A 28-year-old man comes to the emergency department due to 2 weeks of headaches, fever, and episodes of inattentiveness. The patient has a history of Hodgkin lymphoma and is undergoing treatment with combination chemotherapy. Temperature is 38.2 C (100.8 F), blood pressure is 138/84 mm Hg, and pulse is 72/min. Lumbar puncture reveals an elevated opening pressure, and cerebrospinal fluid analysis shows moderately increased protein levels and low glucose levels. Light microscopy of the cerebrospinal fluid is shown in the image. Which of the following should be included in initial treatment for this patient's current condition?

Question

A 28-year-old man comes to the emergency department due to 2 weeks of headaches, fever, and episodes of inattentiveness.  The patient has a history of Hodgkin lymphoma and is undergoing treatment with combination chemotherapy.  Temperature is 38.2 C (100.8 F), blood pressure is 138/84 mm Hg, and pulse is 72/min.  Lumbar puncture reveals an elevated opening pressure, and cerebrospinal fluid analysis shows moderately increased protein levels and low glucose levels.  Light microscopy of the cerebrospinal fluid is shown in the image.  Which of the following should be included in initial treatment for this patient's current condition?

Quizplus · Accepted Answer

11ec160b_387f_9812_9249_9dba31c14586_MD0001_00 Cryptococcus neoformans is an opportunistic yeast that can be visualized with India ink staining. India ink stains the background of the slide, which allows the thick polysaccharide capsule of the yeast to be visualized (clear halo between the dark background and the center of the organism). India ink staining of the cerebrospinal fluid (CSF) is a common diagnostic modality in those with suspected cryptococcal meningitis. However, CSF cryptococcal (polysaccharide) antigen testing is more sensitive and specific, so it is also usually performed. Culture of the fungus on Sabouraud agar confirms the diagnosis. Patients with cryptococcal meningitis usually develop slowly worsening headache, fever, and lethargy. Immunocompromised individuals are at greatest risk, particularly those who have AIDS or hematologic cancers or patients on chronic glucocorticoids. CSF analysis usually shows low glucose, increased protein, and mild pleocytosis with a predominance of lymphocytes. Initial treatment involves induction therapy with amphotericin B and flucytosine. Once patients are stabilized, they are switched to long-term maintenance therapy with fluconazole. (Choices B and C) Ampicillin is used to treat Listeria meningitis; Listeria is a gram-positive rod with characteristic tumbling motility on light microscopy. Ceftriaxone can treat pneumococcal and Haemophilus influenzae meningitis. Ampicillin and ceftriaxone are beta-lactam antibiotics that inhibit peptidoglycan cross-linking and lead to bactericidal effects. Fungi cannot be treated with beta-lactam antibiotics as their cell walls do not contain peptidoglycan. (Choice D) Ganciclovir inhibits viral DNA synthesis and is used to treat cytomegalovirus meningoencephalitis, which is diagnosed using PCR. (Choice E) Pyrimethamine is an antifolate agent used in the treatment of malaria and toxoplasmosis. (Choice F) Azole drugs inhibit the synthesis of ergosterol, a crucial fungal cell membrane component. Spectrum of activity varies based on the particular agent; voriconazole is most effective against Aspergillus. Fluconazole is used for long-term maintenance therapy in cryptococcal meningitis, but is fungistatic at typically used doses and is less effective than amphotericin B for initial treatment. Educational objective: Patients with suspected cryptococcal meningitis can be diagnosed using India ink staining of the cerebrospinal fluid. Treatment with amphotericin B and flucytosine is required at first, followed by long-term fluconazole maintenance therapy.

A 28-Year-Old Man Comes to the Emergency Department Due to 2