2019 Research Forum

Applicant: Kaur Simmer MD R2 Principal Investigator & Faculty Sponsor: Arash Heidari MD

Devastating Case of Cryptococcal Meningitis in an HIV Negative Host

Golriz Asefi MD Graduate RA, Kaur Simmer MD R2, Yoel Olazabal Pupo MD R3, Carol Stewart-Hayostek MD, Arash Heidari MD

INTRODUCTION 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.

PURPOSE We are presenting an HIV negative patient who suffered a devastating and fatal course of disseminated cryptococcal infection. HIPAA/IRB review and approval for the case report was obtained.

DISCUSSION 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 Kern Medical 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. CONCLUSION 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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