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A Case Report of a Brain Herniation Secondary to Cryptococcal Meningitis with Elevated Intracranial Pressure in a Patient with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)
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Journal of Clinical Case Reports

ISSN: 2165-7920

Open Access

Case Report - (2022) Volume 12, Issue 5

A Case Report of a Brain Herniation Secondary to Cryptococcal Meningitis with Elevated Intracranial Pressure in a Patient with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)

Nehemias Guevara1*, Abdulrasheed Akande1, Mailing Flores Chang1, Jane Atallah1 and Carol Epstein2
*Correspondence: Nehemias Guevara, Department of Medicine, Internal Medicine, St. Barnabas Hospital Health System, The Bronx,NY, USA, Tel: +3236188035, Email:
1Department of Medicine, Internal Medicine, St. Barnabas Hospital Health System, The Bronx,NY, USA
2Department of Infectious Disease, Internal Medicine, St. Barnabas Hospital Health System, The Bronx,NY, USA

Received: 25-May-2022, Manuscript No. jccr-22-64817; Editor assigned: 27-May-2022, Pre QC No. P-64817; Reviewed: 07-Jun-2022, QC No. Q-64817; Revised: 11-Jun-2022, Manuscript No. R-64817; Published: 18-Jun-2022 , DOI: 10.37421/2165-7920.2022.12.1506
Citation: Guevara, Nehemias, Abdulrasheed Akande, Mailing Flores Chang and Jane Atallah, et al. “A Case Report of a Brain Herniation Secondary to Cryptococcal Meningitis with Elevated Intracranial Pressure in a Patient with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS).” Clin Case Rep 12 (2022): 1506.
Copyright: © 2022 Guevara N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Background: Cryptococcal meningitis is a major opportunistic infection in individuals with HIV. The worldwide annual incidence is estimated to be approximately one million cases per year, with the most significant burden in sub-Saharan Africa. HIV-associated cryptococcal meningitis continues to have a high mortality rate despite widespread availability and use of HAART.

Case: 36-year-old male with a past medical history of AIDS and a CD4 count of 35 cells/mm3 presented with altered mental status initially thought to be related to using crystalline methamphetamine as reported by EMS. However, a lumbar puncture performed in the emergency department showed elevated CSF opening pressure of 29 cm H2O and positive CSF and serum cryptococcal antigen. The patient was admitted and commenced treatment according to the current IDSA guideline but continued to have waxing and waning mental status. On the fourth day of admission, he complained of headache, had a witnessed seizure, and was taken emergently for a CT scan of the brain, which was negative for any acute intracranial process. The patient was planned for a repeat lumbar puncture but suffered a cardiac arrest before it could be done. He was intubated and transferred to the intensive care unit. CT brain follow-up showed anoxic encephalopathy, development of marked cerebral edema, and complete effacement of the basilar cisterns, suggestive of downward transtentorial herniation; he continued to deteriorate and expired on the seventh day of admission.

Objectives: 1) Describe a case of brain death secondary to increased intracranial pressure due to cryptococcal meningitis in a patient with HIV/ AIDS. 2) Explain the mechanisms of elevation in intracranial pressure in patients with cryptococcal meningitis. 3) Discuss the options for managing elevated intracranial pressure in patients with cryptococcal meningitis. 4) Create awareness in the medical community about the importance of prompt and efficient management of increased intracranial pressure in patients with cryptococcal meningitis.

Conclusion: This case highlights the importance of aggressive management of elevated intracranial pressure in cryptococcal meningitis. It reiterates the need for more data regarding the optimal timing and frequency of therapeutic lumbar puncture and the use of temporary lumbar drainage catheters and ventriculostomy to manage this potentially fatal complication.

Keywords

AIDS • HIV • Cryptococcus • Meningitis • Intracranial pressure • Treatment

Introduction

Cryptococcus is encapsulated, environmental yeast with two main species responsible for most infections in humans [1]. Cryptococcus neoformans and Cryptococcus gattii are transmitted via inhalation of the fungus and spread hematogenously with a preference for the central nervous system where they cause cryptococcal meningoencephalitis [1]. C. gattii classically causes illness in immunocompetent individuals and was associated with an outbreak of cryptococcosis on Vancouver Island Cryptococcus neoformans is a leading cause of infection in immunocompromised hosts [2]. Risk factors include HIV infection, solid organ transplantation using immunosuppressants, sarcoidosis, cirrhosis, and systemic lupus erythematosus [3].

