gms | German Medical Science

10. Kongress für Infektionskrankheiten und Tropenmedizin (KIT 2010)

Deutsche Gesellschaft für Infektiologie,
Deutsche AIDS-Gesellschaft,
Deutsche Gesellschaft für Tropenmedizin und Internationale Gesundheit,
Paul-Ehrlich-Gesellschaft für Chemotherapie

23.06. - 26.06.2010, Köln

Cryptococcal meningitis complicated by hydrocephalus malresorptivus with shunt-reinfection

Kryptokokken-Meningitis mit kompliziertem Verlauf durch Hydrocephalus Malresorptivus und Shunt-Reinfektion

Meeting Abstract

  • S. Schneitler - Universitätsklinik Düsseldorf, Klinik für Gastroenterologie, Hepatologie und Infektiologie, Düsseldorf, Germany
  • S. Reuter - Universitätsklinik Düsseldorf, Klinik für Gastroenterologie, Hepatologie und Infektiologie, Düsseldorf, Germany
  • D. Häussinger - Universitätsklinik Düsseldorf, Klinik für Gastroenterologie, Hepatologie und Infektiologie, Düsseldorf, Germany

10. Kongress für Infektionskrankheiten und Tropenmedizin (KIT 2010). Köln, 23.-26.06.2010. Düsseldorf: German Medical Science GMS Publishing House; 2010. DocP36

DOI: 10.3205/10kit092, URN: urn:nbn:de:0183-10kit0927

Published: June 2, 2010

© 2010 Schneitler et al.
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Outline

Text

Case report: The patient first presented with fever, headaches, psychomotoric slowness and atactic gait. Neutrophilic pleocytosis (395/3 cells) and elevated protein (87mg/dl) were noted in the cerebrospinal fluid (CSF). No pathogen could be identified, the cryptococcal antigen (Ag) test was repeatedly negative. Minor diffusion interference was noted on MRI. Empirical treatment with ceftriaxone, ampicillin and aciclovir did not improve the condition and increasing pleocytosis (1178/3 cells) was documented. After 14 days cryptococcal Ag (1:256) was detected for the first time in the CSF, but microscopically no cryptococci could be detected. Amphotericin B (AMB)+flucytosine (FCS) were started immediately. The antifungal regimen was changed to posaconazole after severe nephrotoxicity. Due to hydrocephalus malresorptivus an external CSF-drainage was implanted, later replaced by a ventriculo-peritoneal (VP) shunt. Despite continued posaconazole treatment a relapse occurred. CSF cultures grew Cryptococcus neoformans, no resistance against antifungals was found and treatment was continued with liposomal AMB+FCS. After temporary improvement, relapse was confirmed by rising cryptococcal Ag together with increasing visual hallucinations. Stabilization was achieved after immediate removal of the infected VP-shunt and the cryptococcal Ag sharply dropped. Under intense rehabilitation and fluconazole maintenance therapy the neuropsychological status finally improved.

Conclusions: Treatment of cryptococcosis remains a challenge. In the present case, antimycotic regimes changed repeatedly due to severe obstacles caused by poor treatment response, shunt infection and serious side-effects. AMB+FCS remain first choice for the treatment of cryptococcosis. Prolonged application of AMB was not tolerated due to severe nephrotoxicity. Progressive disease was noted under posaconazole, although new studies recommend posaconazole as a good therapeutic alternative. Despite sensitivity against all tested antimycotics, a relapse due to shunt infection occurred.

Establishing a diagnosis can be difficult. Cryptococcal Ag was the only initial parameter of infection and was useful for monitoring the course of disease. As in the present case, no apparent underlying condition of immunosuppression can be found in approximately 30% of cases with cryptococcal meningoencephalitis. The prognosis for these patients is poor and hydrocephalus is a frequent complication.