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Pediatric Oncall Journal

Cryptococcal Meningitis 01/09/2014 00:00:00 https://www.pediatriconcall.com/Journal/images/journal_cover.jpg

Cryptococcal Meningitis

Dr Ira Shah.
Medical Sciences Department, Pediatric Oncall, Mumbai, India.

ADDRESS FOR CORRESPONDENCE
Dr Ira Shah, 1/B Saguna, 271/B St. Francis Road, Vile Parle (W), Mumbai 400056.
Abstract
Cryptococcal meningitis is commonly reported in immunocompromised patients or patients with AIDS. We report a child with cryptococcal meningitis without an underlying HIV disease.
 
Introduction
Cryptococcal meningitis is a common opportunistic infection in AIDS patients, particularly in Southeast Asia and Africa. Cases also occur in patients with other forms of immunosuppression and in apparently immunocompetent individuals. (1) Mortality remains high because of the inadequacy of current antifungal drugs and the complication of raised intracranial pressure (1). We report a child with cryptococcal meningitis without immunodeficiency.
 
Case Report
A 12 year old boy presented with headache, fever, vomiting and anorexia since 20 days. He had no convulsions, altered sensorium, previous history or contact with a Koch's patient. He was admitted for above complaints in a nursing home and treated with IV antibiotics for 15 days but did not respond and was referred for further management. On presentation, the child was oriented with vital parameters being normal. He was malnourished and other general examination was normal. He had no meningeal signs or signs of raised intracranial tension and no neurological deficit. On further questioning, there was history of contact with pigeons elicited. In view of this, chronic meningitis such as cryptococcal meningitis was suspected. CSF analysis revealed positive India ink study with 350 cells/cu mm [62% lymphocytes, 38% polymorphs], low CSF sugar (26 mg/dl) and normal proteins (15.4 mg/dl). His CSF TB PCR was negative and CSF culture was negative. An underlying immunodeficiency was suspected but his HIV ELISA was negative and S. immunoglobulins were normal. His hemogram, liver function tests, renal function tests and X-Ray Chest were all normal. MRI brain showed thick meningeal enhancement in basal cistern and brain stem with early hydrocephalus. CSF cryptococcal antigen test was negative. He was treated with IV Amphotericin B [Flucytosine could not be given due to unavailability] for 4 weeks, however there was no improvement and his CSF continued to have persistently low sugar and cells with gradual polymorphic predominance. After 4 weeks of Amphotericin B, his India ink preparation was negative. He then developed left sided hemiplegia with signs of raised intracranial tension and loss of consciousness following which he succumbed to his disease after 5 days.
 
Discussion
Cryptococcus neoformans is an encapsulated yeast found in temperate regions and present in soil with avian droppings. Its reservoir in nature has never been established clearly. Cryptococcal infection occurs by inhalation of fungal spores and disseminates via the blood stream. It rarely spreads by local extension to CNS (2). After exposure, extent of disease depends upon the host immunity. In immunocompetent patients, the disease is usually restricted to the lung. When the immune system fails, it may involve any organ like brain, meninges, skin, eyes and skeletal system. Cryptococcosis is rare in children. In adults, it is predominantly seen in HIV infected individuals and rarely in non-HIV patients. (1)

Cryptococci grows as foci in the brain but with minimal or no inflammatory response so that cystic clusters of fungi expand and displace the brain tissue without directly destroying it. Thus, patients usually present with headache, nausea, dizziness, low grade fever. With progression of the disease, it may involve the basilar meninges and brain substance itself leading to brain swelling and compression of cranial nerves which may be fatal. This chronic granulomatous meningitis may lead to impairment of CSF flow and cause hydrocephalus with raised intracranial pressure and deterioration and even dementia. Patients would then present with impairment of hearing, personality changes, papilledema, nuchal rigidity and raised ICT. In patients with AIDS, cryptococcal meningitis may develop with minimal or no signs referable to the CNS (3).

Prognosis is variable. Good outcome is expected if headache was the initial system, patient has normal mental status; is not immunodeficient, has normal CSF glucose with CSF leucocyte count of < 20 cells/cu mm, a negative CSF India ink stain, normal CSF opening pressure and a cryptococcal antigen titre of < 1:32 in CSF & serum. Diagnosis established by CSF India Ink preparation, culture and serology. (India ink preparation may be positive in only upto 50% of cases. Complement fixing antibody in CSF may be positive in over 75% of patients and CSF antigen test may be useful which is positive in over 94% of patients. (Titre > 1:8 are considered significant). (4) Treatment consists of IV Amphotericin B & IV flucytosine during intensification phase and fluconazole during continuation phase. (5)
 
Compliance with Ethical Standards
Funding None
 
Conflict of Interest None
 
  1. Bicanic T, Harrison TS. Cryptococcal meningitis. Br Med Bull. 2005; 72: 99-118.  [CrossRef]  [PubMed]
  2. Casadevall A, Steenbergen JN, Nosanchuk JD. 'Ready made' virulence and 'dual use' virulence factors in pathogenic environmental fungi-the Cryptococcus neoformans paradigm. Cur Opin Microbiol. 2000; 6: 332-337.  [CrossRef]
  3. Park MK, Hospenthal DR, Bennett JE. Treatment of hydrocephalus secondary to cryptococcal meningitis by use of shunting. Clin Infect Dis. 1999; 28: 629–633.  [CrossRef]  [PubMed]
  4. Powderly WG, Cloud GA, Dismukes WE, Saag MS. Measurement of cryptococcal antigen in serum and cerebrospinal fluid: value in the management of AIDS-associated cryptococcal meningitis. Clin Infect Dis. 1994; 18, 789–792.  [CrossRef]  [PubMed]
  5. Brouwer AE, Rajanuwong A, Chierakul W et al. Combination antifungal therapies for HIV-associated cryptococcal meningitis: a randomised trial. Lancet. 2004; 363: 1764–1767.  [CrossRef]


Cite this article as:
Shah I. CRYPTOCOCCAL MENINGITIS. Pediatr Oncall J. 2006;3: 21.
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