Diagnostic dilemma in managing relapsing episodes of Cryptococcal meningitis in HIV infected patient; a case report

W S Pannala,J D Ranatunga,L P P Godakandaarachchi,A Wijewickrama

doi:10.4038/joshhm.v2i0.46

Abstract

HIV associated morbidity and mortality has dramatically been reduced over the past decade with introduction of antiretroviral therapy (ART). However, significant number of undiagnosed patients still present with advanced HIV disease. Cryptococcal meningitis, commonly caused by the fungus Cryptococcus neoformans , is one of the commonest central nervous system opportunistic infection among those who diagnosed during advanced stage of disease. Relapsing episodes of Cryptococcal meningitis is not uncommon following successful treatment. Relapses may occur due to treatment failure or development of paradoxical cryptococcal immune reconstitution inflammatory response (IRIS) following immunological recovery with ART. However, the exact cause of relapse occurring after commencement of ART is indistinguishable from treatment failures and IRIS. Here, we present a case of a patient with HIV who had been treated for Cryptococcal meningitis that subsequently developed two recurrent episodes of Cryptococcal meningitis after initial Cryptococcal treatment, within consecutive two months while on ART.

Highlights

HIV associated morbidity and mortality has dramatically been reduced over the past with introduction of antiretroviral therapy (ART)
Subgroup of patients will develop relapsing episodes of meningitis after successful initial response. This can either be due to treatment failure or paradoxical cryptococcal immune reconstitution inflammatory response (IRIS)
Whereas in IRIS patients experiences a clinical deterioration as a consequence of rapid and dysregulated restoration of antigen specific immune responses during the treatment with antiretroviral therapy or ART(4)

Summary

Introduction

HIV associated morbidity and mortality has dramatically been reduced over the past with introduction of antiretroviral therapy (ART). The organisms most commonly associated with HIV-related cryptococcal disease are C. neoformans var. Subgroup of patients will develop relapsing episodes of meningitis after successful initial response. This can either be due to treatment failure or paradoxical cryptococcal IRIS. Whereas in IRIS patients experiences a clinical deterioration as a consequence of rapid and dysregulated restoration of antigen specific immune responses during the treatment with antiretroviral therapy or ART(4). Paradoxical Cryptococcal-IRIS occurs around 6% to 45% patients with HIV associated Cryptococcal meningitis who survive to start ART(5). We present a case of a newly diagnosed patient with HIV who had been treated for Cryptococcal meningitis that subsequently developed two recurrent episodes of meningitis after initial treatment response, within consecutive two months while on antiretroviral therapy

Case history

Discussion

Findings

Analyses Reveal the African Origin and Strain