Cryptococcal meningitis presenting as acute onset bilateral cerebellar infarct

Mishra, Ajay Kumar; Vanjare, Harshad Arvind; Raj, Promila Mohan

doi:10.4103/0976-3147.193537

Cited by 11 publications

(9 citation statements)

References 4 publications

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“…24,36,46 Adult studies have found that stroke is not common in HIV without an additional underlying disease state. 47 These disease states include infections including varicella zoster virus, 42 cryptococcus, 48,49 neurocysticercosis, 50 hepatitis B, 51 syphilis, 52 and tuberculosis, 53 as well as neoplastic and prothrombotic states. 47 Immune reconstitution syndrome 54 and ART may also contribute to cerebrovascular disease, with evidence for both protease inhibitors 55 and efavirenz 56 potentially contributing to cerebrovascular disease.…”

Section: Discussionmentioning

confidence: 99%

Brain Magnetic Resonance Imaging Findings Associated With Cognitive Impairment in Children and Adolescents With Human Immunodeficiency Virus in Zambia

Dean

Buda

Adams

et al. 2020

Pediatric Neurology

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Background: Cognitive impairment is common in children and adolescents with human immunodeficiency virus (HIV). Brain magnetic resonance imaging (MRI) is a potentially useful tool to investigate the pathophysiology of HIV-associated cognitive impairment and may serve as a biomarker in future clinical trials. There are few published data on brain imaging in children with HIV in sub-Saharan Africa. Methods: Thirty-four perinatally infected subjects with HIV and age-matched HIV-exposed uninfected controls between the ages nine and 17 years were recruited from the Pediatric Center of Excellence in Lusaka, Zambia, as part of the HIV-associated Neurocognitive Disorders in Zambia study. Brain MRI sequences were acquired, and clinical and volumetric assessments were performed. Subjects underwent a comprehensive neuropsychologic battery, and cognitive impairment status was classified using a global deficit score approach. Regression models were used to evaluate relationships between MRI findings and cognitive function. Results: We identified cerebrovascular disease in seven of 34 subjects with HIV compared with zero of 17 controls (21% vs 0%, P ¼ 0.04). We also identified decreased total brain volumes (1036 vs 1162 cm 3 , P ¼ 0.03) and decreased cortical thickness in the right temporal lobes (3.12 vs 3.29 mm; P ¼ 0.01) and right fusiform gyri (3.10 vs 3.25 mm; P ¼ 0.02) of HIV-infected subjects with cognitive impairment. Conclusions: These findings support the hypothesis that brain volumes may be useful biomarkers for cognitive outcomes in children with HIV. Further studies are necessary to investigate mechanisms of cerebrovascular disease and volume loss in children with HIV.

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Section: Discussionmentioning

confidence: 99%

Brain Magnetic Resonance Imaging Findings Associated With Cognitive Impairment in Children and Adolescents With Human Immunodeficiency Virus in Zambia

Dean

Buda

Adams

et al. 2020

Pediatric Neurology

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“…2,14 Other uncommon neurovascular manifestations that has been reported are bilateral cerebellar involvement, recurrent infarctions, and progressive vascular dementia. 9,18,19 Patients with CCM and infarcts are known to have high mortality and significant neurological deficit. 3 In our subgroup of patients, poor outcome was 50% higher among patients with infarcts and mortality was twice as compared to patients without infarct which is significantly higher than reported previously.…”

