Repeated Lumbar Punctures Research Articles

Acyclovir resistance in herpes simplex virus type I encephalitis: a case report

Acyclovir resistance is rarely seen in herpes simplex virus (HSV) type I encephalitis. Prevalence rates vary between 0.5 % in immunocompetent patients (Christophers et al. 1998; Fife et al. 1994) and 3.5–10 % in immunocompromised patients (Stranska et al. 2005). We report a 45-year-old, immunocompetent (negative HIV antigen/antibody testing), female patient, without previous illness who developed—after a febrile prodromal stage—aphasia and psychomotor slowing. Cerebral magnetic resonance imaging (cMRI) showed right temporal and insular T2-hyperintense lesions with spreading to the contralateral temporal lobe. Cerebrospinal fluid (CSF) analysis yielded lymphocytic pleocytosis and elevated protein level. Polymerase chain reaction testing for HSV type I showed a positive result in repeat lumbar puncture. HSV type I encephalitis was diagnosed and intravenous acyclovir treatment was initiated (750 mg t.i.d.). Acyclovir treatment was intensified to 1000 mg t.i.d., due to clinical deterioration, ongoing pleocytosis and progression on cMRI 5 days after initiation of antiviral therapy. In parallel, acyclovir resistance testing showed mutation of thymidine kinase gene at position A156V prompting foscarnet therapy (60 mg t.i.d.). Patient’s condition improved dramatically over 2 weeks. Acyclovir resistance is rare but should be considered in case of clinical worsening of patient’s condition. To our knowledge, this is the first report of acyclovir resistance in HSV type I encephalitis of an immunocompetent and previously healthy patient in Austria.

Spontaneous rupture of congenital hydrocephalous: a rare complication

Hydrocephalous represents a diverse group of conditions that result from impaired circulation and/or absorption of CSF, or in rare circumstances, from increased production of CSF by choroid plexus papilloma. Hydrocephalous could be classified as communicating and non communicating. Hydrocephalous resulting from obstruction within ventricular system is called obstructive or non communicating hydrocephalous whereas that resulting from obliteration of subarachanoid cisterns or malfunction of arachanoid villi is called communicating or non obstructive hydrocephalous. Both forms can be congenital or acquired. The first surgical treatment reported in literature was performed by Hippocrates in 5th century B.C., who punctured the lateral ventricle in a patient with obstructive HC. Several procedures and devices have been developed since then, such as external ventricular drainage, external lumbar drainage, repeated lumbar puncture, Ommaya reservoir insertion, or ventriculosubgaleal diversion, ventriculoperitoneal and ventriculoatrial shunts.In untreated cases, head size may continue to increase. Spontaneous external rupture of hydrocephalous is rare presentation. Very few cases have been reported till date.

Repeat lumbar puncture in adults with bacterial meningitis

In a prospective nationwide cohort study performed in the Netherlands from 2006 to 2014 we analysed clinical and laboratory characteristics of adults with community-acquired bacterial meningitis who underwent repeat lumbar puncture. Repeat lumbar puncture was performed in 124 of 1490 included episodes (8%), most commonly because of clinical deterioration (42%). Median cerebrospinal fluid (CSF) leucocyte count on admission was 1473 cells/mm3. Median CSF cell count showed a decrease of 19% when repeated within 2 days; of 84% within 3–7 days, of 93% within 8–14 days and of 98% within 15–21 days. Repeat lumbar puncture confirmed the diagnosis of meningitis in eight patients with normal initial CSF examination. Repeat CSF cultures yielded bacteria in nine patients, which led to identification of an underlying source of infection in two. We conclude that repeat lumbar puncture is performed in a small proportion of adults. Although it should not be seen as routine it can be useful in selected cases to confirm diagnosis, to exclude relapsing or persistent infection, or for therapeutic purpose in communicating hydrocephalus.

