A 25-year-old man from Ghana was admitted to our hospital for an altered mental state, weight loss, neck pain, cough, fever, nausea, vomiting, and photophobia for 7 days. He reported a cough with greenish phlegm and blood-tinged sputum and a weight loss of ~20 lb in the last month. He reported that he could not eat because he was always nauseous and experienced nonbilious, nonprojectile vomiting. He denied chest pain, difficulty breathing and swallowing, diarrhea, dysuria, and skin rashes. His past medical history included intermittent asthma and migraines, but he was not on any medications. He did not have any significant family history or prior surgeries. He reported that he smoked 10 cigarettes a day for the past 5 years, drank alcohol occasionally, and denied illicit drug use except for marijuana. He reported that he last traveled to Ghana 6 months priorly, and he denied having contact with sick persons. He reported that he was sexually active with many partners but denied any prior sexually transmitted diseases.
Examination revealed a cachectic young male with a heart rate of 102 beats/min, a blood pressure of 108/69 mmHg, a respiratory rate of 20 breaths/min, a temperature of 98 F, and a 96% oxygen saturation in ambient air. He had a body mass index of 19.2 kg/m2 and was lethargic but oriented. He had no icterus or cervical or axillary lymphadenopathy. He had clear bilateral breath sounds, and his cardiovascular and abdominal examinations were unremarkable. He had a good pulse and no peripheral edema.
On admission, the patient tested positive for HIV with a CD4 count less than 20 and a high viral load. Pneumonia and meningitis resulting from opportunistic infections were considered, and he was treated for bacterial meningitis and tuberculosis (TB) even though the lumbar puncture was delayed because the patient was restless and uncooperative. The lumbar puncture results showed a pressure of 23 cm H2O, a white blood cell count of 2, a red blood cell count of 57, a protein level of 102 mg/dl, and a glucose level of 25 mg/dl. The Gram stain and bacterial antigen tests were negative.
There was a high suspicion of pulmonary TB and tuberculous meningitis due to recent travel to Ghana, and the initial chest X-ray showed multiple nodular opacities suggestive of miliary TB (Figure 1(a)). The micronodular appearance was confirmed by a chest CT scan without contrast (Figure 1(b)). Despite a quantiFERON negative test result, quadruple therapy for TB with isoniazid, pyrazinamide, ethambutol, and rifampin (RIPE) was continued.
On succeeding days, yeast was growing in the patient's blood cultures and a Gram stain of the patient's cerebrospinal fluid (CSF) showed presence of yeast cells. The titer of Cryptococcus in the CSF was greater than 1 : 1024 and was eventually identified as Cryptococcus neoformans. Thus, antibacterial meningitis treatment was discontinued, and the patient was started on amphotericin B and flucytosine. Anti-TB medications were continued. He underwent placement of a lumbar drain due to a persistent headache and photophobia. Antiretroviral treatment was not started, but the patient was treated with prophylaxis medications for opportunistic infections. At this time, the patient had four persistently negative acid-fast bacilli sputum smears and was negative for the sputum Mycobacterium tuberculosis PCR test.
The patient underwent FFB with BAL and TBBx. In the BAL, >100,000 CFU/mL of Staphylococcus haemolyticus grew; thus, the treatment for bacterial pneumonia was modified. Tissue culture and TBBx showed the presence of Cryptococcus neoformans. Higher magnification microscopy showed the presence of both hyphae and yeast cells (Figures 2(a) and 2(b)). The patient showed clinical improvement and was discharged on oral fluconazole.