Cryptococcal meningitis due to Cryptococcus neoformans is a major opportunistic infection in individuals with HIV/AIDS, particularly if the CD4 count is less than 100 cells/mm3 [4].

The condition is more prevalent in sub-Saharan Africa but occurs even in developed countries like the United States. The worldwide annual incidence is estimated to be approximately one million cases per year, with the most significant burden in sub-Saharan Africa [1]. Mortality from HIV-associated cryptococcal meningitis remains high despite the widespread availability of HAART [5]. In the hospital, mortality from cryptococcal meningitis is estimated to be between 30% - 50% despite treatment with antifungal agents [6].

A common life-threatening complication of cryptococcal meningitis in HIV patients is raised Intracranial Pressure (ICP) greater than 25 cm H2O. Elevated ICP may be asymptomatic at the time of diagnosis or may be associated with symptoms like headache, vomiting, confusion, loss of vision, hearing impairment, or even death [7]. One of the key principles in the treatment of cryptococcal meningitis is the management of elevated ICP, as it has been shown in studies to be an important determinant of treatment outcome [8]. Rolfes, et al. reported that therapeutic lumbar punctures were associated with a 69% relative improvement in survival in 248 patients with HIV-associated cryptococcal meningitis in Uganda and South Africa. Several other studies have reported a survival benefit with aggressive management of elevated ICP until pressures have normalized. Despite these findings and treatment guidelines recommending aggressive ICP management in cryptococcal meningitis, there is no consensus regarding the optimal timing and frequency of therapeutic lumbar puncture [4,8].

We report the fatal case of a patient with HIV-associated cryptococcal meningitis and raised ICP and examine the role of frequent therapeutic lumbar punctures in the management elevated ICP which is a cause of significant morbidity and mortality in cryptococcal meningitis.

Case Narrative

36-year-old male with a past medical history of the Human Immunodeficiency Virus (HIV) with Acquired Immunodeficiency Syndrome (AIDS) (poor Highly Active Antiretroviral Therapy (HAART)), major depressive disorder, and unspecified psychotic disorder comes to the Emergency Department (ED) after being found with altered mental status, vital signs on arrival to ED were blood pressure of 158/93 mmHg, Heart Rate (HR): 86 beats/ minute, Respiratory Rate (RR): 18 breaths/minute, O2 saturation 96% on room air, temperature 97.9 F. On physical examination, pupils 3 mm reactive to light bilaterally, no cervical adenopathies, lungs were clear to auscultation, heart sounds were normal, no murmurs, abdomen soft and non-tender, moving all extremities with no focal deficits.

Social history was notable for crystal meth use. Initial blood work was remarkable for leukopenia, mild hyponatremia, and mild elevation of transaminases (Table 1). CT brain was negative for any acute intracranial abnormality (Figure 1). After 12 hours of observation in the ED patient had worsening agitation, groaning, and speaking nonsensical words with a mild grade fever of 100.9 F and sinus tachycardia for which lumbar puncture was done (Table 2) opening pressure was 29 mmHg and serum cryptococcal antigen and RPR was positive (Table 3). The patient was started on amphotericin B liposomal + flucytosine. Cryptococcal meningitis and cryptococcemia diagnoses were made.

Table 1: Laboratory data.

Variables On Admission Reference Range
White cell count 3.8 4.2-9.1 10*3/uL
Neutrophils 53.60% 34.0-67.9%
Lymphocytes 22.70% 21.8-53.1%
Monocytes 12.00% 5.3-12.2%
Eosinophils 0.00% 0.8-7.0%
Hemoglobin 13.9 13.7-17.5 gm./dL
Hematocrit 42.6 40.1-51.0%
Platelet count 206 150-450 10*3/uL
MCV 88.9 79.0-92.2 fL
MCH 29 25.7-32.2 pg
MCHC 32.6 32.3-36.5 gm/dL
Sodium 133 135-145 mEq/L
Potassium 3.8 3.5-5.3 mEq/L
Chloride 98 96-108 mEq/L
Glucose 123 70-99 mg/dL
Calcium 9.4 9.2-11.0 mg/dL
Creatinine 1 0.6-1.2 mg/dL
ALT 37 4-36 IU/L
AST 46 8-33 IU/L
Bilirubin total 0.7 0.1-1.2 mg/dL
TSH 0.95 0.34-5.60 u[IU]/mL
Magnesium 1.9 1.3-2.1 mEq/L
clinical-case-reports-brain

Figure 1. Initial CT brain.

