Dhoubhadel Bhim Gopal, Laghu Ujjwal, Poudel Raju, Morimoto Konosuke, Ariyoshi Koya
School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
Department of Respiratory Infections, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan.
Case Rep Infect Dis. 2021 Jul 29;2021:9994804. doi: 10.1155/2021/9994804. eCollection 2021.
Cryptococcal meningitis, which has a high mortality rate, is rare in immunocompetent children. Although many immunocompromised conditions are identified as predisposing factors, congenital heart disease in children is not well recognized as a predisposing factor for the disease. A 12-year-old female child presented with a progressively increasing headache for one month. There was history of vomiting and fever off and on. On examination, she had a pansystolic murmur and meningeal signs. Lumbar puncture was done; opening pressure was high (27 cm HO) and white blood cell (WBC) count in cerebrospinal fluid (CSF) was slightly high. Gram staining, India ink preparation, and culture of CSF were negative. Cryptococcal antigen (CrAg) test was not available. Echocardiography showed a 12 mm ventricular septal defect (VSD). The patient was diagnosed as meningitis with VSD and treated with intravenous ceftriaxone and vancomycin; however, she did not improve after 7 days of antimicrobial treatment. She was then transferred to another hospital where India ink and culture of CSF showed cryptococcus; CrAg test was done, and it was positive. Despite the treatment with lyposomal amphotericin B and flucytosine, she died on 9 day of admission in pediatric intensive care unit. It is necessary for global advocacy for need of availability of CrAg test in resource-limited regions. Treating doctors should consider VSD, a congenital heart disease, as a predisposing factor for cryptococcal meningitis in children. As CrAg is more sensitive than India ink and culture, it should be the first line of investigation in suspected cases.
隐球菌性脑膜炎死亡率很高，在免疫功能正常的儿童中较为罕见。虽然许多免疫功能低下的情况被确定为易感因素，但儿童先天性心脏病作为该疾病的易感因素尚未得到充分认识。一名12岁女童出现进行性加重的头痛1个月。有间断呕吐和发热史。检查时，她有全收缩期杂音和脑膜刺激征。进行了腰椎穿刺；初压高（27cmH₂O），脑脊液白细胞计数略高。脑脊液革兰染色、墨汁涂片和培养均为阴性。无法进行隐球菌抗原（CrAg）检测。超声心动图显示有12mm室间隔缺损（VSD）。该患者被诊断为VSD合并脑膜炎，接受静脉注射头孢曲松和万古霉素治疗；然而，抗菌治疗7天后病情并无改善。随后她被转至另一家医院，脑脊液墨汁涂片和培养显示有隐球菌；进行了CrAg检测，结果为阳性。尽管接受了脂质体两性霉素B和氟胞嘧啶治疗，但她在入住儿科重症监护病房的第9天死亡。有必要在全球范围内倡导在资源有限地区提供CrAg检测。治疗医生应将先天性心脏病VSD视为儿童隐球菌性脑膜炎的易感因素。由于CrAg比墨汁涂片和培养更敏感，在疑似病例中应作为一线检测方法。
