Gadolinium enhancement of the cerebrospinal fluid in a patient with meningeal fibrosis and cryptococcal infection

We describe the case of a 52-year-old man, with cryptococcal meningitis and meningeal fibrosis who had undergone ventricular shunting. Gd-DTPA-enhanced T1-weighted MRI revealed diffuse meningeal enhancement. Remarkably, there was enhancement of the pia mater and posterior fossa subarachnoid space.

Cryptococcal meningitis in African children

Three cases of cryptococcal meningitis in Malawian children aged 6 weeks, 3 years and 9 years are described. Only 23 cases of cryptococcal meningitis in children have been described previously, but in children from Europe and the USA. These are therefore the first cases of cryptococcosis to be described in African children.

Dentate nuclei involvement in AIDS patients with CNS cryptococcosis: imaging findings with pathologic correlation

PURPOSE

Our goal was to describe the involvement of the dentate nuclei in AIDS patients with CNS cryptococcosis since this finding has not been emphasized in previous radiological literature.

METHOD

Plain and contrast-enhanced CT of the brain (10 and 10), MR studies (1 premortem and 1 postmortem), and autopsy findings in 11 AIDS patients with CNS cryptococcosis were reviewed. The imaging studies and pathological specimens were analyzed for signs of meningitis, presence of dilated Virchow-Robin spaces, gelatinous pseudocysts, cryptococcoma, ventriculomegaly, choroid plexus, and ependymal lesions.

RESULTS

Five of 11 patients were found at autopsy to have macroscopically visible "cystic" lesions in the dentate nuclei that were not detected on CT (10 patients), but were seen on premortem MR (1 patient). Macroscopic supratentorial (basal ganglia, thalamic, midbrain) lesions were detected by CT in 5 of 11 patients and by MR in 2 of 2 patients. Enhancement of the leptomeninges was seen in only 1 patient by CT despite pathological evidence of cryptococcal meningitis in all 11 patients. Dilated Virchow-Robin spaces were seen in all 11 pathologic specimens and in the 2 MR studies but not on CT. Communicating hydrocephalus was detected by CT in two patients.

CONCLUSION

CT scans of the brain underestimate infratentorial parenchymal cryptococcal disease. MR is a more sensitive procedure to evaluate cerebellar and brainstem cryptococcosis, including the dentate nuclei, which in our autopsy series was not an uncommon site to be infected with cryptococcal gelatinous pseudocysts.

Central nervous system cryptococcosis: parenchymal calcification and large gelatinous pseudocysts

In an 11-year-old immunocompetent girl with protracted cryptococcal infection of the central nervous system, CT showed multiple areas of parenchymal calcification. MR imaging showed large gelatinous pseudocysts around the brain stem. These imaging features and the child's age are unusual for intracranial cryptococcosis.

Cryptococcosis in Denmark: an analysis of 28 cases in 1988-1993

A total number of 31 events of systemic cryptococcal infection in 28 patients was identified in a nation-wide survey over 6 years from 1988 to the end of 1993. All medical records were reviewed, 24 of the patients were HIV-infected. Meningitis was diagnosed in 25 patients, and fungemia in 8 patients. The most frequent symptom was headache followed by fever. The median duration in days of fever, headache, and other neurological signs/symptoms before diagnosis was 12, 8 and 2 days, respectively, and, after diagnosis and start of treatments 7, 11 and 12 days, respectively. There was a significant correlation between the duration of headache and the duration of neurological signs/symptoms but not between headache and fever. More than 50% of the patients died within 5 months after the diagnosis. In 39% of the cases, the patients were orally treated with various antifungal drugs before the diagnosis. The rate of cryptococcosis (cumulative) in Danish AIDS patients was estimated to be 1.7%. The HIV-positive patients were, at the time of the cryptococcal diseases, profoundly immunocompromised, with a median CD4+ cell count of 18 (range: 0-78)/microliters. From 24 patients at least 1 isolate of Cryptococcus neoformans was typed, all being var. neoformans, identical with serotype A/D.

