Challenges in diagnosis and management of Cryptococcal immune reconstitution inflammatory syndrome (IRIS) in resource limited settings.
In many resource-limited settings, cryptococcal meningitis (CM) contributes up to 20% of all deaths with further complications due to Immune Reconstitution Inflammatory Syndrome (IRIS). We present a case report on a patient who developed CM-IRIS and then subsequent CM-relapse with a fluconazole-resistant organism and then later CM-IRIS once again, manifesting as cystic cryptococcomas, hydrocephalus, and sterile CSF. In this case we, demonstrate that CM-IRIS and persistent low level cryptococcal infection are not mutually exclusive phenomena. The management of IRIS with corticosteroids may increase the risk of culture positive CM-relapse which may further increase the risk of recurrent IRIS and resulting complications including death. We also highlight the role of imaging and fluconazole resistance testing in patients with recurrent meningitis and the importance of CSF cultures in guiding treatment decisions.
Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda. amusubire@yahoo.com
A K
AK
Musubire
B D
BD
Meya
H
H
Mayanja-Kizza
R
R
Lukande
L D
LD
Wiesner
P
P
Bohjanen
R D
RD
R Boulware
D017088:AIDS-Related Opportunistic Infections / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D000328:Adult; D000666:Amphotericin B / Q000627:therapeutic use; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D003455:Cryptococcus neoformans / Q000302:isolation & purification*; D019468:Disease Management; D017809:Fatal Outcome; D015725:Fluconazole / Q000627:therapeutic use; D015658:HIV Infections / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D006295:Health Resources; D006801:Humans; D054019:Immune Reconstitution Inflammatory Syndrome / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D008297:Male; D016919:Meningitis, Cryptococcal / Q000134:cerebrospinal fluid / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D012008:Recurrence; D014454:Uganda
D019380:Anti-HIV Agents; D000935:Antifungal Agents; D000666:Amphotericin B; D015725:Fluconazole