Immune reconstitution inflammatory syndrome in cryptococcal meningitis - a rare phenomenon?

Immune reconstitution inflammatory syndrome in cryptococcal meningitis - a rare phenomenon? History and admission findings: A 38-year old patient with previously untreated HIV infection presented with progressive cephalgia, photophobia, polydpsia and nausea/vomiting. Investigations: Clinical findings revealed a reduced general state of health and focal neurological deficits. Laboratory findings demonstrated a lymphocytopenia. In addition to positive crytococcus culture and antigen titer in cerebrospinal fluid/serum, Cryptococcus neoformans was detected by light microscopy (India ink stain) in cerebrospinal fluid. Diagnosis, treatment and course: A cryptococcal meningitis was diagnosed. After initiating antifungal and antiretroviral treatment the clinical course worsened after months 2, 3, and 5, respectively. Apart from unspecific inflammation in the lab work, no signs of disease relapse or therapy refractory course were found in additional diagnostics. After critical evaluation of the clinical course and diagnostic results, immune reconstitution inflammatory syndrome (IRIS) was diagnosed. Clinical improvement was achieved during adjuvant treatment with steroids within six months. Conclusions: In the presence of neurological symptoms, cryptococcal meningitis is a rare but possible differential diagnosis in daily routine. Diagnosis can be easily achieved by India ink stain in combination with culture of cerebrospinal fluid as well as antigen detection in most cases. Tests of antifungal resistance should be reserved for patients who do not respond to initial treatment, patients with atypical course of disease or failing longterm antifungal therapy. The IRIS is no rare complication after initiation of antiretroviral treatment in HIV associated cryptococcal infections. It is an important differential diagnosis in an atypical course of disease, and sufficient treatment is usually achieved by steroids.