The spectrum of MRI findings in CNS cryptococcosis in AIDS

We retrospectively reviewed the cranial MRI appearances of 25 patients with AIDS and microbiologically proven central nervous system (CNS) cryptococcosis. Four patients had a normal scan. Ten patients had dilated perivascular Virchow-Robin spaces that were hyperintense on T2-weighted images. Nine of these patients developed progressive cryptococcomas, eight in the basal ganglia and one in the cerebral white matter. The cryptococcomas displayed high signal on T2-weighted and intermediate to low signal on T1-weighted images. None enhanced after dimeglumine gadopentetate. No abnormal dural or leptomeningeal enhancement was detected in any patient. One patient developed an acquired arachnoid cyst during treatment of CNS cryptococcosis which was thought to represent a focal collection of organisms and mucoid material within the subarachnoid space. In addition either cerebral atrophy and/or background white matter hyperintensity on T2-weighted images was present in 19/25 patients. In two patients the neuropathological findings at autopsy correlated well with the imaging abnormalities. In conclusion, this spectrum of MRI appearances in CNS cryptococcosis reflects the pathological mechanism of invasion by the fungus, but a normal scan or one with features of CNS HIV infection such as atrophy or white matter hyperintensity does not exclude the diagnosis.

Unusual pattern of enhancement in cryptococcal meningitis: in vivo findings with postmortem correlation

Leptomeningeal enhancement on CT and MR imaging studies secondary to cryptococcal meningitis is an uncommon finding. In immunocompromised patients, this meningitis incites only a mild inflammatory reaction and abnormalities are often absent on imaging studies. We recently encountered two patients with cryptococcal meningitis in whom postcontrast MR imaging showed thick enhancing subarachnoid spaces. Both had cryptococcal meningitis at autopsy. In a different patient with cryptococcal meningitis, postmortem MR imaging and pathologic examinations showed that these areas of enhancement correspond to abundant mucoid material secreted by the yeasts.

Intracranial hypertension and cryptococcal meningitis in a girl with AIDS

A girl with HIV infection acquired at birth by blood transfusion, was admitted at the age of 10 years for diplopia, vomiting, headache and papilledema. CT scan was negative. A lumbar puncture revealed clear CSF, protein 0.40 g/l, glucose 2 mmol/l, 5 mononuclear cells/mm3. The Indian ink preparation and the latex agglutination antigen test were positive for Cryptococcus n. Treatment with amphotericin B and flucytosine was started. After 10 days, since the in vitro susceptibility testing of the isolates showed resistence to both drugs, fluconazolo (400 mg/day) was started. Acetazolamide, furosemide and spironolactone were then added to the antifungal therapy for the persistence of severe intracranial hypertension. Diuretics were maintained for 10 weeks. The patient returned to school two and half months after the admission to the hospital. After 19 months, she is doing well and she is on maintenance of fluconazole (200 mg/day). We hypothesized that the increased intracranial pressure would be due to an impaired CSF reabsorption probably as a consequence of a direct cryptococcal infiltration of the villi.

Assessment of a PCR technique for the detection and identification of Cryptococcus neoformans

The 18S ribosomal RNA gene of Cryptococcus neoformans was amplified by polymerase chain reaction (PCR). The primers CPL1 and CPR4 were tested for their ability to amplify DNA from 30 strains of C. neoformans and 27 specimens of cerebrospinal fluid (CSF) from patients with cryptococcal meningitis. A 343 bp product was obtained and its specificity confirmed by Southern hybridization with an internal sequence (INSR4) probe. The sensitivity was 100 fg by Southern analysis and 1 pg using the PCR. Neither human nor a variety of other fungal and bacterial strains (n = 78) gave an amplified product. This PCR method can detect as few as 5 cells ml-1 of C. neoformans in spiked-CSF following a simple processing procedure. The developed system of PCR was more sensitive than the culture method and revealed a very high specificity. The PCR was easy to perform and needed only 4 h for all processes from receiving the CSF to detection of a specific DNA band after agarose gel electrophoresis. This would provide another rapid laboratory method for the diagnosis of cryptococcal meningitis.

Tuberculous meningitis. Clinical characteristics and comparison with cryptococcal meningitis in patients with human immunodeficiency virus infection

OBJECTIVE

To determine the prevalence and causes of meningitis in patients with human immunodeficiency virus (HIV) infection.

DESIGN

A prospective study of HIV-associated neurologic complications carried out from 1988 to 1992.

SETTING

A tertiary care university hospital in Madrid, Spain. PATIENTS. A total of 142 patients, 65% of whom were injecting drug users.

RESULTS

Thirty-six episodes of meningitis were diagnosed in 33 patients (23%). Of these, 17 cases (47%) were tuberculous meningitis (5 definite and 12 probable) and 7 (19%) corresponded to cryptococcal meningitis. Comparative studies of the tuberculous and cryptococcal meningitis cases showed injecting drug use as the most common form of HIV transmission in the tuberculous meningitis (P = .03) and a lower mean CD4+ cell count in the cryptococcal meningitis group (P = .02).