Intradural epidermoid cyst with atypical magnetic resonance imaging and clinical presentation

Epidermoid cysts are a rare benign neoplasm of spine. They account for only 1% of all benign spinal tumors. These cysts are either congenital or acquired, like after repeated lumbar puncture. They can present anywhere in the spinal cord, and are intradural. They can be intra- or extra-medullary. As the cysts are slow growing, they are mostly reported after some sensorimotor or in some cases after bowel and bladder involvement. Typical magnetic resonance imaging (MRI) findings are a hyperintense signal on T2-weighted (T2W) and hypointense T2W images. Diagnosis is confirmed on histopathologic examination. The treatment is complete excision and if not then maximum debulking of the tumor. We present a case of 27-year-old male with only tingling and mild weakness in the left lower limb. He was diagnosed with intradural tumor with MRI findings showing hyperintense signal on T1-W and isointense signal on T2W images. This is an uncommon presentation. It was enmeshing around rootlets so had to be debulked. The diagnosis was confirmed on histopathologic examination. Postoperatively recovery was excellent with no neurological deficit.

How to HaNDL This Case?

Headache and neurological deficits with cerebrospinal fluid (CSF) lymphocytosis (HaNDL) is a self-limited, benign neurological entity that may constitute a diagnosis dilemma since it can mimic a variety of conditions including aseptic meningitis, meningoencephalitis, migraine with aura and stroke. We report a case of a 31-year-old Caucasian man admitted at the emergency department for sudden onset of dysarthria and paresthesias in the right upper limb, after 2 weeks of complaints of headache associated with mild nausea. After extensive blood investigation, CSF study, electroencephalogram and neuroimaging, central nervous system infections, autoimmune and vascular diseases were excluded. CSF study revealed lymphocytic pleocytosis, normal glucose and slightly elevated protein concentration. Magnetic resonance imaging (MRI) showed a diffuse leptomeningeal enhancement, a decreased and delayed perfusion to the entire left hemisphere. The patient improved with supportive and symptomatic management. Two days after discharge, he developed a similar clinical picture and recovered completely 30 minutes after admission. His repeated lumbar puncture (LP) showed progressive improvement as expected due to the clinical resolution and MRI did not reveal any of the previous changes. Given the presentation (clinical picture, imaging and CSF studies), the subsequent similar and self-limited episode and having excluded other causes, a final diagnosis of HaNDL was made. HaNDL is one of the most frequent stroke mimics and probably not as rare as commonly thought. It has a good prognosis since this monophasic, self-limiting condition runs its course usually within a few months from onset, without any neurological sequelae. J Med Cases. 2016;7(3):84-86 doi: http://dx.doi.org/10.14740/jmc2419w

Occam's Razor Need Not Apply: A Case of Concurrent Cryptococcal Meningitis and Primary Central Nervous System Lymphoma in an Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Patient

A 28-year-old man with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (CD4 cells 4/1%) was diagnosed and treated for cryptococcal meningitis (CM) 3 weeks before admission with a 14-day course of amphotericin and flucytosine and subsequently discharged on oral fluconazole. However, surveillance of cerebrospinal fluid (CSF) cultures collected before discharge later turned positive for Cryptococcus neoformans and he was called back for evaluation. On admission, the patient reported headache, diplopia, and overall malaise. A head computed tomography showed new enhancing mass lesions in the left and right caudate nuclei with vasogenic edema (Figure 1). Repeat lumbar puncture showed a high opening pressure of 35 mmH2O and C neoformans detected by antigen and CSF culture. He was resumed on amphotericin and flucytosine induction therapy for presumed relapsed CM with possible cryptococcoma. A magnetic resonance imaging (MRI) of the brain was obtained and showed 2 different lesions with increased density, restricted diffusion, and low T2 signal relative to normal brain parenchyma, which were most concerning for central nervous system (CNS) lymphoma or toxoplasmosis and less concerning for cryptococcoma by radiographic appearance (Figure 2). Further CSF studies ruled out toxoplasmosis but showed positive Epstein-Barr virus DNA polymerase chain reaction, again concerning for CNS lymphoma. A brain biopsy could not be obtained due to the location of lesions. Therefore, MRI spectroscopy was performed and showed an increase in the size of both masses suggestive of malignancy (Figure 3) and an elevated choline peak with decreased N-acetylaspartate (NAA) peak, consistent with high-grade CNS lymphoma (Figure 4). The patient was started on antiretroviral therapy and steroids with initial improvement in symptoms, but he subsequently developed acute neurologic decompensation requiring emergent whole brain radiation therapy, which was complicated by hemodynamic instability and hypothermia. He eventually stabilized and was discharged on oral fluconazole and to complete radiation as an outpatient followed by high-dose methotrexate therapy (Figure 5).

