Abstract
One of the complications of the use of antiretroviral therapy (ART), immune reconstitution inflammatory syndrome (IRIS), is particularly problematic in the management of cryptococcal meningitis. We present the case of a 35-year-old male with acquired immune deficiency syndrome diagnosed with extensive central nervous system (CNS) cryptococcal disease, including meningitis and multiple intracranial cysts, diagnosed eight weeks after the initiation of ART. The patient experienced a relapsing and remitting clinical course despite repeated courses of potent antifungal therapy and aggressive management of raised intracranial pressure. This review highlights therapeutic dilemmas and strategies in the management of CNS cryptococcosis complicated with IRIS and highlights gaps in available treatment guidelines.
Highlights
N co Introduction No Despite the widespread availability and use ence to medications, but he had resumed antiretroviral drugs for about 10 weeks
Four weeks prior to presentation to our hospital, he had been diagnosed with cryptococcal meningitis (CM) in an outside hospital and had received a 7 day course of intravenous amphotericin B
He was alert and ori- consistent with meningitis and ventriculitis ed with human immunodeficiency virus ented to time, place and person; a mini mental (Figure 1).The patient was started on induc
Summary
Contributions: OO, conception of the article, drafting, editing and reviewing the manuscript; MV, drafting, editing and reviewing the manu-. Cryptococcus gattii.[20,21] center retrospective review of 29 patients with study conducted among ART-naïve patients in Cryptococcus gattii is an increasingly recog- CNS cryptococcal disease, the majority of Botswana showed no benefit of early initiation nized cause of more severe cryptococcal dis- whom were HIV positive, evaluated the per- of ART (within 7 days) versus delayed therapy ease in both immunocompetent and immuno- formance of different modalities of brain imag- (after 28 days) on CSF clearance of cryptococdeficient individuals This species has a ing: computerized tomography (CT) versus cal organisms despite high rates of IRIS in the predilection for the CNS including formation MRI in detection of lesions associated with early ART group.[38] of cryptococcomas, and demonstrates a poorer intracranial cryptococcosis.[32] The study found There is no data on approaches to the use of response to antifungal therapy.[19,22] In clinical that MRI was more sensitive than CT scan in ART in patients with unmasking cryptococcal practice, speciation of cultured cryptococcal detecting abnormalities; notably, half of the IRIS, such as in our patient.
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