CONCLUSIONS

Tuberculous meningitis was the prime type of meningitis, which was associated with HIV transmission by injecting drug use. Cryptococcal meningitis appears in more advanced stages of HIV infection, which determines its characteristic presentation.

[A case of acquired immunodeficiency syndrome associated with cryptococcemia and cryptococcal meningitis]

A case of acquired immunodeficiency syndrome (AIDS) developed cryptococcosis which was successfully treated with amphotericin B (AMPH) and fluconazole (FLCZ) is reported. A 52-year-old man was admitted because of pyrexia and oral candidiasis. He had a history of multiple sexual exposures to persons at risk for AIDS in Thailand. On admission, serologic tests for human immunodeficiency virus (HIV)-1 were positive on both EIA and Western blot analysis for anti-HIV-1 antibody. Furthermore, test for cryptococcal antigen and fungal cultures from blood and cerebrospinal fluid revealed that he was suffering from cryptococcemia and cryptococcal meningitis. In spite of identification of Cryptococcus neoformans in his blood and cerebrospinal fluid, the finding of cerebrospinal fluid had a minimal inflammatory response with mild elevation of protein. He was initially treated with intravenous AMPH, 10 to 30 mg a day, for 7 weeks, and then was given oral FLCZ, 400 mg a day, for the suppressive therapy. His fever subsided three weeks after the start of AMPH therapy. He was eventually discharged 9 weeks after the start of therapy without any symptoms, and continued to receive oral FLCZ as an out-patient. Thus, attention should be paid to diagnosis and treatment for cryptococcal meningitis in AIDS patients.

[Meningeal cryptococcosis. Retrospective study of 7 cases]

In the analysis of medical records of 7 patients in one neurological service, different clinical aspects of cryptococcal meningitis such as diagnostic criteria, risk factors, clinical features, CSF features, and therapeutical features are reviewed. The finding on India ink preparation of Cryptococcus neoformans in the cerebrospinal fluid and the distinguishing clinical features of a chronic meningitis were the only diagnostic criteria in these 7 cases. Treatment with amphotericine B was the sole mean in the management of these cases. There were only two cases of complete cure, and 5 patients deceased. Intravenous associated with intrathecally injection of amphotericine B has been carried out in the two successfully treated patients.

Intraventricular cryptococcal cysts

The case of a 55-year-old immunocompetent woman with central nervous system cryptococcosis and multiple intraventricular cysts is presented. The cysts did not enhance on MR and had signal characteristics similar to cerebrospinal fluid on T1- and T2-weighted images; their intensity was lower than cerebrospinal fluid on proton density-weighted images.

[Granulomatous form of cerebral cryptococcosis: a case report]

Cryptococcal granuloma or toruloma of the central nervous system is very rare, meningoencefalitis or meningitis being most common. The authors present the case of an immunocompetent male patient of 56 years old with initial clinical symptoms of intracranial hypertension due to an occípito-parietal crytococcal granuloma that was removed surgically. The patients was treated post operatively with anphotericin-B and 5-fluorcytosine. Pathophysiology, neuroimaging, diagnosis and treatment of this rare entity are discussed.

Cryptococcal meningitis

Fungal meningitis caused by the yeast Cryptococcus neoformans is most commonly seen in patients with defective T-lymphocyte function. This article focuses on the clinical presentation, diagnosis and management of patients with cryptococcal meningitis, in the setting of AIDS and other immunocompromised hosts, and in 'normal' individuals.

[Acute disseminated encephalomyelitis (ADEM)-like exacerbation in the patients with cryptococcus meningitis treated successfully by steroid pulse therapy]

A 58-year-old man was admitted to our hospital with suspicion of aseptic meningitis. He had been well until the day before admission, when he became suffering from headache and nausea. Cerebral spinal fluid (CSF) analysis on admission revealed Cryptococcus neoformans. Neurological examination and brain CT scan showed no abnormality. On the 5th hospital day, he noticed ataxia and weakness in his right extremities and soon fell into drowsy to comatose state. CSF study revealed marked elevation of pleocytosis and oligoclonal IgG bands. The T2 weighted image of brain MRI showed multiple high intensity areas, mainly in the white matter, in cerebellar hemisphere, vermis, left medulla oblongata, left occipital lobe and parieto-occipital lobe. Steroid pulse therapy remarkably improved neurological deficit as well as MRI abnormalities. He became alert at the next day. Ataxia and motor weakness disappeared in a week. Laboratory examination before the pulse therapy revealed impairment of T cell response to mitogens and reduced number of CD8-positive cells. These abnormalities in the cell-mediated immunity were completely corrected by the steroid pulse therapy. It was hypothesized that cryptococcus infection induced the autoimmune mechanism which resulted in the ADEM-like exacerbation.