Practice guideline: Idiopathic normal pressure hydrocephalus: Response to shunting and predictors of response: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.

We evaluated evidence for utility of shunting in idiopathic normal pressure hydrocephalus (iNPH) and for predictors of shunting effectiveness. We identified and classified relevant published studies according to 2004 and 2011 American Academy of Neurology methodology. Of 21 articles, we identified 3 Class I articles. Shunting is possibly effective in iNPH (96% chance subjective improvement, 83% chance improvement on timed walk test at 6 months) (3 Class III). Serious adverse event risk was 11% (1 Class III). Predictors of success included elevated Ro (1 Class I, multiple Class II), impaired cerebral blood flow reactivity to acetazolamide (by SPECT) (1 Class I), and positive response to either external lumbar drainage (1 Class III) or repeated lumbar punctures. Age may not be a prognostic factor (1 Class II). Data are insufficient to judge efficacy of radionuclide cisternography or aqueductal flow measurement by MRI. Clinicians may choose to offer shunting for subjective iNPH symptoms and gait (Level C). Because of significant adverse event risk, risks and benefits should be carefully weighed (Level B). Clinicians should inform patients with iNPH with elevated Ro and their families that they have an increased chance of responding to shunting compared with those without such elevation (Level B). Clinicians may counsel patients with iNPH and their families that (1) positive response to external lumbar drainage or to repeated lumbar punctures increases the chance of response to shunting, and (2) increasing age does not decrease the chance of shunting being successful (both Level C).

NCO-07CASE REPORT: CARCINOMATOUS OPTIC NEUROPATHY

38 years old female presented with progressive double vision followed by decreased visual acuity in left eye to almost 20/400 and later right eye. Her initial MRI B was unremarkable. LP showed opening pressure of 60, WBC 2, protein 144, normal glucose. Fundoscopic examination did not reveal any papilloedema. Considering her progressive vision loss and double vision, EVD was placed with resolution of her double vision and very mild improvement in her visual acuity. After 2 days, VP shunt was placed but her visual acuity got worse afterwards. MRV brain showed possible venous sinus thrombosis left transverse, sigmoid and internal jugular vein. At this point she also started having progressive numbness/tingling and weakness in her lower extremities. CT abdomen showed colon mass so she had colon biopsy showing poorly differentiated adenocarcinoma. At this point she was transferred to our facility for further evaluation. MRI T and L spine showed spinal root enhancement, repeat LP showed protein 1501, WBC 3 and normal glucose. EMG showed early intraspinal process at multiple levels affecting the lumbar and cervical spinal roots. Colon biopsy was repeated and confirmed poorly differentiated adenocarcinoma. Her CA 125 was 447 so ovarian carcinoma was suspected. CONCLUSION: Opthalmoplegia in our patient was probably from ICP secondary to carcinomatous meningitis. Even with progressive vision loss, she did not have papilledema so retrobulbar optic neuropathy was suspected which was thought to be secondary to paraneoplastic syndrome.

