1/176. Cryptococcus meningoencephalitis in AIDS: parenchymal and meningeal forms. CT and MRI in one case of cryptococcus neoformans infection showed contrast-enhancing parenchymal lesions resembling granulomata or abscesses. After an initial phase without contrast enhancement, the full extent of the lesions was visible within 2 weeks of presentation. The enhancing masses were assumed to represent intracerebral cryptococcomas. Despite evidence of massive meningeal infection on cerebrospinal fluid (CSF) examination, no radiological signs of meningitis, invasion of the Virchow-Robin spaces or ventriculitis could be demonstrated. With antimycotic treatment the contrast enhancement disappeared and cystic, partly calcified lesions remained. recurrence of meningeal infection without radiological correlates was apparent in this stage. In a second case of proven cryptococcus meningitis, dilation of Virchow-Robin spaces or cysts in the adjacent parenchyma were the main abnormalities on MRI. Enhancing masses were not detected. These cases may represent two different reactions of the immunocompromised hosts to infection with C. neoformans: widening of the perivascular spaces as a correlate of the more typical meningeal infection and enhancing parenchymal lesions as a sign of further invasion from the CSF spaces. Enhancement of cryptococcomas, indicating an inflammatory response in the surrounding brain, is not typical in patients with impairment of immune function. ( info) |
| A case report of a patient infected with human immunodeficiency virus (hiv) is described. The patient presents with a multitude of medical complaints that are of acute or subacute onset. The medical examination of these complaints is described and includes algorithms for the diagnosis and treatment of the most common hiv-related opportunistic infections, including pneumocystis carinii pneumonia, toxoplasmosis, mycobacterium avium complex, cytomegalovirus infection, and cryptococcal meningitis. ( info) |
3/176. Cryptococcal prostatic abscess in an immunocompromised patient: a case report and review of the literature. A case of cryptococcal prostatic abscess in a 65-year-old Chinese man with immunosuppression from treatment of myasthenia gravis is presented. The patient was diagnosed to have cryptococcaemia when he presented with fever and urinary symptoms. Further investigations confirmed cryptococcal meningitis and imaging studies showed a hypodense lesion in the prostate. This proved to be an abscess and it was deroofed transurethrally. histology of the prostatic tissue revealed the presence of Cryptococcus. The prostate can be a site of persistent cryptococcal infection and may take the form of an abscess. It should be drained transurethrally to prevent relapse. ( info) |
4/176. Treatment of hydrocephalus secondary to cryptococcal meningitis by use of shunting. hydrocephalus can be associated with increased morbidity and mortality in cryptococcal meningitis if left untreated. Both ventriculoperitoneal and ventriculoatrial shunting have been used in persons with cryptococcosis complicated by hydrocephalus, but the indications for and complications, success, and timing of these interventions are not well known. To this end, we reviewed the clinical courses of 10 non-human immunodeficiency virus-infected patients with hydrocephalus secondary to cryptococcal meningitis who underwent shunting procedures. Nine of 10 patients who underwent shunting had noticeable improvement in dementia and gait. Two patients required late revision of their shunts. Shunt placement in eight patients with acute infection did not disseminate cryptococcal infection into the peritoneum or bloodstream, nor did shunting provide a nidus from which Cryptococcus organisms proved difficult to eradicate. Shunting procedures are a safe and effective therapy for hydrocephalus in patients with cryptococcal meningitis and need not be delayed until patients are mycologically cured. ( info) |
5/176. Midbrain infarction: a rare presentation of cryptococcal meningitis. A 20-year-old farmer who had headache and fever for 1 month, suddenly developed left hemiplegia, tremor in left arm and titubation followed by deep coma. Cranial CT scan revealed an infarction in right crus of midbrain. His CSF revealed 66 mg/dl protein, 10 lymphocytes/mm3, and 70 mg/dl glucose. CSF was positive for cryptococcal antigen. He improved following i.v. amphotericin 0.5 mg/kg and fluconazole 200 mg daily, continued for 6 and 12 weeks respectively. Infarctions though rare in cryptococcal meningitis should be considered in patients with chronic meningitis with vasculitis. ( info) |
6/176. Use of cerebrospinal fluid shunt for the management of elevated intracranial pressure in a patient with active AIDS-related cryptococcal meningitis. Persistently elevated intracranial pressure (ICP) is one of the most accurate predictors of a poor prognosis in patients with AIDS-related cryptococcal meningitis. We present a severe case of persistent cryptococcal meningitis in a patient with advanced AIDS, complicated by elevation of ICP. A ventriculoperitoneal shunt was placed that successfully lowered the ICP and alleviated the associated symptoms. The elevated ICP secondary to AIDS-related cryptococcal meningitis should be treated aggressively. Despite the risk of shunt complications, cerebrospinal fluid shunts can be considered in these patients if they do not respond to other treatment. ( info) |
7/176. Bilateral trochlear nerve palsy associated with cryptococcal meningitis in human immunodeficiency virus infection. This is the report of a case of bilateral trochlear nerve palsy secondary to cryptococcal meningitis in a 34-year-old woman with acquired immune deficiency syndrome. Based on clinical and neuroradiologic findings, it is concluded that in the present case, a postinflammatory shrinking of the arachnoid has stretched the fourth cranial nerves at their point of emergence from the dorsal surface of the brainstem. ( info) |
| Only one case of wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) has been described in central nervous system cryptococcosis. The disorder was initially unilateral, then became bilateral with skew deviation and vertical upgaze deficit. We report a case of WEBINO in central nervous system cryptococcosis in a patient with acquired immune deficiency syndrome. magnetic resonance imaging revealed high signal on T2 images in the right midbrain, left frontal vertex, left splenium, and cerebellum. With treatment, the internuclear ophthalmoplegia improved; however, the convergence insufficiency remained. Disruption of input from cortical supranuclear locations or the region of the rostral interstitial nucleus of the medial longitudinal fasciculus has been proposed as a mechanism in the absence of convergence. This correlates in our patient with the lesions seen on magnetic resonance images. ( info) |
9/176. Massive pleural effusions in cryptococcal meningitis. Cryptococcal infection uncommonly presents with pulmonary manifestations and even more rarely so as massive bilateral effusions. Pleural involvement is usually associated with underlying pulmonary parenchymal lesions and is unusual while on antifungal therapy. We report a patient with cryptococcal meningitis who, while on intravenous 5-flucytosine and amphotericin b, developed life-threatening bilateral massive pleural effusions with evidence of spontaneous resolution, consistent with prior hypothesis of antigenic stimulation as the cause of pleural involvement. ( info) |
10/176. Successful medical treatment of multiple cryptococcomas: report of a case and literature review. We report a 35-year-old man diagnosed as having CNS cryptococcosis with multiple cryptococcomas, presenting with headache, papilloedema and impaired mental function in a previously healthy man. Cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis with low glucose level. Gram's stain, acid fast bacilli stain and Indian ink examination were all negative. CSF cryptococcal antigen was positive, however, several fungal cultures were negative. Early cranial CT scan showed focal cerebritis over the right temporal lobe while subsequent imaging studies showed multiple contrast-enhancing masses with severe surrounding brain oedema over bilateral frontoparietal areas. brain biopsy showed cryptococcal granulomatous lesions. Treatment was successful with antifungal agents and steroids without surgical removal. ( info) |