A 38-year-old male was seen at his local clinic with a 6-month history of loss of weight (approximately 10 kg) and progressive loss of appetite. A rapid HIV test was performed and was positive. Additional blood tests confirmed a CD4 cell count of 2 cells/muL and a positive CrAg LFA. Targeted screening of patients with CD4 cell counts of less than 100 cells/muL for cryptococcal antigenemia was recently introduced into selected laboratories in South Africa as part of the National Strategic Plan on HIV, STIs, and TB. After a positive serum CrAg LFA test, the patient was referred to our hospital for a lumbar puncture to exclude CM. He reported no headache, neck stiffness, fever, visual impairment, or night sweats. Although he had a productive cough approximately 3 weeks ago, it had resolved with antibiotics prescribed by his local clinic. On examination, temporal wasting and generalized lymphadenopathy were present. Neurological examination revealed no neck stiffness, focal neurologic deficit, papilledema, or cranial nerve involvement. No cutaneous lesions or pulmonary signs were present. The remainder of the systemic examination was normal.
Laboratory blood tests showed a normocytic anaemia with haemoglobin of 11.8 g/dL. The cerebrospinal fluid (CSF) on admission was clear in appearance, and further analysis revealed lymphocytes of 1 cells/muL, neutrophils of 0 cells/muL, protein of 0.48 g/dL (normal: 0.15-0.45 g/dL), and glucose of 3.2 mmol/L (normal: 2.8-4.4 mmol/L). CSF Gram's stain, CrAg latex antigen (LA), and India ink were all negative. Xpert MTB/Rif assay of early morning sputum samples was negative for tuberculosis. A chest radiograph showed no abnormalities.
A diagnosis of disseminated cryptococcosis was made. Antifungal therapy was started with high dose fluconazole of 800 mg daily according to the South African screen-and-treat algorithm for ART-naive patients with a positive CrAg and negative lumbar puncture. Cotrimoxazole was also given as prophylaxis to prevent pneumonia from Pneumocystis jiroveci. The patient was discharged from hospital a day after his admission. At the 2-week follow-up visit, the fluconazole dose was reduced to 400 mg daily and ART:with tenofovir, emtricitibine, and efavirenz:was initiated. At the 2-month visit, the fluconazole dose was further reduced to a maintenance dose of 200 mg daily. So far he is doing well and reports no symptoms of meningitis.