IMAGES IN CLINICAL MEDICINE
Cryptococcus neoformans Meningoencephalitis
Raul Recio, and Ana Perez-Ayala
N Engl J Med 2018; 379:281
DOI: 10.1056/NEJMicm1801051
A 36-year-old man presented to the emergency department with a 2-week history of fever, headache, drowsiness, and photophobia. He was previously healthy and was sexually active with men. The physical examination was notable for a temperature of 38.3°C and neck stiffness. Computed tomography of the head was normal. The opening pressure on lumbar puncture was 29 cm of water (reference range, <20 cm). The cerebrospinal fluid (CSF) cell count was 340 cells per microliter (reference range, 0 to 10), with 90% mononuclear cells, which were predominantly lymphocytes. The glucose level was 46 mg per deciliter (2.6 mmol per liter; reference range, 40 to 70 mg per deciliter [2.2 to 3.8 mmol per liter]), and the protein level was 0.80 g per liter (reference range, 0.15 to 0.45). Gram’s stain (Panel A) and India ink stain (Panel B) revealed abundant encapsulated, round yeasts, with some budding forms. The cryptococcal antigen titer was 1:128, and the CSF culture grew Cryptococcus neoformans. No other pathogen was detected. A test for the human immunodeficiency virus antibody was positive; the viral load was 300,000 copies per milliliter, and the CD4+ count was 7 cells per microliter (reference range, 500 to 1450). Induction therapy with liposomal amphotericin B and flucytosine was started, and resolution of symptoms and negative results on CSF culture were noted after 2 weeks of treatment. Consolidation therapy with fluconazole was started, and antiretroviral therapy was later prescribed.
一名36岁男性患者因发热、头痛、嗜睡及畏光2周到急诊科就诊。患者既往健康，是同性恋患者。体格检查发现，体温38.3°C，颈项强直。头颅CT正常。腰穿初压 29 cmH2O（正常值<20 cm）。脑脊液(CSF)细胞计数340/ml（正常值0 to 10），单核90%，主要为淋巴细胞。糖 46 mg/dl（2.6 mmol/L；正常值 40 to 70 mg/dl [2.2 to 3.8 mmol/L]），蛋白 0.80 g/L（正常值0.15 to 0.45）。革兰染色（图A）及墨汁染色（图B）显示大量有包膜的圆形酵母菌，部分成出芽状。隐球菌抗原滴度1:128，CSF培养分离到新型隐球菌。未发现其他致病微生物。HIV抗体检测结果阳性；病毒载量300,000拷贝/ml，CD4细胞计数 7/ml（正常值500 to 1450）。开始进行脂质体两性霉素B和氟胞嘧啶的诱导治疗，2周后临床症状消失，CSF培养转阴。随后进行氟胞嘧啶的巩固治疗，并进行抗逆转录病毒治疗。