Treatment of idiopathic intracranial hypertension by endovascular improvement of venous drainage of the brain

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a syndrome of elevated intracranial pressure (ICP) in the absence of any known causative factor. Most patients with IIH respond to weight reduction, repeated lumbar punctures and carbonic anhydrase inhibitors, such as acetazolamide and topiramate to reduce cerebrospinal fluid (CSF) production. Despite a number of pathogenetic theories, the cause of IIH remains unknown. With the availability of magnetic resonance (MR) venography and cerebral angiography, venous disease is increasingly being discussed as the etiology of IIH, with a high proportion of patients presenting with nonthrombotic unilateral or bilateral dural venous sinus stenoses. Based on this observation, endovascular stenting of stenotic dural sinuses in patients with IIH has gained popularity. Whether dural venous sinus stenoses are the cause or the consequence of increased ICP is still under debate. In patients with failure of conservative treatment or non-compliance, a more aggressive treatment, such as CSF shunting or surgical optic nerve fenestration, should be performed. For approximately 13 years endovascular stenting of the stenotic sinuses has been used and discussed as an alternative and effective treatment of IIH. Since the first report in 2002, individual cases and case series have been published demonstrating that stents immediately lower the venous pressure gradient, which is associated with clinical improvement. This effect occurs within days or weeks and is permanent in many cases.

THE GREAT IMITATOR

ObjectiveWe aim to present a 45 year-old PVC plant worker with no prior history of mental illness who was admitted to a psychiatric ward with complex neuropsychiatric symptoms. He initially...

Eosinophilia à deux: a brain nagging souvenir from the Philippines

Angiostrongylus cantonensis is the most common cause of eosinophilic meningitis. Although a rare condition among travelers, increased travel and global transportation of food products may result in more cases across non-endemic, developed countries in the future. We here describe two men with headache and painful skin after visiting the Philippines as presenting symptoms. Subsequently, confusion and focal neurologic symptoms developed. Both had increased serum eosinophils; however, CSF eosinophilia was only demonstrated after repeated lumbar puncture. In the CSF of both, Angiostrongylus spp. DNA was detected. Both were treated with albendazole combined with corticosteroids, after which symptoms improved.

Low cerebrospinal fluid protein in prepubertal children with idiopathic intracranial hypertension.

To evaluate a clinical observation that prepubertal children with idiopathic intracranial hypertension (IIH) have low cerebrospinal fluid (CSF) protein levels compared to healthy children and pubertal patients with IIH. The medical records of prepubertal and pubertal IIH patients and controls seen in the pediatric neuro-ophthalmology clinic at Duke between 2003 and 2013 were retrospectively reviewed. The control group consisted of children who had normal intracranial pressure on lumbar puncture performed to evaluate for headaches or anomalous-looking optic nerves. The records were analyzed with attention to demographic characteristics, clinical presentation, course, and lumbar puncture results. A total of 23 prepubertal children with IIH (age range, 0.75-13 years), 16 pubertal patients with IIH (age range, 13-21 years), and 12 controls (age range 3-14 years) were included. CSF analysis revealed that prepubertal children with IIH had significantly lower CSF protein levels (17.3 ± 5.7 mg/dL) compared to pubertal subjects with IIH (23.4 ± 8.4 mg/dL; P = 0.019) or healthy controls (23.5 ± 6.4 mg/dL; P = 0.011). Furthermore, 9 of 23 prepubertal IIH patients (39%) had abnormally low CSF protein level (<15 mg/dL), compared to zero pubertal IIH patients (P = 0.005) and zero controls (P = 0.015). Acetazolamide increased CSF protein level in 100% of patients who underwent repeat lumbar puncture after starting the medication (average increase, 10.3 ± 6.6 mg/dL). Low CSF protein level may have diagnostic utility as a biomarker for prepubertal IIH. Furthermore, this finding suggests that some cases of prepubertal IIH may be caused by CSF overproduction rather than decreased CSF resorption.

Corticosteroids for parasitic eosinophilic meningitis.

