A Case Report: Tragic Death in a Young Patient with Human Immunodeficiency Virus Due to Cryptococcal Meningitis
A Case Report: Tragic Death in a Young Patient with Human Immunodeficiency Virus Due to Cryptococcal Meningitis
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DOI：
10.7759/cureus.4652
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发表时间：
2019-05-13
影响因子：
1.2
通讯作者：
Zhang, Xiao Chi
中科院分区：
文献类型：
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作者：
Loye, Ayomide;Gabriel, Onyinye;Zhang, Xiao Chi
隐球菌性脑膜炎是一种全身性感染，可见于免疫抑制患者。精神状态改变、嗜睡和迟钝是预后不良或晚期疾病进程的警告信号。我们介绍了一名 23 岁女性，她既往有通过垂直传播获得的人类免疫缺陷病毒 (HIV) 的显着病史，她因头痛在 10 天内逐渐恶化、视力模糊、畏光、恶心和呕吐以及进行性记忆丧失而就诊于急诊科 (ED)。她的血液检查、胸部平片和非造影脑部计算机断层扫描（CT）均正常。在急诊室，她发烧到华氏 102 度，变得更加困惑和焦躁，时不时地尖叫和大喊大叫。腰椎穿刺（LP）显示白细胞计数升高，并且新型隐球菌呈阳性；由于患者情绪激动，无法获得开启压力。尽管及时静脉注射抗生素和抗真菌药物，但她短暂但脆弱的住院治疗导致精神状态下降，需要插管和多次腰椎穿刺治疗，开放压力高达 55 cm H2O。该患者患有全身缺血性脑病，并在住院第二天死亡。该病例凸显了患有隐球菌性脑膜炎的年轻免疫功能低下患者的快速失代偿，以及早期疾病管理和神经内科和神经外科咨询服务的重要性。急诊医学 (EM) 医生在治疗隐球菌性脑膜炎患者颅内压 (ICP) 升高时的一个重要范式差异是避免使用乙酰唑胺、甘露醇和类固醇，并考虑对严重隐球菌性脑膜炎进行神经外科干预的指征。
Cryptococcal meningitis is a systemic infection that can be seen in immunosuppressed patients. Altered mental status, somnolence, and obtundation are warning signs of poor prognosis or advanced disease processes.We present a 23-year-old female with a past medical history significant for human immunodeficiency virus (HIV) obtained via vertical transmission who presented to the emergency department (ED) with a gradual onset of worsening headache over 10 days, with blurry vision, photophobia, nausea and vomiting, and progressive memory lapses. Her blood tests, chest plain radiograph, and non-contrast brain computed tomography (CT) were normal. In the ED, she developed a fever of 102 degrees F and became more confused and agitated, with interspersed screaming and yelling. A lumbar puncture (LP) showed elevated white blood cell count and was positive for Cryptococcus neoformans; an opening pressure was unable to be obtained due to patient agitation. Despite prompt intravenous antibiotics and antifungal medications, her short, but tenuous hospital course involved declining mental status, requiring intubation and multiple therapeutic lumbar punctures, with an elevated opening pressure of up to 55 cm H2O. The patient suffered global ischemic encephalopathy and died on hospital day two.This case highlights the rapid decompensation of a young immunocompromised patient with cryptococcal meningitis, as well as the importance of early disease management and consultation to neurology and neurosurgery services. An important paradigm difference for emergency medicine (EM) physicians in the management of increased intracranial pressure (ICP) in patients with cryptococcal meningitis is avoiding acetazolamide, mannitol, and steroids and considering the indication for neurosurgical interventions for severe cryptococcal meningitis.