A 34-year-old man is brought to the emergency department due to 3 weeks of intermittent fever, headache, malaise, and night sweats. Over the last few days, his headaches have worsened, and he has had blurry and double vision. The patient uses injection drugs and was treated for staphylococcal endocarditis 4 years ago. Temperature is 38.1 C (100.6 F), blood pressure is 150/100 mm Hg, pulse is 66/min, and respirations are 18/min. BMI is 18.4 kg/m². The patient is ill in appearance and somnolent but easily arousable and oriented. There are white plaques on the oropharyngeal mucosa and several skin lesions resembling molluscum contagiosum. There is increased resistance to passive neck flexion. Neurologic examination reveals leftward gaze restriction in the left eye but no other focal weakness or sensory loss. Funduscopy reveals bilateral papilledema. A noncontrast CT scan of the head shows no abnormalities. The patient receives a lumbar puncture; results of the spinal fluid analysis are as follows: Which of the following is the best pharmacotherapy for this patient's current condition?

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Explanation: 11ec2b69_bf94_9a08_8f63_cb023bb4f0e7_MD0005_00 This patient with a history of intravenous drug use presents with indolent manifestations of elevated intracranial pressure including headache, blurred vision, and papilledema. Head CT shows no intracranial mass, and cerebrospinal fluid (CSF) analysis in this patient does not readily indicate a bacterial infection (given the low leukocyte count) or a viral infection (given the high protein and low glucose values). However, the presence of extremely elevated CSF pressures and molluscum contagiosum-like skin lesions raises suspicion for cryptococcal meningoencephalitis in a patient with advanced HIV. Cryptococcus neoformans is a yeast that commonly causes opportunistic CNS infections in patients with AIDS (CD4 counts <100/mm³). Manifestations typically develop over 1-2 weeks and include fever, headache, and lethargy. Skin findings of papular lesions with central umbilication that resemble molluscum contagiosum are common. CSF studies usually reveal the following: papular lesions Markedly elevated opening pressure, often >250-300 mm H₂O Low leukocyte count (<50/mm³) (compared to other meningitides) with a lymphocytic predominance Elevated protein and low glucose Positive India ink preparation or cryptococcal antigen test Patients with HIV who have cryptococcal meningoencephalitis require >2 weeks of fungicidal induction treatment with amphotericin B and flucytosine. (Choice B) Early neurosyphilis can cause meningitis and is typically treated with aqueous crystalline penicillin G. Manifestations often include headache, confusion, and cranial neuropathies. CSF lymphocyte count is usually 200-400/mm³ (unlike in this patient). (Choice C) In adults, the most common causes of bacterial meningitis are Streptococcus pneumoniae and Neisseria meningitidis. Empiric therapy includes a third-generation cephalosporin such as ceftriaxone in addition to vancomycin (to cover some penicillin-resistant S pneumoniae strains). Adults age >50 should also receive ampicillin as they have an increased risk of Listeria monocytogenes meningitis. In this patient, the subacute course and low CSF leukocyte count with lymphocytic predominance make bacterial meningitis less likely. (Choice D) Cytomegalovirus can cause encephalitis in patients with advanced HIV and can be treated with ganciclovir plus foscarnet. Cytomegalovirus encephalitis is typically associated with altered mental status, focal neurologic deficits, and polymorphonuclear (not lymphocytic) pleocytosis on CSF examination. (Choice E) Herpes simplex virus can cause meningitis or encephalitis and is typically treated with acyclovir. The absence of altered mentation makes encephalitis unlikely. This patient with low CSF glucose and markedly elevated opening pressure is more likely to have cryptococcal meningitis. Educational objective: Cryptococcal meningitis should be considered in a patient at high risk for HIV infection. Initial therapy includes amphotericin B and flucytosine. References: Treatment of acute cryptococcal meningitis in HIV infected adults, with an emphasis on resource-limited settings. (http://www.ncbi.nlm.nih.gov/pubmed/18843697) Diagnosis and management of increased intracranial pressure in patients with AIDS and cryptococcal meningitis. The NIAID Mycoses Study Group and AIDS Cooperative Treatment Groups. (http://www.ncbi.nlm.nih.gov/pubmed/10619732)

A 34-Year-Old Man Is Brought to the Emergency Department Due