Table 2: Cerebrospinal fluid analysis.

Variables Result Reference Range
Color Pink Colorless
Appearance Clear Clear
Xantocromía Negative Negative
WBC 10 0-5/mm3
RBC 8165 0-0/mm3
Neutrophil 3 0-6%
Lymphocyte 84 40-80%
Monocyte 7 15-45%
Macrophage 6 %
Other
Cryptococcus Present
Glucose 41 40-70 mg/dL
Protein 78 15-45 mg/dL
Cryptococcal antigen Positive-1:1280 -
Culture CSF Cryptococcus neoformans -
Acid fast bacilli culture No growth -
Fungal culture No fungus isolated -
India Ink preparation Positive for Cryptococcus neoformans -

Table 3: Other laboratory results.

Variables Result Reference Range
Serum cryptococcal antigen Positive-1:640 -
RPR Reactive – 1:32 -
LDH 937 100-190 IU/L
Procalcitonin 0.07 0.00-0.08 ng/mL
Absolute CD4 helper count 35 359-1519 /uL
Urine toxicology:
Barbiturates Negative -
Benzodiazepines Negative -
Cocaine Negative -
Opiates Negative -
THC Negative -

The hospitalization course was complicated by worsening mental status and developing seizures just before the second planned lumbar puncture, which was never done because the patient presented bradycardia progressively until the cardiac arrest. The patient arrested two times with achievement of return of spontaneous circulation within 4 minutes and 2 minutes, respectively. Posterior neurology evaluation was remarkable by the absence of any cerebral or brainstem function. CT brain was repeated, which reported anoxic encephalopathy, development of marked cerebral edema, and complete effacement of the basilar cisterns, suggestive of downward transtentorial herniation (Figure 2) Brain death determination test was by clinical examination and apnea testing, which confirmed death by neurological criteria.

clinical-case-reports-ct-brain

Figure 2. Follow up CT brain.

Discussion

Cryptococcus neoforman is a ubiquitous encapsulated yeast-like fungus. Risk factors for developing symptomatic cryptococcosis include HIV infection with low CD4+ lymphocyte count (<50 cells/mm3), malignancy (chronic leukemia, lymphoma), steroids treatment, organ transplantation, and sarcoidosis [9].

Cryptococcal meningitis is one of the most prevalent opportunistic infections in patients with HIV/AIDS, aiming for approximately 220,000 cases of cryptococcal meningitis worldwide per year, resulting in nearly 181,000 deaths, even though most of these cases are reported in sub-Saharan Africa, have been demonstrated a prevalence of cryptococcal antigenemia to be 2.9% in the USA [10,11]. We are reporting the tragic death of a young male who was admitted with cryptococcal meningitis, and in their large multicenter trial, the NIAID Mycoses.

The mechanism for which C. neoformans increase the intracranial pressure is still poorly understood, however, it has been shown that it is caused due to the significant burden of yeast and polysaccharides that plugs the arachnoid villi [12-14]. Therefore, there exists a positive correlation between the number of organisms and the size of the polysaccharide capsule with the increase in the ICP [14,15]. The factors that have been identified by the Study Group and the AIDS Clinical Trials Group that showed predictive of high mortality during antimycotic therapy were: 1) Cerebrospinal Fluid (CSF) cryptococcal antigen titer greater than 1:1024; 2) abnormal mental status, 3) and a low CSF leukocyte count with high ICP [16,17]. Our patient presented with all of these characteristics, arriving with altered mental status, high intracranial pressure (290), antigen titer 1:1280 with low WBC (10) in the CSF.

Furthermore, an increase in intracranial pressure in patients with cryptococcal meningitis is still one of the most deadly complications, and even though antifungal treatment has improved, intracranial pressure treatment is still a gray area.

