Cryptococcal Meningitis in a Patient with Idiopathic CD4 Lymphocytopenia

Abstract

A 49 year-old Caucasian man presented to the emergency department with altered mental status. His family reported that he had not felt well for several months and they had noticed slurring of his speech over this time. They urged him to seek medical evaluation but he declined. He had been able to continue his daily activities including working a manual labor job installing flooring until the past week although he was experiencing progressive fatigue over the previous month. He had no unusual chemical exposures and had not been out of the country. He had no pets and had no exposure to any exotic animals or birds. He had no significant HIV risk factors. Family reported he had developed bizarre behavior over the past week including answering the door partially undressed. He would not allow family members to come into his home but persisted in stating he was fine. Family reported he had flu like symptoms with cough, upper airway congestion, nausea and vomiting over four to five days prior to presentation. However, these symptoms had now resolved. In addition, he complained of decreased hearing in bilateral ears for the previous two to three days along with imbalance.In the emergency department he was alert and oriented, but noted to be impulsive and removed medical appliances. He requested to sign out against medical advice and tried to leave but was unsteady on his feet and unable to maintain balance, and subsequently agreed to stay. Neurology was consulted for admission. On exam he had generalized weakness, bilateral hearing loss, incoordination, truncal ataxia, nystagmus, a positive Romberg sign, severe gait ataxia, and he was unable to maintain an upright posture. His bilateral horizontal nystagmus was non-fatigable. Deep tendon reflexes (DTRs) were absent but a right Babinski sign was present. Skin exam revealed Condyloma on his penis. Initial work up included CT of the head, Complete blood count, Metabolic panel, Liver function test, blood and urine cultures were obtained. LP was attempted but initially was unsuccessful due to his body habitus.CT of the head was unremarkable. Chest radiograph was normal. Flu, Respiratory virus panel and Syphillis serologies were negative. White blood cell count was elevated at 15,000 cell/mcL with 87.2 % neutrophils and no bands. BMP, LFTs, Ammonia, Vitamin B 12, Folate and TSH and Ammonia were unremarkable. Urinalysis showed moderate ketones. CRP was elevated at 90.7 mg/L. Differential diagnosis included posterior circulation ischemia, alcohol withdrawal, meningitis, and subarachnoid space inflammatory process, an infectious process such as encephalitis, paraneoplastic syndrome, or vitamin deficiency such as Wernicke's encephalopathy. Cryptococcal Meningitis in a Patient with Idiopathic CD4 Lymphocytopenia AbstractA 49 year-old man with a past medical history of hypertension and tobacco use presented to the emergency department after being found by family with altered mental status. Over the previous few months he had experienced progressive fatigue and slurred speech. More...