Cryptococcal meningitis--a case report

Two cases of Cryptococcal meningitis were encountered in the recent past. History of predisposing factors was available in both the patients. The diagnosis of these patients was made on the basis of smear, culture and animal pathogenicity tests.

Problems in the diagnosis of AIDS related cryptococcal meningitis: a case report

Cryptococcal meningitis in a 35-year old male who had a history of chronic alcoholism and sexual promiscuity, is presented here. The patient presented twice, 6 weeks apart, with altered sensorium. On the earlier occasion, CSF examination and CT head scan were entirely normal, while on the second occasion CSF abnormalities were found which led to the diagnosis of cryptococcal meningitis. The patient eventually tested positive for HIV by both the ELISA and Western Blot techniques. Diagnostic problems and management difficulties in AIDS-related cryptococcal meningitis are discussed.

Neurologic opportunistic infections

Three common opportunistic infections in patients with the human immunodeficiency virus are being more accurately diagnosed and effectively treated as a result of recent advances. Toxoplasmosis may be prevented in some cases, and can be recognized and treated noninvasively in most cases. Cryptococcal therapy has been enhanced by successful development of oral azole therapy. Cytomegalovirus encephalitis is now an entity that can be diagnosed antemortem, and thus efforts to treat it can now be evaluated.

Cryptococcal pneumonia in AIDS: is cryptococcal meningitis preceded by clinically recognizable pneumonia?

Identification of cryptococcal infection while it is still in its pulmonary phase might improve the prognosis for patients with AIDS who contract cryptococcosis. Since cryptococcal pneumonia is infrequently diagnosed in the AIDS patient, especially compared with the frequency of diagnosis of cryptococcal meningitis, this retrospective study was designed to investigate the frequency of pulmonary complaints in the months before diagnosis of cryptococcal meningitis. The medical records of 18 patients diagnosed with cryptococcal meningitis were analyzed. Of 18 patients, 14 (78%) had respiratory symptoms during the 4-month period before meningitis appeared, as compared with nine of 18 (50%) at the time of diagnosis and four of 16 (25%) in the 4 months following diagnosis. Seven of the 14 cases of pulmonary disease prediagnosis were of unknown etiology; three were eventually diagnosed as cryptococcal infections during evaluation of the meningitis. The remaining eight infections were attributed to bacteria, respiratory viruses, or Pneumocystis carinii, although three of these cultures also contained yeast, presumed to be Candida species, which were not further examined. Our data suggest the importance of singling out AIDS patients who may have pulmonary cryptococcosis. Cryptocococcsis should be included in the differential diagnosis of pulmonary infection in HIV-positive patients with CD4+ lymphocyte counts < 200/mm3, and full identification of yeasts recovered from sputum or bronchoalveolar lavage fluid cultures should be done. A larger study should be undertaken to better define the incidence of clinically recognizable pulmonary cryptococcosis in AIDS patients.

[A case of cryptococcal meningoencephalitis with the cerebral superficial cystic lesions detected on magnetic resonance imagings]

The patient was a 35-year-old man with confusional state and headache. Analysis of cerebrospinal fluid (CSF) showed 1,383/mm3 cell count, the protein level of 300mg/dl and glucose level of 42 mg/dl. Cryptococcus neoformans was disclosed by India ink preparation. The cryptococcal antigen test was positive at 1:125 by latex agglutination. The diagnosis of cryptococcal meningoencephalitis was determined. Antifungal treatment with amphotericin B resulted in improvement of neurologic signs, CSF findings and cryptococcal antigen test. But two months later, brain MRI demonstrated low intensity areas on T1 weighted image and high intensity areas on T2 and proton weighted images in the cerebral cortical region. Gd-DTPA MRI showed enhanced areas in the cerebral leptomeninges. It was considered that these MRI lesions corresponded to pseudocysts and Gd-DTPA enhanced lesion indicated dilated vessels or destructed blood-brain barrier. After administration of larger doses of amphotericin B, these lesions on MRI disappeared. It is suggested that brain MRI is useful in diagnosis of cryptococcal meningoencephalitis to detect pseudocysts at the cortical region which may imply the early stage of procrastinating process.