Angiostrongylus cantonensis (A. cantonensis) is the major cause of infectious eosinophilic meningitis. Dead larvae of this parasite cause inflammation and exacerbate symptoms of meningitis. Corticosteroids are drugs used to reduce the inflammation caused by this parasite. To assess the efficacy and safety of corticosteroids for the treatment of eosinophilic meningitis. We searched CENTRAL (2014, Issue 11), MEDLINE (1950 to November Week 3, 2014), EMBASE (1974 to December 2014), Scopus (1960 to December 2014), Web of Science (1955 to December 2014), LILACS (1982 to December 2014) and CINAHL (1981 to December 2014). Randomised controlled trials (RCTs) of corticosteroids versus placebo for eosinophilic meningitis. Two review authors (SiT, SaT) independently collected and extracted study data. We graded the methodological quality of the RCTs. We identified and analysed outcomes and adverse effects. We did not identifiy any new trials for inclusion or exclusion in this 2014 update. One study involving 110 participants (55 participants in each group) met our inclusion criteria. The corticosteroid (prednisolone) showed a benefit in shortening the median time to resolution of headaches (five days in the treatment group versus 13 days in the control group, P value < 0.0001). Corticosteroids were also associated with smaller numbers of participants who still had headaches after a two-week course of treatment (9.1% versus 45.5%, P value < 0.0001). The number of patients who needed repeat lumbar puncture was also smaller in the treatment group (12.7% versus 40%, P value = 0.002). There was a reduction in the median time of analgesic use in participants receiving corticosteroids (10.5 versus 25.0, P value = 0.038). There were no reported adverse effects from prednisolone in the treatment group. Corticosteroids significantly help relieve headache in patients with eosinophilic meningitis, who have a pain score of four or more on a visual analogue scale. However, there is only one RCT supporting this benefit and this trial did not clearly mention allocation concealment and stratification. Therefore, we agreed to grade our included study as a moderate quality trial. Future well-designed RCTs are necessary.

Short prolactin profile for monitoring treatment in BH4 deficiency

Tetrahydrobiopterin (BH4) deficiency causes hyperphenylalaninemia and impaired synthesis of serotonin and dopamine, leading to brain degeneration and early death if left untreated. Replacement therapy with neurotransmitters precursors is the cornerstone of treatment, relying on 5-hydroxytryptophan and l-dopa administration. Effective restoration of dopaminergic activity is thickened, like in Parkinson's disease, by the pulsatile pharmacokinetic profile of l-dopa. Monitoring of l-dopa therapy in BH4 deficiency is generally based upon clinical observation and periodical measurement of homovanillic acid (HVA) concentration in the cerebrospinal fluid (CSF). According to the finding that dopamine is the natural inhibitor of prolactin (PRL) incretion, we introduced the use of peripheral PRL measurement as an index of dopaminergic homeostasis, so avoiding the need of repeated lumbar punctures in patients with BH4 deficiency. As a single PRL evaluation can be misleading, due to the dependency of PRL fluctuations on l-dopa administration schedule, here we show that a short PRL profile is suitable for monitoring these patients. Together with the assessment of patients' clinical symptoms, this standardized tool will ensure an objective non-invasive reference to the management of dopaminergic replacement therapy in BH4 deficiency, even in patients treated with dopamine agonists.

Idiopathic intracranial hypertension without papilledema in children: A case series

Papilledema has long been considered a hallmark of idiopathic intracranial hypertension, a disease defined by elevated intracranial pressure with indiscernible etiology. Papilledema is often seen in the pediatric population, and as such can lead to delays in diagnosis, and often misdiagnosis. Here, we describe three children who were confirmed to have idiopathic intracranial hypertension with raised intracranial pressure by repeated lumbar puncture or intracranial pressure monitoring, normal neuroimaging and absence of papilledema. All three cases had atypical clinical presentations with visual disturbances or photophobia. The patients had a normal body mass index. This case series demonstrates that idiopathic intracranial hypertension can manifest in the absence of clinically obvious papilledema, and has, as such, the potential to cause permanent visual loss if the diagnosis is missed.

A nine-week-old girl with fever and seizures.

