Publication

Abstract : Among neuropsychiatry manifestations, disorders like psychosis, mania, delirium, depression and dementia are the commonest and can rarely be seen in patients with central nervous infections. One such condition is cryptococcal meningitis which can present as acute manifestation of organic brain syndrome causing impairment of cognition. A 49-year-old male, a known case of direct Coombs test-positive hemolytic anemia, presented with symptoms of psychosis, on and off fever, and headache of two months' duration. Brain computed tomography (CT) scan was normal and he was diagnosed with psychosis and was started on olanzapine 2.5 mg/day and clonazepam 0.25 mg/day. On day 10 he returned with mild resolution of psychotic symptoms, but worsening of headache and was admitted under neurology for further workup. Magnetic resonance imaging (MRI) of brain was normal and electroencephalogram EEG showed mild degree of generalized nonspecific findings. Cerebrospinal fluid (CSF) opening pressure was 410 mm and CSF was turbid with protein of 373 mg/dl, glucose of 13 mg/dl, cell count of 40/mm 3 , and cytology showed monocytic pleocytosis. Microbiological investigation for bacterial pathogens and fungi on Gram stain was negative, acid-fast staining and polymerase chain reaction for rpoB gene of Mycobacterium tuberculosis was negative and CSF Venereal Disease Research Laboratory (VDRL) test was also non-reactive. Serology for P24 antigen, HIV-1and HIV-2 antibody was also negative. Latex agglutination for cryptococcal antigen was positive while India ink preparation was negative. Routine and fungal cultures of CSF grew mucoid colonies of yeast which were identified as Cryptococcus neoformans var. neoformans by the ID 32C/mini API system (Biomerieux, France). The isolate was susceptible to amphotericin B, itraconazole, fluconazole, voriconazole and 5-fluorocytosine using ATB FUNGUS 3/mini API system (Biomerieux, France). With the confirmation of cryptococcal meningitis the patient was treated with IV amphotericin B along with psychotropic medications. By Day 20 of antifungal therapy the patient showed marked resolution of neuropsychiatry symptoms and CSF cultures were also sterile. He was discharged on Day 22 on oral fluconazole 200 mg twice daily for 12 weeks. All psychotropic medications were discontinued on discharge. He was asymptomatic with no evidence of relapse at seven months' follow-up.