigations: Hb 75%, w.b.c. IO,200/CU. mm., polys 79%, lymphs I5%, eosinos 2%, monos 4%, ESR 5 mm./hour. Urine: Bile nil, albumin+, epithelial cells +. S.A.T. negative, Mantoux negative. Blood urea 48 mg./ioo ml. Blood culture sterile. Chest X-ray: slight emphysema. The temperature was remittent and headache severe. On the sixth day there was neck rigidity and Kemig's sign was present. Lumbar puncture was done. The CSF was under tension and opalescent and contained protein 8o mg./ I00 ml., chlorides 644 mg./Ioo ml., sugar 34mg.!100ml., r.b.c. 3/cu. mm., w.b.c. i6o/cu. mm. (lymphocytes + +). The Wasserman and Kahn reactions were negative in blood and CSF. Progress: Treatment for tuberculous meningitis was started at once and fluid balance maintained by intravenous fluids, when vomiting was severe. The fever, headache and vomiting persisted. Five days later the CSF showed protein 65 mg./ioo ml., chlorides 632 mg./0oo ml., sugar 67 mg./ioo ml., r.b.c. 5/cu. mm., w.b.c. 115/cu. mm. (lymphocytes+ +), X-ray of the skull showed some opacity of the antra. Since there was no response to the anti-tuberculous drugs, and the CSF showed almost no change except for the increase of cells, the possibility of a fungus infection was considered and the CSF sent for examination for yeast cells and for culture. The report on the CSF was as follows:-Yeast cells+ +, Indian ink stain showed capsulated and budding yeast cells+ (Fig. i). On the next day the temperature was normal but the patient was drowsy and complained of severe headache. Vomiting was more frequent. Photophobia was now present and ptosis of the right eye was noted. The pupil on the right side was larger and the reaction to FIG. i.-Indian ink preparation of CSF Cryptococcuscells showing budding and clear area of capsules.