An unusual case of central nervous system cryptococcosis

Opportunistic infections of the central nervous system (CNS) in immunocompromised patients often represent a diagnostic and therapeutic challenge due to the variety of possible infectious agents causing CNS disease. We report the case of a severely immunocompromised 43-year-old woman presenting with headache, confusion, abnormal CSF findings (cell count 237/mm3 with 50% eosinophils and elevated protein), multiple contrast enhancing lesions on CT and MRI in the basal ganglia, and serologic findings compatible with latent or reactivated toxoplasmosis with high IgA and IgG antibody titers against Toxoplasma gondii in whom a final diagnosis of CNS cryptococcosis was made. This case illustrates the considerable difficulties in the differential diagnosis of opportunistic CNS infection in the immunocompromised host. We conclude from our report that (1) the diagnosis of toxoplasma encephalitis should not be based on serological findings but rather be proven by either PCR, mouse inoculation or brain biopsy, (2) CNS cryptococcosis can be associated with marked CSF eosinophilia and multiple cryptococcomas, and (3) cryptococcomas can persist on CT and MRI despite successful antifungal treatment.

Infratentorial cerebral cryptococcosis

In a nonimmunocompromised patient with cerebral cryptococcosis, unique magnetic resonance findings included abnormalities limited to the posterior fossa and cerebellar hemispheric edema, gyriform enhancement of the vermis and cerebellar hemispheres, and infratentorial plaquelike enhancement. Magnetic resonance findings in central nervous system cryptococcosis are discussed.

[Central nervous system cryptococcosis in 10 patients with systemic lupus erythematosus]

Central nervous system compromise is a major cause of morbidity and mortality in SLE. The clinical picture of cerebral cryptococcosis is non-specific and can be mistaken for lupic activity. A retrospective study was undertaken with 10 patients with SLE and cryptococcal meningitis compiled in a 23-year period. The most common symptoms were fever and headache. Lymphocyte counts ranged from 169 to 912 cells/mm. An average delay of 13.6 days in diagnosis was observed in patients with cryptococcal meningitis with no complications and an average delay of 52.4 days in patients with complications. Low lymphocyte counts, observed in all patients, was considered a possible risk factor for cerebral cryptococcosis. To note the association between the delay in the correct diagnosis and complications derived from cerebral cryptococcosis.

[Cryptococcal meningitis in patients without predisposing immunodeficiency]

Cryptococcal meningitis is a chronic or subacute meningeal infection that may have pulmonary or systemic manifestations and is caused by the yeast Cryptococcus neoformans. It has become an increasingly important pathogen in immunocompromised hosts, whereas cryptococcal meningitis is relatively rare in immunocompetent patients. The diagnosis is often delayed because of the sparse and nonspecific symptoms. We present two cases of cryptococcal meningitis in two patients without known predisposing factors. The symptomatology, diagnosis and treatment of the disease are discussed. The two cases illustrate that Cryptococcus neoformans should be considered in patients with cerebral symptoms and fever. The disease is potentially curable and early diagnosis with specific treatment are important prognostic factors.

Resolution of cryptococcal meningitis and associated granuloma lung with antifungal therapy: report of a case

A 49-year-old diabetic male had been unsuccessfully treated with antitubercular therapy for a granulomatous lesion of the left lung detected elsewhere nine months ago. He presented with evidence of meningitis which was found to be due to infection with Cryptococcus neoformans. Both the meningeal and lung lesions resolved after 6 weeks of combined therapy with amphotericin B and flucytosine. The report of the case along with a brief review of the relevant literature is presented.

Cryptococcal meningitis with malaria. A case report

Cryptococcal meningitis is an uncommon infection globally, including Nigeria. This systemic fungal infection often is associated with immunodeficiency. The most common causes of meningitis in Nigeria in the 2-3 year age group are the malaria parasites and bacteria. The concomitant infections of Cryptococcal neoformans and Plasmodium falciparum are uncommon. We present here the report of a case of fatal cryptococcal meningitis with malaria infection in a 2 year old child from Nigeria (one of the malaria endemic regions of the world). This case emphasizes the importance of doing a combination of fungal and bacterial cultures as well as looking for malarial parasites in the determination of etiological agents of meningitis in any hospital in Africa. We suggest that cerebrospinal fluid from meningitis cases must be cultured using Sabouraud dextrose agar and any growth on the agar must be examined using Indian ink.