CASE PRESENTATION A nine-week-old girl presented to the emergency department with a 12 h history of fever and a 1 min generalized tonic-clonic seizure. Review of systems was otherwise negative. Her two-year-old sister experienced a fever and oropharyngeal ulcers two weeks before. On physical examination, she was febrile to 39.2°C rectal, but with otherwise normal vital signs. She was well-appearing and her examination was normal, including the neurological examination. Blood, urine and cerebrospinal fluid (CSF) specimens were obtained, and intravenous ceftriaxone, vancomycin and acyclovir were started. Laboratory investigations showed a normal complete blood cell count and transaminase levels. CSF examination revealed 55 white blood cells/μL (51% monocytes, 37% lymphocytes, 12% neutrophils), 7 red blood cells/μL, normal protein (0.35 g/L) and normal glucose (2.9 mmol/L). An electroencephalogram revealed active epileptiform activity over the right centroparietal regions. She was admitted to the pediatric ward and underwent magnetic resonance imaging of her head, which revealed multifocal nonenhancing lesions in the subcortical white matter of the right precentral gyrus, right cingular gyrus, right corticospinal tract, as well as the right internal capsule and thalamus (Figure 1). Bacterial cultures were without growth and antibiotics were discontinued after 48 h. CSF herpes simplex virus (HSV) 1 and HSV 2 polymerase chain reaction (PCR) (LightCycler 2.0 HSV 1/2 qualitative kit [Roche Diagnostics, Canada]) and enterovirus PCR were also negative. Repeat lumbar puncture and blood testing were performed on hospital day 3. DIAGNOSIS Both the CSF and blood samples obtained on hospital day 3 returned positive results for HSV-1 using PCR, confirming a diagnosis of HSV encephalitis. Extracted DNA from the initial CSF was re-tested using a different laboratory-developed HSV 1 and HSV 2 quantitative realtime PCR assay at another reference laboratory. In retrospect, the initial CSF specimen was positive for HSV 1 (2,675 copies/mL) using this assay, as were the second CSF specimen (21,905 copies/mL) and the blood sample (12,089 copies/mL).

Continued lumbar cerebrospinal fluid drainage in surgery for intracranial aneurysms

Objective To compare the advantages and disadvantages of continuous lumbar cerebrospinal fluid drainage and repeated lumbar puncture for ruptured intracranial aneurysm surgery.Methods 295 patients were enrolled who had ruptured intracranial aneurysm and were treated surgically between Jan 2010 and Jan 2011 in department of neurosurgery.Patients were classified into 2 groups:patients who were performed with continuous lumbar cerebrospinal fluid drainage (group A) and patients who were performed with repeated lumbar puncture (group B).The incidence rates of major surgical complications of both groups were compared and analyzed,including delayed cerebral ischemia,postsurgical hydrocephalus and postsurgical intracranial infection.All patients were followed-up for over 6 months and the surgical outcomes were assessed using modified Rankin scale (mRS).Results The incidence rates of delayed cerebral ischemia were 4.38％ (7/160) and 7.41％ (10/135) in group A and B respectively.There was no significant difference between 2 groups.The incidence rates of postsurgical hydrocephalus were 2.50％ (4/160) and 3.70％ (5/135) in group A and B respectively.There was no significant difference between 2 groups.The incidence rates of intracranial infection were 8.13％ (13/160) and 2.22％ (3/135) in group A and B respectively.There was a higher rate of intracranial infection in group A (P ＜ 0.05).There was no significant difference in mRS between 2 groups after 6-months follow-up.Conclusions Continuous lumbar cerebrospinal fluid drainage showed little advantage over repeated lumbar puncture in reducing the occurrence of major surgical complications,including delayed cerebral ischemia and postsurgical hydrocephalus.While continuous lumbar cerebrospinal fluid drainage had a higher incidence rate of intracranial infection.Continuous Lumbar cerebrospinal fluid drainage might enhance the risk of intracranial infection.The therapeutic indications of continuous lumbar cerebrospinal fluid drainage for ruptured intracranial aneurysm surgery should be considered carefully.The standardized surgical operations should be followed strictly and the importance of asepsis during the surgery should be valued. Key words: Intracranial aneurysm ; Cerebrospinal fluid ; Brain ischemia ; Hydrocephalus ; Central nervous system infections

A prospective study of mortality from cryptococcal meningitis following treatment induction with 1200 mg oral fluconazole in Blantyre, Malawi.

