ER Case Presentation CSF

7/31/2019 ER Case Presentation CSF

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CASE PRESENTATION


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CC: my head hurts and Im afraid

I have meningitis again.

HPI: 31yo c/o headache and neck pain for 3

days, getting progressively worse, similar toprevious episode of meningitis in the past.Pain is pounding, all over, 5/10 today, no

exacerbating or alleviating factors. Admits

to N/V x 1 today, denies fever, chills, rash,SOB, CP


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PMHx

1) HIV with AIDS as of 16 months ago

2) h/o hospitalization for cryptococcal meningitis x 23) Visual impairment and hearing loss 2/2 #1

4) h/o oral thrush

5) h/o herpes zoster Allergies: fish

PSHx

1) s/p appendectomy

2) h/o facial fractures


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FHx non-contributory

SocHx Tobacco: 1ppd x 20 years

EtOH: denies

Drug use: admits to h/o IV cocaine use for ~5 years inthe past, no current use

Medications, noncompliant with all ARV (type unknown)

Dapsone

Fluconazole

Bactrim


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ROS

General: adenopathy, fatigue, chills+ fever, +night sweats, +weakness

HEENT: recent trauma, recent change in vision,

discharge, photophobia, lacrimation,dysphagia, vertigo, +neck stiffness, +b/l vision

loss, can distinguish light and dark, +hearing loss

L ear, unchanged

CV: CP, DOE, PND


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ROS contd

Pulm:

SOB,

hemoptysis,

pleuritic CP GI/GU: +N/V, diarrhea, constipation,hematochezia, dysuria, urethral discharge

Neuro: +depression, +HA, seizure, syncope,

weakness

MSK: arthralgia, myalgia


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PE

VS: T 98.4 HR 72 RR 18 BP 117/67 98% on RA

Gen: cachectic with temporal wasting, NAD,cooperative

HEENT: +occipital tenderness, +mild nuchal rigidity(but negative Kernigs and Brudzinskis), b/l TMclear, PERRL, oropharynx is clear without erythema

or oral thrush, no lymphadenopathy CV: RRR, no murmurs


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PE contd

Pulm: CTAB, no wheezes, no rhales, no rhonchi

Abd: NTND, normoactive BS

Neuro: A+O x 3, intact strength and sensation in allextremeties

Ext: no edema, no deformity, no lesions


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Labs

CBC 11.3

4.1 202

33.7

BMP 135 105 28

3.0 24 1.19 128

APTT 43

PT 13.7

UA Color Yellow

Clarity ClearGlucose Neg

Bilirubin SmallKetones Trace

Spec. G >1.030pH 6.0protein 30

Nitrite Neg

Leuk Est Neg


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CSF Appearance clear colorless

Glucose 55

Protein 65RBCs 96

WBC 3

Segs (%) 0Lymphs(%) 100

Mono (%) 0

Eosinphl (%) 0

Fungal Smear Negative

Crypt. Ag Positive

VDRL Negative

Gram Stain no WBCs, organisms


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Lymphocyte panel:

%Mature T cells (CD3) 94 [57-85]

Absolute CD3 1501 [840-3060]%CD4 (Helper cells) 3 [30-61]

Absolute CD4 52 [490-740]


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Lymphocyte panel:

%Mature T cells (CD3) 94 [57-85]

Absolute CD3 1501 [840-3060]%CD4 (Helper cells) 3 [30-61]

Absolute CD4 52 [490-740]


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Head CT: no evidence of acute intracranialpathology

Cervical CT: No fracture or dislocation


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DDX

Cryptococcal Meningitis

CNS toxoplasmosis

Lymphoma Progressive multifocal encephalopathy

Herpes simplex encephalitis

CMV Brain abscess


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CNS Complications in HIV

Occur in >40% HIV patients

Presenting feature of AIDS in 10-20% of cases

Types of complications

Directly or indirectly from HIV

AIDS dementia complex

Vacuolar myelopathy

Peripheral neuropathies

Immunodeficiency leading to infectious, autoimmune,or neoplastic processes


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CNS Complications in HIV

Occur in >40% HIV patients

Presenting feature of AIDS in 10-20% of cases

Types of complications

Directly or indirectly from HIV

AIDS dementia complex

Vacuolar myelopathy

Peripheral neuropathies

Immunodeficiency leading to infectious, autoimmune,or neoplastic processes

Opportunistic Infections occur when CD < 200


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Immune Reconstitution

Inflammatory Syndrome (IRIS)

Collection of inflammatory disordersassociated with paradoxical worsening of pre-existing infectious processes or unmasking ofsubclinical infections following HAARTinitiation in HIV patients

30-100 days after HAART initiation


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Cryptococcal meningitis

Cryptococcus neoformans encapsulated yeast found in soil andpigeon droppings

Spore inhalation pulmonaryinfection latency reactivationand dissemination

+/- visible lesions on head CT


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Cryptococcal meningitis

1 million cases worldwide, with 700,000deaths

2-7 cases per 1000 HIV-infected patients in

USA 89% occur as CNS manifestation

4th most common OI (PCP, CMV,

mycobacteria) 6-14% mortality

Relapse rate 30-50%


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Clinical Presentation

Headache (73-81%)

Fever (62-88%)

Malaise (38-76%) Nausea and vomiting

(8-42%)

Stiff neck (22-44%)

Visual disturbances (30%)

AMS with somnolence(18-28%)

Photophobia (19%)

Papilledema (10%)

Cranial neuropathies,

including nystagmus andamblyopia (6%)


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Neuroimaging

Cryptococcoma in medula

Cryptococcoma in basal ganglia

Bilateral visual loss due toarachnoiditis at level of optic

nerve or invasion of optic

nerve


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Diagnosis

Definitive diagnosis by CSF culture

Lumbar puncture with opening pressure

Neuroimaging first to r/o mass lesions, risk ofherniation

India Ink stain of CSF

Cryptococcal antigen test of CSF

93-100% sensitive; 93-98% specific

Serum testing if LP not feasible


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CSF analysis

May be normal in 25%, or minimally abnormal in 50%

identification by serology and India Ink are crucial

Normal Cryptococcus

Opening pressure 50200 mm H2O CSF Elevated >200mm H20 (may be

normal in 30%)

Color Colorless Clear

Turbidity Crystal clear Clear or viscous if numerous

cryptococci present

Mononuclear cells


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Treatment

Medical treatment: 3 phases

Induction

Consolidation

Maintenance

Manage ICP


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Elevated ICP

>200cm H20

Occurs in >50% cases

Mechanism?

Cytokine-induced inflammation increased vasulcarpermeability

Fungal antigen clogging arachnoid villi impairedresorption

Manage aggressively in symptomatic patients Daily LPs to reduce opening pressure to


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References

Waxman SG. Chapter 24. Cerebrospinal Fluid Examination.In: Waxman SG, ed. Clinical Neuroanatomy. 26th ed. NewYork: McGraw-Hill; 2010.http://www.accessmedicine.com/content.aspx?aID=5275553. Accessed July 22, 2012.

NN Singh. CNS Cryptococcus in HIV. Medscape. UpdatedNovember 10, 2011.http://emedicine.medscape.com/article/1167389

Cox GM, Perfect JR. AIDS-associated cryptococcalmeningoencephalitis. In: UpToDate, Basow, DS (Ed),UpToDate, Waltham, MA, 2012.

Cox GM, Perfect JR. Microbiology and epidemiology ofcryptococcal infection. In: UpToDate, Basow, DS (Ed),UpToDate, Waltham, MA, 2012.

ER Case Presentation CSF

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