G Serrano Ocaña, J Ortiz Sablon, I Ochoa Tamayo
arvs, cryptococcosis, hiv-aids, meningitis
G Serrano Ocaña, J Ortiz Sablon, I Ochoa Tamayo. Disseminated Cryptococcosis: Case report. The Internet Journal of Neurology. 2008 Volume 10 Number 2.
Life-threatening infections caused by the
After the lungs and CNS infection, the next most commonly involved organs in disseminated cryptococcosis are the skin, prostate and medullary cavity of the bones. The diagnosis is established by the isolation of organism in culture, histopathology, or detection of its polysaccharide capsular antigen. The acute mortality rate for HIV infected patients is 10-25%; most deaths are attributable to cryptococcal meningitis.
In the following pages the authors describe a patient presenting with Cryptococcal meningitis, severe thrombocytopenia and moderate anemia. She fully recovered after antifungal therapy (amphotericin B and fluconazole). Written consent was obtained from the patient before this article was conceived.
A 20-years-old african woman with previous history of pulmonary tuberculosis also HIV- positive, on HAART (3TC, D4T, efavirenz and bactrim), four days ago was seen presenting severe headache, fever and photophobia was admitted from 25 April to 10 May 2008. On
She received treatment with amphotericin B 35 mgs daily intravenously for two weeks, then continued with fluconazole 400 mgs daily for eight weeks, also received prophylactic treatment with bactrim, and ARVs (3TC, D4T and efavirenz). Latest FBC was taken on 16-07-2008 showed a remarkable improvement WCC 5 x 109/l , Hb 10.6 g/l and platelet 225 x 109/l and MCV 93 fl.
Although the overall incidence of cryptococcosis is unknown, it is higher among patients with AIDS in Africa and Southeast Asia than in the United States, whereas it appears less frequently in Europe.  Prior to the discovery of amphotericin B in 1955, 80% of patients with CNS involvement died within 2 years of diagnosis.
In the developed world, the introduction of potent antiretroviral therapies resulted in a decrease in the incidence of opportunistic infections associated with AIDS. In those with HIV infection, cryptococcal infection occurs in the advanced stages of the disease when the CD4+ count is usually less than 50-200 cells/µL.  Unfortunately in our setting not all HIV patients are receiving ARV's or when they came there disease is very advanced often with very low CD4 cell count, making there very susceptible to develop this type of infection.
Bone marrow cryptococcosis is a classical, albeit relatively infrequent, presentation in patients with acquired immunodeficiency syndrome (AIDS) [4,5]
The laboratory diagnosis of cryptococcosis is established by the isolation of organism in culture, histopathology, or detection of its polysaccharide capsular antigen. 
The organism grows in blood and chocolate agar within 3-5 days. Analysis of cerebrospinal fluid (CSF) usually reveals a poor white blood cell (WBC) count, inflammatory response, with a normal or low-CSF glucose levels, and a positive cryptococcal antigen test. The India ink test is more specific and helps in demonstrating the fungus. The level of antigen titer corresponds to the severity of disease.
In tissue specimens,
Imaging techniques like computed tomography (CT) or magnetic resonance imaging (MRI) of the head are used for detecting complications such as, hydrocephalus or mass lesions, where surgery may be indicated. 
The acute mortality rate for patients with HIV WHO Stage IV is 10-25%. Most deaths are attributable to cryptococcal meningitis and occur within two weeks after diagnosis, and many may be related to increased intracranial pressure. In cohorts of HIV-infected patients from sub-Saharan Africa, cryptococcosis has accounted for 13–44% of all deaths.
Flucytosine (5FC) in combination with amphotericin B (AMB) is standard therapy for cryptococcal meningitis. [7,8,9,10]
Severe attacks of cryptococcal meningitis are treated with liposomal amphotericin (Abelcet, AmBisome, Amphocil) induction therapy (0.6 - 1.0 mg/kg per day). Liposomal amphotericin causes far fewer adverse effects than the standard form of the drug and is more effective than standard amphotericin in AIDS patients. [1,6,7,8]
Fluconazole has been found to be particularly effective due to its high bioavaibility, excellent CSF penetration and long half-life. Therefore, it is regarded as the drug of choice for prophylactic therapy. The mortality of disseminated cryptococcosis is 70-80% in untreated patients compared with those treated with systemic antifungal agents. 
Raised intracranial pressure: daily serial lumbar punctures with withdrawal of large volumes of CSF to achieve a closing pressure of <25 cm H2O or 50% of initial opening pressure. [1,7]
To Dr Nel and Dr. Littleton from the Department of hematology Provincial Hospital Port Elizabeth for their continuous support and valuable help and to Dr. Diana Oelofse from the National Health Laboratory Services Port Elizabeth for her kindness and continuous support.