Case Report: Cryptococcal meningitis in an apparently immunocompetent patient in Nepal - challenges in diagnosis and treatment

Abstract

A 50 year old woman from Nepal had clinical features suggestive of meningitis. Cerebrospinal fluid (CSF) analysis was normal except for the presence of cryptococcal antigen. The inclusion of test for Cryptococcus in the CSF helped in making the diagnosis of cryptococcal meningitis in our patient who was apparently immunocompetent. Treatment with liposomal amphotericin B could not be started on time due to financial constraints. The patient had a stroke and further deteriorated. Liposomal amphotericin B is stocked by the government of Nepal for free supply to patients with visceral leishmaniasis, but the policy does not allow the drug to be dispensed for other infections. The family members of our patient acquired the drug within a few days from a government center using their political connections and following administering the treatment the patient improved. This case demonstrates the utility of considering cryptococcal meningitis as a differential diagnosis, and including tests for Cryptococcus when dealing with immunocompetent patients presenting with meningitis. It also demonstrates the effects of the sociopolitical situation on health care delivery in low- and middle-income countries (LMICs) such as Nepal.

Disseminated cryptococcosis in a deceased with HIV‐1 diagnosed by minimally invasive tissue sampling technique

“…Cryptococcus causes meningoencephalitis and disseminated cryptococcosis usually in immunocompromised hosts, 4,5 though cases of cryptococcal meningitis have also been reported in immunocompetent patients. [6][7][8] The research on the prevalence of cryptococcosis is very sparse in literature from Nepal. In a record review of one fiscal year in the major tertiary center of Nepal, among 15 patients with Cryptococcal meningoencephalitis, the majority (9, 60%) had HIV infection.…”

Atypical Presentation of Pediatric Systemic Lupus Erythematosus Complicated by Cryptococcal Meningitis

“…Cryptococcus is an opportunistic fungal pathogen that leads to rare life-threatening infection. Meningoencephalitis and disseminated cryptococcosis are usually common complications reported in immunocompromised hosts [ 7 , 8 ]. In the presented case, we reported a pediatric systemic lupus erythematosus patient complicated by rapidly disseminating cryptococcal infection which exhibited a latency in the child CNS followed by an attack of infection flare-up which was successfully treated, but slowly progressive brain cell atrophy due to longstanding disease resulted in her death.…”

“…Our presented case lived in low socioeconomic and hygienic status, and she denied contact with pigeon or birds. However, the fungus might have been indirectly transmitted via other sources such as vegetables, fruits, and dairy products [ 8 ].…”

“…Indian ink stain was positive in our case. In HIV-positive patients, its sensitivity increases up to 80% due to higher fungal loads in the CSF, while in HIV negative patients, the sensitivity is only 30–50% [ 8 , 23 ]. CSF culture is considered the gold standard for cryptococcal diagnosis, but it has several diagnostic obstacles as long time is needed for fungus to grow, while time is very critical for management of meningitis cases with evolving lifetime neurological complications [ 24 ].…”

Diabetes mellitus as a risk factor for cryptococcal meningitis in immunocompetent

“…Repeat CSF culture to confirm sterilization is recommended before starting the consolidation phase [ 15 ]. In resource-limited, the low-income country such as Nepal, the unavailability of Flucytosine can lead to increased mortality and morbidity [ 16 , 17 ].…”