LETTER
Hippokratia 2014, 18(4):380
Koufakis T, Tsapakidis K , Gabranis I
Department of Internal Medicine, General Hospital of Larissa, Larissa, Greece
Key words: Cryptococcus neoformans, meningitis, liposomal amphotericin-B, fluconazole
Corresponding author: Theocharis Koufakis MD, PhD, Department of Internal Medicine, General Hospital of Larissa, Larissa, Greece, e-mail: thkoyfak@hotmail.com
Dear Editor,
Cryptococcal meningitis is a central nervous system infection, caused by the encapsulated yeast, Cryptococcus neoformans (C. neoformans). It is generally considered as an opportunistic infection, but it has also been described in previously healthy individuals1. In certain parts of the world, such as sub-Saharan Africa, where HIV prevalence is extremely high, cryptococcal meningitis is reported to be the commonest cause of community-acquired meningitis2. Differently, the relevant reports from Greece are few, either because cryptococcal meningitis is rare among Greek patients, or because it is underdiagnosed.
We report a case of a 69 years old, HIV-negative, female patient, who presented to the Emergency Department of our Hospital, with a two-week history of fever and headache and recent onset of altered mental status. She had a three-year history of Non-Hodgkin’s Lymphoma. A brain computed tomography scan and a retinoscopy were carried out on admission, but did not reveal any abnormal findings. A lumbar puncture was performed and cerebrospinal fluid (CSF) direct microscopy, following India ink preparation, detected multiple encapsulated yeast cells, typical of C. neoformans. The microorganism was also isolated from the CSF culture. She was treated with a combination of liposomal amphotericin-B (4 mg/kg per day) and fluconazole (400 mg per day), due to the fact that the proposed by the literature treatment with amphotericin and flucytosine, was not available in our hospital, at that time. The patient’s clinical condition was significantly improved after 3 days of therapy. In a repeated lumbar puncture 15 days after admission, CSF proved to be sterile. The patient was discharged 25 days later, on oral fluconazole (400 mg per day) for 8 weeks and consequently, on 200 mg per day for 6 months. In her follow up visits, she remained free of fever and any neurological symptoms or signs. She died 15 months later, due to complications of her hematological malignancy.
In conclusion, we here present a case of a patient with cryptococcal meningitis, successfully treated with a combination of antimicrobial agents, others than those suggested by the literature, as optimal therapy3. Cryptococcal meningitis should always be considered in immunosuppressed patients, presenting with fever and symptoms from the central nervous system. Its clinical presentation can be subacute and deceptive, therefore, its diagnosis requires a proper evaluation of both clinical and laboratory findings.
References
1. Thompson H. Not your “typical patient”: cryptococcal meningitis in an immunocompetent patient. J Neurosci Nurs. 2005; 37: 144-148.
2. Bicanic T, Harrison TS. Cryptococcal meningitis. Br Med Bull. 2005; 72: 99-118.
3. Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2010; 50: 291-322.