NYU Medical Grand Rounds Clinical Vignette Mark H. Adelman, M.D. PGY-2 2/19/13 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

43 year old man presents with headache, neck pain for approximately one week Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Diagnosed with HIV in 2002, on HAART until he lost insurance in 2009 Doing well until 10 days prior to admission, felt like there was “fluid swishing in my ears” Four days later, vomited multiple times, began to experience headache and neck stiffness History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Presented to ER, head CT, left AMA prior to complete evaluation Headache, neck stiffness, nausea/vomiting continued No relief with naproxen, ibuprofen Returned to ER for unremitting headache History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Past Medical History: Bipolar II Past Surgical History: Hernia repair as a child Social History: No tobacco. Rare alcohol. Infrequent intranasal cocaine, semi- weekly cannabis use Sex with men Family History: noncontributory Allergies: No known drug allergies Medications: Naproxen, ibuprofen as needed U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination General: Well appearing man, alert, in mild distress Vital Signs: T: 97.5, BP: 125/78, HR: 55, RR: 16, O2 sat: 96%RA Neck pain with flexion/extension Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CBC: Hemoglobin 16.7 Remainder of CBC was within normal limits Basic metabolic panel: Potassium 3.5 Remainder of basic was within normal limits Hepatic panel: ALT 74 Remainder of hepatic panel was within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CSF Opening pressure WBCs (84% lymphocytes, 16% monocytes) Protein 64 India ink, culture, cryptococcal antigen, HSV PCR pending Blood cultures: pending CD4 count and HIV-1 RNA: pending U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Studies Chest X-Ray: 1cm nodular opacity in right midlung CT head: no acute intracranial findings U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Cryptococcal meningitis Viral meningitis HSV encephalitis Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 1: Amphotericin, flucytosine. Acyclovir Hospital Day 2: CD4 count 52 (5%). HIV-1 RNA 28,400. Trimethoprim-sulfamethoxazole Repeat lumbar puncture Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 3: CSF India ink stain + for cryptococcus CSF cryptococcal antigen + (1:8,192) Serum cryptococcal antigen + (1:32,768) CT chest: Multiple round, nodular opacities right lower lobe. Mediastinal, pretracheal, right hilar lymphadenopathy Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 4: Headache improved HSV PCR negative. Acyclovir discontinued HD#1 CSF fungal culture + for cryptococcus Hospital Days 5-7 Induced sputum negative for AFB x3 HD#2 CSF fungal culture + for cryptococcus Blood cultures + for cryptococcus Bronchoscopy: BAL, transbronchial lymph node/lung biopsies negative for AFB, + for cryptococcus Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 8: Repeat LP: opening pressure 36 Cryptococcal antigen 1:512. Culture negative. VDRL + IV penicillin G Hospital days 9-14 Recurrent headaches serial LPs until opening pressure 20. Cultures negative Right occipital lymphadenopathy Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 15 Amphotericin, flucytosine discontinued Oral fluconazole started Hospital Day 16 Fine needle aspiration of occipital lymph node Hospital Day 18 IV penicillin discontinued FNA + for cryptococcus Discharged home with virology follow-up in one week Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Disseminated cryptococcosis Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS