A 50-year-old man is brought to the emergency department due to fever, malaise, confusion, and worsening headache for the last 8 days. He has a history of advanced AIDS and is noncompliant with antiretroviral therapy. His most recent CD4 lymphocyte count a month ago was 29/mm³. His other medical problems include hypertension and chronic hepatitis C infection.
The patient's temperature is 38.8 C (101.8 F) , blood pressure is 110/70 mm Hg, pulse is 94/min, and respirations are 16/min. He is disoriented to place and time and has a left-sided visual field deficit. The remainder of the examination is unremarkable.
CT scan of the head without contrast is normal. A lumbar puncture yields the following results:

India ink preparation of the cerebrospinal fluid shows encapsulated yeast. The patient is started on amphotericin B.
In addition to antifungal therapy, which of the following is the most effective strategy to improve this patient's outcome?

Question

A 50-year-old man is brought to the emergency department due to fever, malaise, confusion, and worsening headache for the last 8 days. He has a history of advanced AIDS and is noncompliant with antiretroviral therapy. His most recent CD4 lymphocyte count a month ago was 29/mm³. His other medical problems include hypertension and chronic hepatitis C infection.
The patient's temperature is 38.8 C (101.8 F) , blood pressure is 110/70 mm Hg, pulse is 94/min, and respirations are 16/min. He is disoriented to place and time and has a left-sided visual field deficit. The remainder of the examination is unremarkable.
CT scan of the head without contrast is normal. A lumbar puncture yields the following results:

India ink preparation of the cerebrospinal fluid shows encapsulated yeast. The patient is started on amphotericin B.
In addition to antifungal therapy, which of the following is the most effective strategy to improve this patient's outcome?

Quizplus · Accepted Answer

11ec193a_9627_f00d_853d_2f6d8d12e61a_MD0002_00 This patient's presentation is consistent with cryptococcal meningoencephalitis, an invasive fungal infection caused by Cryptococcus neoformans. Although the organism originates from a pulmonary infection, patients with HIV most commonly have meningoencephalitis symptoms (eg, headache, fever, stiff neck, malaise). Antifungal therapy is the preferred initial treatment for yeast eradication and is frequently given in several phases. Induction therapy consists of 2 weeks of amphotericin B +/- flucytosine. Patients who achieve cerebrospinal fluid (CSF) yeast eradication may be switched to 8 weeks of consolidation therapy with fluconazole. Most are then given daily maintenance fluconazole for 1 year, but it is discontinued in select asymptomatic patients whose CD4 counts increase to >100/mm³ with antiretroviral therapy. ³ Increased intracranial pressure (ICP), indicated by CSF opening pressure >200 mm H₂O (20 cm H₂O), occurs in >50% of cryptococcal meningoencephalitis patients and can cause headache, altered mentation, visual/hearing loss, and cranial nerve deficits. Increased ICP is associated with increased mortality. If there are symptoms of increased ICP, lumbar puncture (LP) is recommended to reduce ICP to <200 mm H₂O (20 cm H₂O) or by 50%. It often needs to be repeated daily if ICP elevation and symptoms persist. Patients who do not respond to serial LPs and antifungal therapy may require ventriculostomy drain. (Choice A) Acetazolamide is often used to reduce ICP and pulmonary edema in altitude sickness, but it is not effective in cryptococcal meningoencephalitis. In addition, acetazolamide may lead to renal injury when given with amphotericin B. (Choice B) Corticosteroids may reduce intracerebral edema (eg, vasogenic edema around brain tumors), but they are not effective in reducing ICP due to cryptococcal meningoencephalitis. (Choice C) It is unclear when to start antiretroviral therapy in the setting of cryptococcal meningoencephalitis, but giving it prematurely may lead to immune reconstitution inflammation syndrome. Most clinicians prefer to start antiretroviral therapy 2-10 weeks after starting antifungal therapy. (Choice D) Mannitol can reduce ICP from cerebral edema (eg, traumatic brain injury), but it is not effective in cryptococcal meningoencephalitis. Educational objective: Cryptococcal meningoencephalitis usually presents in HIV patients with headache, fever, stiff neck, and possible altered mental status with neurological deficits. Treatment involves prompt antifungal therapy in 3 phases (induction, consolidation, and maintenance). Patients often require serial lumbar punctures to reduce the increased intracranial pressure frequently seen with the infection. __________ References: 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) Treatment of acute cryptococcal meningoencephalitis in HIV infected adults, with an emphasis on resource-limited settings. (http://www.ncbi.nlm.nih.gov/pubmed/18843697)

A 50-Year-Old Man Is Brought to the Emergency Department Due