Schulze K, Schmiedel S, van Lunzen J
Sektion Infektiologie und Tropenmedizin, I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf.
Dtsch Med Wochenschr. 2012 Apr;137(16):834-7. doi: 10.1055/s-0032-1304867. Epub 2012 Apr 11.
A 38-year old patient with previously untreated HIV infection presented with progressive cephalgia, photophobia, polydpsia and nausea/vomiting.
Clinical findings revealed a reduced general state of health and focal neurological deficits. Laboratory findings demonstrated a lymphocytopenia. In addition to positive crytococcus culture and antigen titer in cerebrospinal fluid/serum, Cryptococcus neoformans was detected by light microscopy (India ink stain) in cerebrospinal fluid.
DIAGNOSIS, TREATMENT AND COURSE: A cryptococcal meningitis was diagnosed. After initiating antifungal and antiretroviral treatment the clinical course worsened after months 2, 3, and 5, respectively. Apart from unspecific inflammation in the lab work, no signs of disease relapse or therapy refractory course were found in additional diagnostics. After critical evaluation of the clinical course and diagnostic results, immune reconstitution inflammatory syndrome (IRIS) was diagnosed. Clinical improvement was achieved during adjuvant treatment with steroids within six months.
In the presence of neurological symptoms, cryptococcal meningitis is a rare but possible differential diagnosis in daily routine. Diagnosis can be easily achieved by India ink stain in combination with culture of cerebrospinal fluid as well as antigen detection in most cases. Tests of antifungal resistance should be reserved for patients who do not respond to initial treatment, patients with atypical course of disease or failing longterm antifungal therapy. The IRIS is no rare complication after initiation of antiretroviral treatment in HIV associated cryptococcal infections. It is an important differential diagnosis in an atypical course of disease, and sufficient treatment is usually achieved by steroids.
一名38岁既往未接受过治疗的HIV感染患者，出现进行性头痛、畏光、多饮及恶心/呕吐症状。
临床检查发现患者全身健康状况下降，存在局灶性神经功能缺损。实验室检查显示淋巴细胞减少。除脑脊液/血清中隐球菌培养阳性及抗原滴度升高外，脑脊液经光学显微镜检查（印度墨汁染色）发现新型隐球菌。
诊断、治疗及病程：诊断为隐球菌性脑膜炎。开始抗真菌及抗逆转录病毒治疗后，分别在第2、3和5个月临床病程恶化。除实验室检查显示非特异性炎症外，进一步检查未发现疾病复发或治疗抵抗的迹象。在对临床病程和诊断结果进行严格评估后，诊断为免疫重建炎症综合征（IRIS）。在使用类固醇辅助治疗的6个月内临床症状改善。
出现神经系统症状时，隐球菌性脑膜炎在日常临床中虽罕见但为可能的鉴别诊断。多数情况下，通过印度墨汁染色结合脑脊液培养及抗原检测可轻松做出诊断。对于初始治疗无反应、疾病病程不典型或长期抗真菌治疗失败的患者，应进行抗真菌药敏试验。IRIS是HIV相关隐球菌感染开始抗逆转录病毒治疗后并不罕见的并发症。在疾病不典型病程中它是重要的鉴别诊断，通常使用类固醇可实现充分治疗。
