Title : Double Trouble: Co-infection with Cryptococcal Meningitis and Japanese Encephalitis
Abstract:
Background: Cryptococcal meningitis (CM) is the most common central nervous system infection (CNSI) among patients with severe immunodeficiency syndrome secondary to human immune deficiency virus. Co-infection with other CNSI is relatively common especially with TB meningitis and neurosyphilis however, there was no reported case of co-infection with Japanese encephalitis (JE).
Case Presentation: A 51-year-old female from Nueva Vizcaya Municipality was admitted in the emergency room with a chief complaint of change in behavior with a notable exposure to domesticated chickens. The patient was admitted a week before in a local hospital due to intermittent severe diffuse headache associated with high-grade fever, nausea, and vomiting. Physical examination showed akinetic mutism, no frontal release signs, no craniopathies, no weakness, positive nuchal rigidity, Kernig’s and Brudzinki’s signs.
Laboratory test results are as follows: lymphocytopenia, high c-reactive protein and Erythrocyte Sedimentation Rate. Serum electrolytes, liver biochemistry, and creatinine were unremarkable.
Lumbar puncture showed an elevated opening pressure with no pleocytosis, a low glucose ratio and an elevated protein level. CSF PCR for other notable viruses, acid-fast staining, and Gene Xpert were negative. CSF Cryptococcal Antigen Latex Agglutination System (CALAS) and CSF IgM-capture ELISA for JE showed confirmatory results with seronegative result for HIV.
Electroencephalogram revealed a cortical-subcortical dysfunction. Cranial MRI showed nodular hyper-intensity on the right temporal area in T2-Flair and peripheral nodular enhancement post contrast. She was managed with a meningitic dose of Ceftriaxone and was later on shifted to liposomal amphotericin B and flucytosine as induction therapy. During her hospital stay, her blood culture revealed methicillin-resistant Staphylococcus aureus- mecA gene positive was noted on blood A and B subsequently, intravenous antibiotics were immediately started. Unfortunately, she died of respiratory failure and septic shock after a month of admission.
Discussion: Cryptococci infection is persistently common in males in both seronegative and seropositive HIV patients. Cryptococcus species are frequently present in territories associated with wood debris, soil, and bird excreta (usually pigeon droppings and chicken manure) (5). The estimated mortality rate of cryptococcal meningitis in a recent study conducted in Wuhan, China was 35% (36/103). JE is a vector-borne disease transmitted by Culex mosquitoes. In the Philippines, cases were recorded since 2017 in Nueva Vizcaya. Cryptococcus species are frequently present in territories associated with wood debris, soil, and bird excreta (usually pigeon droppings and chicken manure). The estimated mortality rate of cryptococcal meningitis in a recent study conducted in Wuhan, China was 35% (36/103).
The sensitivity and specificity of CALAS in detecting CM were 98-100%. Using IgM-captured ELISA in detecting JE offers sensitivity and specificity of 98% and 99% respectively. Among these mentioned microorganisms, there was no recorded cross-reactivity during testing.
Conclusion: The coexistence of two lethal types of central nervous system infection is indicative of a poorer outcome based on the reported individual mortality rates of JE and CM. Here we present a case of an immunocompetent host with a dual infective pathology which resulted in an unfavorable outcome.
Audience take away:
- The audience will learn the possible outcome a patient with Cryptococcal Meningitis and Japanese Encephalitis co-infection.
- This scenario will help other doctors recognize this type of co-infection and to possibly manage it in a more effective manner.
- The audience could expand other co-infections in terms of neurologic infectious diseases and their possible outcomes.
