Abstract Details

Title Management of Refractory Elevated Intracranial Pressure (ICP) in an Immunocompetant Host with Cryptococcal Meningitis

Topic Infections/AIDS/Prion Disease

Presentation(s) P03 - (-)

Poster/Presentation
Number 249

Objective

Background BACKGROUND: There have been few cases of cryptococcal meningitis with associated ventriculitis in immunocompetent patients described in the literature. Refractory hydrocephalus is a major contributor to morbidity and mortality in cryptococcal meningitis. Our case demonstrates the importance of aggressive ICP management in addition to standard antifungal therapy.

Design/Methods DESIGN/METHODS: A case report of a 41 year-old male diagnosed with cryptococcal meningitis with refractory elevated ICP.

Results RESULTS: A 41 year-old male presented with headaches and diplopia. MRI brain demonstrated enhancement of the choroid plexus and hydrocephalus. LP revealed elevated opening pressure and CSF cryptococcal antigen was positive. No cause of immunosuppression was found. Despite aggressive management with daily CSF lumbar drainage, he required placement of an external ventricular device. A third ventriculostomy was attempted for CSF diversion but was unsuccessful due to anatomic distortion of the third ventricular floor. A right frontal ventriculoperitoneal shunt (VPS) was placed. One week later, he became confused and had worsening hydrocephalus. After several shunt revisions and a septal fenestration to facilitate ventricular communication, a left frontal VPS was placed and connected to his existing shunt via a biventricular system due to post-infectious ventricular entrapment. Several weeks later, he was readmitted with worsening headaches. Head CT revealed widening of the temporal horns, and a left temporal VPS was placed with return of his mental status to baseline. Three weeks later he developed left sided weakness. Head CT demonstrated a markedly widened right temporal horn and he had right temporal shunt placement. With four VP shunts in place, he remained clinical stable.

Conclusions CONCLUSIONS: Treatment of elevated ICP in patients with cryptococcal meningitis is critical to decreasing the morbidity and mortality of the condition. Aggressive management with multiple VPS was required in our case report.

Authors/Disclosures
Kiran Thakur, MD, FAAN (Columbia University College of Physicians and Surgeons) PRESENTER	Dr. Thakur has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Delve Bio.
Sheila Oren, MD, MBA (Neuroderm)	Sheila Oren, MD, MBA has received personal compensation for serving as an employee of Neuroderm. Sheila Oren, MD, MBA has received personal compensation in the range of $0-$499 for serving as a Consultant for Neuroderm.
	No disclosure on file
Sarah Wahlster, MD	Dr. Wahlster has nothing to disclose.
Khamidulla Bakhadirov, MD (Kaiser Permanente Medical Center)	No disclosure on file
	No disclosure on file
	No disclosure on file

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