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: The patient is hospitalized and antimicrobial therapy is administered. Further cerebrospinal fluid studies confirm the diagnosis, and the patient is also found to be HIV positive with a CD4 count of 26/mm³. He had initial symptom relief but the severe headache returned, and he has also started to experience worsening nausea, vomiting, and lethargy. Neurologic examination shows no new focal deficits. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: Patients with AIDS who have cryptococcal meningoencephalitis often have dramatic cerebrospinal fluid fungal burdens (>1,000,000 yeast/mm³). The yeast and capsular polysaccharides can clog the arachnoid villi, which prevents cerebrospinal fluid outflow and increases intracranial pressure (ICP). Pressure elevations can often be dramatic (>250 mm H₂O), resulting in headache, vomiting, visual changes, papilledema, and cranial nerve palsies. If untreated, brain herniation and death may occur. As such, patients with cryptococcal meningitis who develop recurrent symptoms of elevated ICP require serial lumbar punctures until symptoms abate. Occasionally, recalcitrant cases require more permanent treatment such as ventriculoperitoneal shunt. (Choice A) Caspofungin is an echinocandin used to treat severe Candida and Aspergillus infections. Echinocandins are not efficacious against Cryptococcus neoformans. (Choice B) Dexamethasone is often added to the treatment of bacterial meningitis (eg, meningococcal meningitis) to reduce inflammation, morbidity, and risk of death. Dexamethasone is not recommended for the treatment of cryptococcal meningitis. (Choice C) Mannitol is an osmotic agent used to treat elevated ICP caused by trauma, intracranial hemorrhage, central nervous system tumors, and stroke. Mannitol is not effective in cryptococcal meningitis; patients require serial lumbar punctures. (Choice E) Patients with AIDS who develop cryptococcal meningitis require the initiation of antiretroviral therapy (ART) to improve CD4 count and prevent recurrence. However, the early initiation of ART can be associated with life-threatening immune reconstitution inflammatory syndrome; ART initiation is typically delayed until there is sustained clinical improvement with treatment (generally after 2-10 weeks). Educational objective: Patients with AIDS who develop cryptococcal meningitis may have increased intracranial pressure. Manifestations include headache, vomiting, visual changes, papilledema, and cranial nerve palsies. Patients may require repeated lumbar punctures to reduce the elevated pressure. References: Relationship of cerebrospinal fluid pressure, fungal burden and outcome in patients with cryptococcal meningitis undergoing serial lumbar punctures. (http://www.ncbi.nlm.nih.gov/pubmed/19279443) Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/20047480)

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