Justice
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A 30-year-old man with HIV infection is evaluated because of a 1-week history of increasing headaches, low-grade fever, anorexia, nausea, and vomiting. He has not received any prescribed medications for the past 3 years because he believes that herbs and vitamins provide better therapy.
On physical examination, the patient appears lethargic. Temperature is 38.2 °C (100.8 °F). He has extensive seborrheic dermatitis of the face and appears to have lost weight. His neck is supple. There are no focal neurologic findings. Hematocrit is 32%, the leukocyte count is 2500/μL, and the platelet count is 150,000/μL. Lumbar puncture is performed. The opening pressure is 39 cm H2O, leukocyte count is 25/μL, protein is 65 mg/dL, and glucose is 50 mg/dL (simultaneous plasma glucose is 95 mg/dL). An India ink preparation shows many encapsulated budding yeasts, and the cryptococcal antigen titer is greater than 1:8192.
In addition to beginning antifungal therapy, which of the following should be done next?
A. No additional therapy is indicated
B. Request that a neurosurgeon place a ventriculoperitoneal shunt as quickly as possible
C. Perform lumbar punctures daily
D. Give dexamethasone, 8 mg daily for 1 week
E. Begin highly active antiretroviral therapy
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| nyimalay
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E
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| dr.wad
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E .....cryptococcal infections means that CD4 count is less than 200.
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| Justice
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A surprise:
The correct answer is C
This patient with untreated HIV infection has cryptococcal meningitis, which now occurs primarily in patients who do not benefit from or refuse to take antiretroviral therapy and in those who present with cryptococcal meningitis as the first manifestation of their HIV infection. He undoubtedly has a CD4 cell count of less than 200/μL (perhaps even less than 50/μL). Patients with AIDS tend to have a huge burden of cryptococcal organisms and a minimal host response, as shown by the cerebrospinal fluid findings in this patient. Increased intracranial pressure due to cryptococcal meningitis is found most often in patients with HIV infection but may also occur in patients with cryptococcal meningitis who do not have AIDS. Therefore, measurement of opening pressure at the time of lumbar puncture is especially important. The postulated mechanisms of increased intracranial pressure include cerebral edema secondary to the osmotic effect of the huge amount of polysaccharide capsular material as well as diminished absorption of cerebrospinal fluid because of plugging of the arachnoid villi with the same capsular material.
Increased intracranial pressure is associated with a high mortality rate in AIDS patients who have cryptoccocal meningitis. The high mortality rate is directly related to the height of the pressure. Measures to decrease the pressure should be instituted immediately, preferably by daily lumbar punctures in order to drain enough cerebrospinal fluid to normalize the pressure. Some patients may require a ventriculoperitoneal shunt. However, this is not an emergent procedure and should not be done before antifungal agents are started. Although both should be given, neither antiretroviral agents nor antifungal agents will lower the intracranial pressure. The use of corticosteroids in this setting is controversial and may be associated with a poorer outcome.
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