Section: Discussionmentioning

confidence: 99%

Cerebrovascular injury in cryptococcal meningitis

Mishra

Vanjare

Muliyil

et al. 2017

International Journal of Stroke

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Background Cryptococcal meningitis continues to be one of the common causes of chronic central nervous system infection worldwide. Individuals with cryptococcal meningitis can occasionally present with small vessel vasculitis causing infarcts primarily in the basal ganglia, internal capsule, and thalamus. Literature regarding patterns of cerebrovascular injury among patients with cryptococcal meningitis is scanty, and outcome following these vascular involvements is unknown. Aim To study the clinical profile, imaging findings, and details of vascular territory involved among patients admitted with cryptococcal meningitis and central nervous system infarct in a tertiary care center from India. And to compare the outcomes of patients of cryptococcal meningitis with or without central nervous system infarcts in terms of mortality and morbidity, Methodology A total of 151 patients with microbiologically proven cryptococcal meningitis over a time span of 11 years were retrospectively enrolled into the study. Of these, 66 patients met the inclusion criteria of having appropriate imaging of the brain. The presence of infarct in the imaging was analyzed by two independent radiologists. Patterns of central nervous system involvement and types of vascular injury were ascertained based on radiological parameters. Clinical parameters and outcomes of patients with and without infarcts were compared. Results Twenty (13%) of these patients had evidence of central nervous system infarcts on imaging. The mean age of patients with and without infarcts was 41 years and 38 years, respectively. Male predominance was present among both the groups. The presence of fever, neck stiffness, positive blood culture, and hydrocephalus in central nervous system imaging was similar among patients with or without infarct. Longer duration of illness, low sensorium at the time of presentation, low Glasgow Coma Scale score, presence of meningeal inflammation, cryptococcomas, and basal exudates in imaging were higher in patients with infarct. All the infarcts were of the lacunar type. Sixty percent of the cerebrovascular infarcts were acute in nature, 50% of these being multiple. Unilateral infarcts were seen in 70% of the patients. The most common site of infarct was the basal ganglia, others being distributed over the thalamus, frontal, temporal, parieto-occipital regions in the descending order. The presence of neurovascular involvement in the form of infarcts to the risk of morbidity and mortality had an odds ratio of 9.1 and 2.6, respectively. Conclusion Neurovascular involvement in chronic cryptococcal meningitis is a rare entity. These tend to present as multiple lacunar infarcts. Mortality and morbidity associated with these patients is higher when compared to patients who do not have infarcts. This result suggests that vascular injury plays a role in predicting outcome of patients with cryptococcal meningitis. Future studies are needed to understand the mechanism by which vascular events (infarcts) occur and result in poor outcome.

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“…These lacunar infarcts tend to be acute, unilateral and multiple with predominant periventricular distribution attributable to the involvement of circle of Willis by basal exudates of chronic meningitis. Other uncommon10 neurovascular manifestations include cerebellar involvement,11 recurrent infarctions and progressive vascular dementia.…”

Section: Discussionmentioning

confidence: 99%

Deceptively asymptomatic cryptococcaemia in a renal transplant recipient: the lull before a storm

et al. 2019

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Cryptococcal infection constitutes around 3% of opportunistic infections in solid organ transplant recipients. Most common organ affected in renal transplant recipients (RTRs) is central nervous system and usually presents with chronic meningoencephalitis (CME). Ischaemic stroke as a consequence of cryptococcal meningoencephalitisis rare and possibly due to the involvement of intracranial vessel by exudates causing vasculitis-related thrombosis. In this context, we describe an unusual case of asymptomatic cryptococcaemia in an RTR, progressing on to acute ischaemic stroke secondary to acute CME with near complete neurological recovery following timely diagnosis, early and appropriate antifungal treatment. The index case attempts to re-emphasise the significance of mandatory screening required to exclude the possibility of dissemination of cryptococcaemia in RTRs besides highlighting the requirement of prolonged induction phase with combination therapy, particularly in presence of stroke.

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Cryptococcal meningitis presenting as acute onset bilateral cerebellar infarct

Cited by 11 publications

References 4 publications

Brain Magnetic Resonance Imaging Findings Associated With Cognitive Impairment in Children and Adolescents With Human Immunodeficiency Virus in Zambia

Brain Magnetic Resonance Imaging Findings Associated With Cognitive Impairment in Children and Adolescents With Human Immunodeficiency Virus in Zambia

Cerebrovascular injury in cryptococcal meningitis

Deceptively asymptomatic cryptococcaemia in a renal transplant recipient: the lull before a storm

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