ABSTRACT
To determine the frequency, imaging characteristics, neuroanatomical distribution and dynamics of magnetic resonance imaging findings in HIV-associated cryptococcal meningitis in immunocompromised patients we compared patients without antiretroviral therapy with patients undergoing immune reconstitution. Neuroimaging and clinical data of 21 consecutive patients presenting to a German HIV centre in a 10-year period between 2005 and 2014 were reviewed. We identified eight patients with magnetic resonance imaging findings related to cryptococcal disease: five patients without antiretroviral therapy and three patients receiving effective antiretroviral therapy resulting in immune reconstitution. The pattern of magnetic resonance imaging manifestations was different in the two groups. In patients not on antiretroviral therapy, pseudocysts (n = 3) and lacunar ischaemic lesions (n = 2) were detected. Contrast-enhancing focal leptomeningeal and/or parenchymal lesions were found in all patients under immune reconstitution (n = 3). Magnetic resonance imaging lesions suggestive of leptomeningitis or meningoencephalitis were detected in all patients with a recurrence of cryptococcal meningitis under immune reconstitution, which differs from the classical magnetic resonance imaging findings in patients without antiretroviral therapy. In antiretroviral therapy-treated patients with past medical history of cryptococcal meningitis, detection of contrast-enhancing focal meningeal and/or parenchymal lesions should prompt further investigations for a recurrence of cryptococcal meningitis under immune reconstitution.
Subject(s)
AIDS-Related Opportunistic Infections/diagnosis , Antiretroviral Therapy, Highly Active/adverse effects , Cryptococcus neoformans/isolation & purification , HIV Infections/diagnosis , Immune Reconstitution Inflammatory Syndrome/diagnosis , Meningitis, Cryptococcal/diagnosis , AIDS-Related Opportunistic Infections/complications , AIDS-Related Opportunistic Infections/drug therapy , Adult , Anti-HIV Agents/therapeutic use , Antifungal Agents/therapeutic use , Arachnoid Cysts/pathology , Female , Fluconazole/therapeutic use , Germany , HIV Infections/complications , HIV Infections/drug therapy , Humans , Immune Reconstitution Inflammatory Syndrome/complications , Immune Reconstitution Inflammatory Syndrome/drug therapy , Immunocompromised Host , Magnetic Resonance Imaging , Male , Meningitis, Cryptococcal/complications , Meningitis, Cryptococcal/drug therapy , Middle Aged , NeuroimagingABSTRACT
We report a case of a symptomatic relapse of HIV-related cryptococcal meningoencephalitis eight years after the first diagnosis on the background of immune reconstitution. The findings as well as the clinical course suggests a combination of smouldering localised infection and enhanced inflammatory reaction related to immune restoration due to antiretroviral therapy. A combination of antifungal and anti-inflammatory therapy resulted in clinical and radiological improvement. Our case challenges the concept that immune reconstitution inflammatory syndrome and microbiological relapse are dichotomous entities.
Subject(s)
AIDS-Related Opportunistic Infections/diagnosis , Cryptococcus neoformans/isolation & purification , Immune Reconstitution Inflammatory Syndrome/diagnosis , Meningitis, Cryptococcal/diagnosis , AIDS-Related Opportunistic Infections/drug therapy , Anti-HIV Agents/therapeutic use , Antifungal Agents/therapeutic use , Antiretroviral Therapy, Highly Active , Biopsy , Brain/pathology , Cryptococcus neoformans/genetics , Female , Fluconazole/therapeutic use , HIV Infections/drug therapy , Humans , Male , Medication Adherence , Meningitis, Cryptococcal/drug therapy , Recurrence , Treatment OutcomeSubject(s)
Acquired Immunodeficiency Syndrome/pathology , Leukoencephalopathy, Progressive Multifocal/pathology , Myoclonus/pathology , Acquired Immunodeficiency Syndrome/complications , Humans , JC Virus/isolation & purification , Leukoencephalopathy, Progressive Multifocal/complications , Male , Middle Aged , Myoclonus/complicationsABSTRACT
We report a case of cryptococcal immune reconstitution inflammatory syndrome affecting the lungs, and 10 months later the cervical lymph nodes, in the absence of cryptococcal meningitis, in advanced HIV infection. Our report demonstrates the organ-specificity of the timing of the inflammatory response and illustrates the organ-specific interplay of immunity and infection in cryptococcal disease.
