Meningitis Due to Cryptococcus gattii in an Immunocompetent Patient

Abstract

A 30-years-old male, driver by occupation, was admitted to neurology department with chief complaints of high-grade fever, intermittent, moderately severe headache lasting for 30 days associated with multiple episodes of vomiting. He had no history of seizures, ear discharge or earache, nor any focal neurological deficit, head trauma, weight loss, chronic cough, drug abuse including steroids, blood transfusion, or high-risk behavior. He did not have any history of cutaneous or respiratory manifestations neither he had any history of tuberculosis, diabetes, malignancy or any other such chronic illness.On examination, the patient was febrile (39°C) and conscious, alert, oriented to time, place and person. Higher motor functions were intact and speech was normal. Signs of meningeal irritation (nuchal rigidity and Kernig's sign) and bilateral papilloedema was present. Examination of other systems revealed no obvious abnormality.Laboratory investigations revealed Haemoglobin of 11mg/dl, raised total leukocyte count (13,000/mm cu.) with 78% lymphocytes. Serum electrolytes, renal function tests, and liver function tests were within normal limits. A Cerebrospinal Fluid (CSF) examination revealed 210 cells/mm 3 , predominantly lymphocytes, with protein 92mg/dl and glucose 22 mg/dl (corresponding blood glucose was 136 mg/dl). A Computerized Tomography (CT) scan of the head and a Chest X-ray were both normal. The CSF specimen was received in laboratory for microbiological investigations such as staining, culture and sensitivity. Macroscopically, the CSF was clear and without coagulum. On microscopy, Gram stain showed round budding yeast cells varying in size [Table/ Fig-1a]. There were no acid fast bacilli on Ziehl-Neelsen (ZN) stain. India ink preparation showed characteristic round budding yeast cells varying in size with distinct halos [Table /Fig-1b]; a bacterial culture was sterile. The CSF Cryptococcal Latex Agglutination Test (CALAS, Meridian Diagnostics, Cincinnati, Ohio) for Cryptococcal Antigen (CRAG) was positive, with a titer of 1:1024. Serum was also tested for CRAG and was positive. A presumptive diagnosis of cryptococcal meningitis was given to the clinicians and patient was promptly put on Amphotericin B and Flucytosine. Subsequently, culture on Sabouraud's dextrose agar yielded smooth colonies of yeast after five days of incubation at 37°C, with no growth at 30°C. With a battery of tests and biochemical reactions performed [Table/ Fig-2], [Table/ Fig-3a and b] the isolate was characterized as C.gattii. Serotyping of the organism was not possible at this point.The anti-fungal susceptibility testing of the isolate was performed by using microbroth dilution technique and results were interpreted according to Clinical and Laboratory Standards Institute (CLSI) guidelines [1]. The Minimum Inhibitory Concentration (MIC) values for fluconazole, Amphotericin B (Amp B), and voriconazole were ≤ 1 μg/ml, 0.50 μg/ml, and ≤ 0.12 μg/ml respectively. Also E-Test (AB Biodisk, Sweden) was used for Amphotericin B, which show...

Ecoepidemiology of Cryptococcus gattii in Developing Countries

“…was isolated from a surgical wound [ 61 ]. In addition, in India, it was isolated from HIV-positive and HIV-negative patients [ 62 , 63 ]. Environmental niches of C. gattii s.l.…”

Cryptococcal meningitis: An under-reported disease from the hills of Uttarakhand: A hospital-based cross-sectional study

“…To the best of our knowledge, there is only one case report on cryptococcal meningitis from the state of Uttarakhand by Patil et al [9] Ours is the first cross-sectional study on prevalence and clinical profile of cryptococcal meningitis from the state of Uttarakhand. Cumulative records of cryptococcal meningitis from India and rest of the world have been depicted in Tables 3 and 4, respectively.…”

Cryptococcosis

“…52,54 However, although rare, severe disease with dissemination and development of cryptococcal meningitis progressing from asymptomatic infection has been documented. [55][56][57][58] In a retrospective study of patients presenting with pulmonary cryptococcosis, patients with pulmonary plus extrapulmonary disease were more likely to have underlying cirrhosis, headache, weight loss, fever, altered mental status, or high-dose corticosteroids than patients with localized pulmonary disease. 59 Among PLWH, symptoms of pulmonary cryptococcosis are nonspecific.…”