Female patient, 37 years old, with stage C 3 HIV infection (according to CDC 1993 classification), diagnosed in 2003, when she presented a pneumonia bycystis jirovesi.
In March 2004 she presented cryptococcal meningitis characterized by headache, qualitative compromise, fever and meningeal signology.
Cerebrospinal fluid (CSF) study showed proteins of 5.68 g/l, leukocytes 5/field, 100% mononuclear, glucose of 30 mg/dl (concomitant blood glucose 98 mg/dl), positive Gram stain.
High number of positive blood cultures.
CSF culture positive for cryptococcal neoformans.
Immunofluorescence (IFI) for toxoplasmosis: negative, ADA 12 U/l, negative sputum smear.
Computed tomography (CT) showed bilateral caudatid hypodensity, interpreted as a vascular lesion.
Amphotericin B 40 mg daily was administered for 14 days (560 mg in total).
The patient was successfully treated with fluconazole 400 mg vo every 12 h and acetazolamide/trimethoprim (800 mg/160 mg) 1 tablet a day.
The culture was negative for CSF at 15 days, but positive for Chinese ink.
Viral load (15.04.04): copies 11,000, logarithm 4 (copies/ml).
CD4+ count was undetectable.
Antiretroviral therapy with efavirens 600 mg at night, lamivudine 150 mg every 12 h and stadydine 30 mg every 12 h was initiated on an outpatient basis in 2004.
Later on, on May 21, 2004, the patient was readmitted due to suspected reactivation of cryptococcal meningitis due to intense headache, thermal elevation, impairment of the general state of one week of evolution, meningeal signology and no neurological awareness.
Brain CT without contrast, with no new lesions.
CSF showed proteinorrhachia: 1.14 g/l, glucose 0.41 mg/dl, 14 leukocytes per field, 100% mononuclear, negative culture, Chinese ink with capsulated yeasts.
ADA 8.4 U/L and negative sputum smear.
Negative CSF culture for Koch.
Negative VDRL.
Amphotericin B 35 mg daily was indicated for 14 days (490 mg in total), prophylaxis with acetazolamide/trimethoprim (800 mg/160 mg) one tablet a day.
She remained asymptomatic until May 2005, when she was hospitalized for 6 days of evolution, characterized by mild to moderate holocraneal headache, nausea, simple confusion and neck stiffness, without fever.
Brain CT was requested, which reported lesions consistent with vasculitis.
The CSF study showed clear, transparent liquid, with increased fat, glycorrachy 45 mg/dl (glycemia 78 mg/dl), proteinuria 0.55 g/l, negative sputum smear microscopy 5 per field, 100% mononuclear culture.
It continued under similar conditions, but with disappearance of meningeal signology.
Lumbar puncture was repeated, giving rise to clear, transparent CSF with increased goiter, glycorrachy: 60 mg/dl, proteinorrhachia 0.24 g/l, Chinese nonreactive VDRL + mononuclear cell culture: 124+
Treatment with AGA was maintained.
Magnetic resonance imaging (MRI) revealed enhancement of the abdomen and lesions consistent with cryptoma and inflammatory reaction.
Based on the clinical picture, based on imaging findings and immunological recovery, the diagnosis of inflammatory reinstallation syndrome associated with cryptococcosis meningeal was proposed.
Symptomatic treatment with nonsteroidal anti-inflammatory drugs and lumbar punctures evacuating cerebrospinal fluid were performed.
With this treatment the patient presented a progressive clinical improvement, finding 3 months later (September 2005) asymptomatic of his neurological condition.
