Devastating Case of Cryptococcal Meningitis in an HIV Negative Host
Golriz Asefi1, Simmer Kaur1, Yoel Olazabal Pupo2, Carol Stewart-Hayostek2, Arash Heidari1. 1Internal Medicine, Kern Medical-UCLA, Bakersfield, California, United States, 2Family Medicine, Rio Bravo, Bakersfield, California, United States
Purpose of Study Cryptococcal meningitis is an opportunistic fungus transmitted by inhalation of infective spores from an environmental source. The most common presentation is in patients with HIV or a known immunocompromised condition. Recent studies, however, have shown an increasing incidence of cryptococcal infection amongst immunocompetent hosts. We are presenting an HIV negative patient who suffered a devastating and fatal course of disseminated cryptococcal infection.
Methods Used Case report
Summary of Results A 46-year-old African American woman with hypertension and diabetes was incidentally found to have a speculated right upper lobe mass but lost to follow up. She then presented to an outside hospital with a severe headache and found to have disseminated Cryptococcus neoformans grown in CSF and Blood. Liposomal amphoteric B and flucytosine was initiated for 5 weeks. She developed cachexia, mental status deterioration, and contracture of extremities. She was admitted to our hospital right after discharge with a new onset of a seizure. Imaging showed no intracranial lesions but re-demonstrated the lung lesion which was biopsied and showed pulmonary cryptococcoma. Induction therapy with liposomal amphotericin B and dexamethasone taper was restarted. Elevated intracranial pressures were reduced by the serial lumbar punctures and temporary lumbar drain. Fluctuating serum and CSF Cryptococcus Ag titers were noted, but cultures remained negative. HIV test was negative. Blood was sent to NIH for immunogenetics testing but did not show any known defect. IV voriconazole was started, and she was discharged on comfort care to her family. Patient remained relatively stable until 5 months later when she presented with septic shock due to line infection and passed away ten days later in comfort care.
Conclusions Little is known about the mechanism of progression of Cryptococcus meningitis in Non-HIV hosts. Perhaps the underlying cause remains deep in the host immunogenetics. The management of recurrent progressive forms of this disease remains difficult, and trending titers has not shown to be helpful. Some experts recommend high dose glucocorticoid adjuvant therapy. Further research is needed to uncover the complex dynamic between this evolving fungus and its human host counterpart.
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