ObjectiveWe have previously reported high ten-week mortality from cryptococcal meningitis in Malawian adults following treatment-induction with 800mg oral fluconazole (57% [33/58]). National guidelines in Malawi and other African countries now advocate an increased induction dose of 1200mg. We assessed whether this has improved outcomes.DesignThis was a prospective observational study of HIV-infected adults with cryptococcal meningitis confirmed by diagnostic lumbar puncture. Treatment was with fluconazole 1200mg/day for two weeks then 400mg/day for 8 weeks. Mortality within the first 10 weeks was the study end-point, and current results were compared with data from our prior patient cohort who started on fluconazole 800mg/day.Results47 participants received fluconazole monotherapy. Despite a treatment-induction dose of 1200mg, ten-week mortality remained 55% (26/47). This was no better than our previous study (Hazard Ratio [HR] of death on 1200mg vs. 800mg fluconazole: 1.29 (95% CI: 0.77–2.16, p = 0.332)). There was some evidence for improved survival in patients who had repeat lumbar punctures during early therapy to lower intracranial pressure (HR: 0.27 [95% CI: 0.07–1.03, p = 0.055]).ConclusionThere remains an urgent need to identify more effective, affordable and deliverable regimens for cryptococcal meningitis.

Management of HIV-associated cryptococcal disease in South Africa

In routine-care settings, the 10-week mortality associated with cryptococcal meningitis (CM) is high, even with prompt, appropriate antifungal treatment and correctly timed initiation of antiretroviral therapy (ART). While early diagnosis of HIV infection and initiation of ART prior to the development of AIDS is the most important way to reduce the incidence of CM, a cryptococcal antigenaemia screen-and-treat intervention has the potential to reduce mortality by identifying patients prior to onset of CM. Antifungal treatment for HIV-associated CM is divided into three phases over a minimum period of 1 year: (i) a 2-week induction phase, including intravenous amphotericin B deoxycholate as a backbone; (ii) an 8-week consolidation phase with fluconazole 400 mg daily; and (iii) a maintenance phase with fluconazole 200 mg daily. Amphotericin B should be paired with another antifungal agent to maximise cerebrospinal fluid fungal clearance. World Health Organization guidelines emphasise that patients receiving amphotericin B-containing regimens should have access to a ‘minimum package of toxicity prevention, monitoring and management to minimise the serious amphotericin B-related toxicities particularly hypokalaemia and nephrotoxicity’. Raised intracranial pressure is a serious and often fatal complication of CM, which requires good pressure management with repeat lumbar punctures. ART should be initiated 4 - 6 weeks after starting antifungal therapy. In many cases, relapse CM among South African patients occurs because of suboptimal adherence to secondary prophylaxis with fluconazole and/or the antifungal not being prescribed.

H1N1 ENCEPHALOPATHY: SUPPORT FOR AUTOIMMUNE PATHOGENESIS

<h3>Presentation</h3> This 22 year old lady was admitted with a one-week history of flu-like illness, confusion and seizures. Brain MRI showed high signal in the splenium of the corpus callosum. LP showed an opening pressure (OP) of 21cmH20, 38 WCC (95% lymphocytes), protein of 77.6 g/dL, with no organisms. She did not respond to acyclovir, ceftriaxone and steroids. <h3>Progress</h3> She subsequently developed features of raised intracranial pressure. Repeat LP showed an OP of &gt;40 cmH20 with 94 WCC (100% lymphocytes). She was then started on IVIg with improvement over the next few days leading to complete recovery. <h3>Diagnosis</h3> CSF viral studies were negative. Virology showed a rise in H1N1 influenza titre. Anti NMDA receptor antibodies and ANA were negative. <h3>Discussion</h3> Influenza H1N1 presents with neurological features in 6% of cases and the splenial abnormality is characteristic. The pathogenesis is considered autoimmune because the CSF shows no viruses, antibodies or cytokines, and because of the response to IVIg. This case report supports the autoimmune basis of Influenza H1N1 encephalopathy.