Conclusion and Results
Due to high suspicion of HIV infection, the diagnosis was verified by serological testing with absolute CD4 count less than 50 cells/mm3. After starting antiretroviral therapy(ART) including dolutegravir, tenofovir and emtricitabin, his level of consciousness gradually decreased and his headache got worse. A computed tomography (CT) scan of the brain showed no abnormality. The patient underwent a lumbar puncture and cerebrospinal fluid (CSF) analysis revealed:10 cells, predominantly lymphocytes, Protein: 343 mg/dl, and Glucose: 98 mg/dl (corresponding blood glucose 284 mg/dl). The direct microscopic examination of CSF with India ink staining showed budding and non-budding yeast compatible with crypococcus spp. As shown in Figure 2. Liposomal amphotericin B in combination with fluconazole (due to the unavailability of flucytosin) was started with serial lumbar puncture for management of elevated intracranial pressure. After one week, He was intubated due to worsening hypoxia. Then a bronchoscopy was performed and his bronchoalveolar lavage was also positive for Cryptococcus spp. Respiratory distress worsened rapidly and he died 2 weeks after starting antifungal therapy.
In conclusion, as early diagnosis of cryptococcal infection is the key to improving outcomes, any newly diagnosed HIV patient presenting with subacute or chronic headache, particularly those who are CD4-deplete, should be investigated for cryptococcal meningitis.