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.