Cryptococcosis

Cryptococcal disease is the most common life-threatening fungal infection in patients with AIDS. The most common manifestation, meningitis, has an indolent presentation that may lead to a delay in diagnosis. Although clinical trials have demonstrated efficacy with fluconazole in some patients, amphotericin B, with or without flucytosine, is the treatment of choice. Lifelong suppression of cryptococcal disease after initial therapy, however, is best achieved with fluconazole. Prognostic staging systems and primary prophylaxis of cryptococcal disease are also discussed.

Warning symptoms of sinister headache

Headache is a common complaint. In most patients, it is usually a problem of migrainous or tension-type headache. It is crucial that a physician is able to differentiate sinister causes of headache from the more benign ones. Six cases are presented to illustrate the fact that there are clues in the history to suggest a sinister cause of headache even though there are minimal or no neurological deficits on physical examination. At some point of time, these cases were examined by a senior physician but they were diagnosed as migrainous or tension-type headaches. The first case is a 41-year-old labourer with cryptococcal meningitis. He presented with severe headaches at a relatively late age. A 20-year-old female complained of the worst headache she ever had and this was due to a subarachnoid haemorrhage. The third case was a young woman with a large parietal meningioma. Her headaches had recently assumed a different character. The fourth case involved an investment manager who developed headaches with transient diplopia and projectile vomiting and investigations revealed an ependymoma. A shipyard worker complained of a constant headache which disturbed his sleep. Two weeks after medical consultation, the character of his headache changed and he developed diplopia in all directions of gaze. He succumbed to pituitary apoplexy. The final case is a 28-year-old woman who had a complicated migraine. CT scan of the brain showed a large arterio-venous malformation.

Cryptococcal meningitis in Lilongwe and Blantyre, Malawi

Infection with Human Immunodeficiency Virus is widespread in Malawi and cryptococcal meningitis is a common problem in those with AIDS. A review of microbiology laboratory records in Lilongwe and Blantyre between July 1991 and January 1993 identified 31 patients with cryptococcal meningitis. Diagnosis was based on a positive India ink stain of CSF and/or culture of Cryptococcus neoformans. There were 16 men (median age 38 years) and 15 women (median age 28 years) in the investigation. The median duration of symptoms was 2 weeks. The clinical presentation was varied, the most frequent features being headache (97%), neck stiffness (74%), fever (61%) and altered consciousness (58%). CSF WBC count, glucose and protein concentrations were non-specific. Most patients could not afford anti-cryptococcal chemotherapy and their median survival time after diagnosis was 4 days. Patients who could afford such treatment survived for up to several months. Diagnosis is useful for prognostic reasons and may save patients unnecessary treatment if tuberculous meningitis is the alternative diagnosis. Cryptococcal antigen detection tests may improve diagnostic accuracy. The problem of cryptococcal meningitis is likely to become increasingly common as HIV infection becomes more widespread.

False-negative cerebrospinal fluid cryptococcal latex agglutination tests for patients with culture-positive cryptococcal meningitis

Three cases of false-negative cerebrospinal fluid latex agglutination test results for patients with culture-positive cryptococcal meningitis are reported. False-negative results occurred in settings of low cryptococcal antigen concentrations in cerebrospinal fluid and were dependent on the latex agglutination test kit used. Investigation of each case revealed that prozone phenomena or interference from bound antibody or protein could not account for the false-negative results.

[Cryptococcosis of the central nervous system and infection by HIV. Clinical-evolutive characteristics in 13 cases]

Cryptococcosis is the fourth cause of infection of the Central Nervous System in patients with infection by HIV. Despite this fact, the series published in our country are referred to a limited number of cases. We describe the most relevant characteristics of 13 patients with meningitis by Cryptococcus neoformans. We used as inclusion criteria a positive culture of the Cephalorhachidian Fluid (CRF). We observed a significant reduction in the levels of CD4 lymphocytes in all patients, the absence of meningitic syndrome in more than 50% cases (8/13) and a normal CRF cytobiochemistry in three patients. The thoracic radiography was normal in all cases but two, although the cryptococcus was cultured in a transbronchial biopsia of a patient with normal thoracic radiography. The Computerized Axial Tomography showed frequent alterations (5/13). Eight patients were treated with amphotericin B (0.5 mg/kg/d) and five with fluconazol (400 mg/day). Despite following a maintenance therapy with fluconazol (200 mg/d), we had two cases of recurrence in the group previously treated with fluconazol. The level of leukocytes in the CRF was the only prognosis factor (p < 0.05). Five patients died during their first hospitalization due to causes related to the infection by cryptococcus. New therapeutical guidelines are needed in order to improve the prognosis of these patients.