Current treatment for cryptococcal meningitis is divided into 2 phases, first is induction with amphotericin B (0.7-1 mg/kg/d) plus flucytosine (100 mg/kg/d for two weeks) and then followed by fluconazole (400 mg/d) for a minimum of 10 weeks, after ten weeks with fluconazole this can be reduced 200 mg/d, depend on patient clinical status, alternative regimens are available as well, and in a patient with renal impairment lipid formulations of Amphotericin B are available and preferred [18,19].

Our patient was started on Amphotericin B liposomal (due to AKI at admission) and flucytosine.

Use of steroids, acetazolamide, and mannitol in the setting of increased ICP due to cryptococcal meningitis is not recommended [20-24].

Multiple clinical trials are ongoing regarding the use of steroids in cryptococcal meningitis, with promising results, but at the moment are still not recommended as an adjunct therapy [25-27].

Management of ICP in the setting of cryptococcal meningitis is still a challenge with high mortality, morbidities, and severe immediate and later complications such as strokes, blinds (either the direct spread of inflammation to the optic nerves (optic neuritis), or compressive optic neuropathy secondary to raised ICP) and several other, however, brain herniation, is the most deadly complication of cryptococcal meningitis, even after the resolution of the disease, some studies have shown the patients that presented cryptococcal meningitis with an elevation of ICP increase the risk of dying at one year after the first presentation, and overall crucial and independent factors for poor prognosis in patients with CM [28-32].

Some studies have shown the mortality of CM in patients with HIV/AIDS can be higher as 50% in the first two weeks after the diagnosis, this could be associated with the increase in the burden of the cryptococcus after the initiation of the treatment and subsequent increase in ICP, the reason why close monitoring of any signs in clinical deterioration, change in mental status is recommended, especially is open pressure of the intracranial pressure was increased since the beginning of the CM [33,34].

Current treatments for high ICP include serial LP and shutting [35,36]. As part of treatment for increased ICP, Lumbar puncture is based on clinical manifestations and has shown survival improvement in different studies and the benefit of aggressive LP as treatment is greatest. Then the concern is the risk of the herniation that has been described as well [34,37-39]. The cut-off for LP as part of the treatment is open pressure of more than 250, which has decreased mortality and better outcomes, and the goal should be to keep open pressure <200. The frequency is unclear based on the clinical assessment [12,31,33,34,40].

Alternative therapeutics approaches such as CSF shunting through a lumbar drain or ventriculostomy are available and should be considered for patients when LP is not well tolerated, or symptoms worsen even with repetitive LP, sudden decline in mental status, or evidence of hydrocephalus [41-44].

Unfortunately, our patient died, and the second LP never was possible to be done. Further imaging studies showed anoxic encephalopathy, development of marked cerebral edema, and complete effacement of the basilar cisterns, suggestive of downward transtentorial herniation. (Figure 2) Brain death determination test was by clinical examination and apnea testing, which confirmed death by neurological criteria.

Regarding the timeline to start HAART, it has been proved to delay the initiation of the HAART prevents Immune Reconstitution Inflammatory Syndrome (IRIS) and decreases mortality six months after initiating HAART, it is recommended to start HAART therapy 4 to 6 weeks after antifungal agents are initiated, and CSF should be clear at the time.

Conclusion

Highlights the importance of aggressive management of elevated intracranial pressure in cryptococcal meningitis. It reiterates the need for more data regarding the optimal timing and frequency of therapeutic lumbar puncture, use of temporary lumbar drainage catheter and ventriculostomy in the management of this potentially fatal complication.

References

  1. Sloan, Derek J. and Victoria Parris. "Cryptococcal meningitis: Epidemiology and therapeutic options." Clin Epidemiol 6 (2014): 169-182.
  2. Google Scholar, Crossref, Indexed at

  3. Kidd, Sarah Elizabeth, F. Hagen, R.L. Tscharke and M. Huynh, et al. "A rare genotype of Cryptococcus gattii caused the cryptococcosis outbreak on Vancouver Island (British Columbia, Canada)." Proc Natl Acad Sci USA 101 (2004): 17258-17263.
  4. Google Scholar, Crossref, Indexed at

  5. Henao-Martínez, Andrés F., Lilyana Gross, Bryan Mcnair, Bruce McCollister, et al. "Risk factors for cryptococcal meningitis: A single United States center experience." Mycopathologia 181 (2016): 807-814.
  6. Google Scholar, Crossref, Indexed at

