Treatment and Outcome of HIV-associated Cryptococcal Meningoencephalitis in Resource Limited Settings: Case Report

Present a case report showing clinical challenge in treatment choice for HIV-associated cryptococcal meningoencephalitis in resource limited settings. Cryptococcal meningoencephalitis (CME) is a serious opportunistic infection which is a major cause of morbidity and mortality in people living with HIV (PLWHIV) with advanced disease. CME is responsible for nearly 20% of all deaths related to advanced HIV disease. Reporting the case of a 27-year-old male patient who presented with subacute onset of headache, nausea, vomiting, general weakness and fever lasting for two weeks prior to admission followed by altered mental status. CT of the head and fundoscopy were unremarkable. Cerebrospinal fluid (CSF) analysis revealed 13 cells, proteins 1.5 g/L. Screening for HIV was positive and he was transferred to the Clinic for Infectious Diseases, Sarajevo. HIV was confirmed, viral load was 98.800 copies/ml and absolute CD4 count 20/mm³. Repeated lumbar puncture (LP) revealed 30 cells, proteins 0.5 g/L, mild hypoglycorrhachia, CSF PCR positive for Cryptococcus neoformans. We started induction therapy with liposomal amphotericin B 3 mg/kgTT/day plus fluconazole 800 mg/day (due to unavailability of flucytosine) for 14 days followed by consolidation therapy with fluconazole 400 mg/day for 8 weeks. Maintenance therapy with oral fluconazole 200 mg/day is still on course. CSF sterilization achieved two weeks after starting antifungals. Antiretrovirals initiated six week after starting antifungals with regimen tenofovir disoproxil fumarate/emtricitabine plus dolutegravir. In resource limited settings antifungal therapy options remain a challenge for clinicians with the aim to achieve the best outcome with available drugs.