  7. Guidelines for the diagnosis, prevention, and management of cryptococcal disease in HIV-infected adults, adolescents and children. (2022).
  8. Skipper, Caleb, Mahsa Abassi, and David R. Boulware. "Diagnosis and management of central nervous system cryptococcal infections in HIV-infected adults." J Fungi Basel Switz 5 (2019): 65.
  9. Google Scholar, Crossref, Indexed at

  10. Abassi, Mahsa, David R. Boulware and Joshua Rhein. "Cryptococcal meningitis: Diagnosis and management update." Curr Trop Med Rep 2 (2015): 90-99.
  11. Google Scholar, Crossref, Indexed at

  12. Rolfes, Melissa A., Kathy Huppler Hullsiek, Joshua Rhein and Henry W. Nabeta, et al. "The effect of therapeutic lumbar punctures on acute mortality from cryptococcal meningitis." Clin Infect Dis 59 (2014): 1607-1614.
  13. Google Scholar, Crossref, Indexed at

  14. Perfect, John R., William E. Dismukes, Francoise Dromer and David L. Goldman, et al. "Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america." Clin Infect Dis 50 (2010): 291-322.
  15. Google Scholar, Crossref

  16. Gambarin, Kimberly J., and Richard J. Hamill. "Management of increased intracranial pressure in cryptococcal meningitis." Curr Infect Dis Rep 4 (2002): 332-338.
  17. Google Scholar, Crossref, Indexed at

  18. C. neoformans Infection Statistics.” Fungal Diseases, CDC. (2020).
  19. Jemal, Mohabaw, Teshiwal Deress, Teshome Belachew and Yesuf Adem. "Prevalence of cryptococcal antigenemia and associated factors among HIV/AIDS patients at felege-hiwot referral hospital, Bahir Dar, northwest Ethiopia." Int J Microbiol 2021 (2021): e8839238.
  20. Google Scholar, Crossref, Indexed at

  21. Denning, David W., Robert W. Armstrong, Bradley H. Lewis and David A. Stevens. "Elevated cerebrospinal fluid pressures in patients with cryptococcal meningitis and acquired immunodeficiency syndrome." Am J Med 91 (1991): 267-272.
  22. Google Scholar, Crossref, Indexed at

  23. Fine Structure of Cerebral Fluid Accumulation: V. “Transfer of Fluid From Extracellular to Intracellular Compartments in Acute Phase of Cryptococcal Polysaccharide Lesions.” JAMA Neurol, JAMA Network. (2022).
  24. Loyse, Angela, Helen Wainwright, Joseph N. Jarvis and Tihana Bicanic, et al. "Histopathology of the arachnoid granulations and brain in HIV-associated cryptococcal meningitis: Correlation with cerebrospinal fluid pressure." AIDS 24 (2010): 405-410.
  25. Google Scholar, Crossref, Indexed at

  26. Robertson, Emma J., Grace Najjuka, Melissa A. Rolfes and Andrew Akampurira, et al. "Cryptococcus neoformans ex vivo capsule size is associated with intracranial pressure and host immune response in HIV-associated cryptococcal meningitis." J Infect Dis 209 (2014): 74-82.
  27. Google Scholar, Crossref, Indexed at

  28. Lee, Su Jin, Hee Kyoung Choi, Jungmin Son and Kye Hyung Kim, et al. "Cryptococcal meningitis in patients with or without human immunodeficiency virus: experience in a tertiary hospital." Yonsei Med J 52 (2011): 482-487.
  29. Google Scholar, Crossref, Indexed at

  30. Saag, Michael S., William G. Powderly, Gretchen A. Cloud and Patrick Robinson, et al. "Comparison of amphotericin B with fluconazole in the treatment of acute AIDS-associated cryptococcal meningitis." N Engl J Med 326 (1992): 83-89.
  31. Google Scholar, Crossref, Indexed at

  32. Saag, Michael S., Richard J. Graybill, Robert A. Larsen and Peter G. Pappas, et al. "Practice guidelines for the management of cryptococcal disease." Clin Infect Dis 30 (2000): 710-718.
  33. Google Scholar, Crossref

  34. Thompson, Melanie A., Michael A. Horberg, Allison L. Agwu and Jonathan A. Colasanti, et al. "Primary care guidance for persons with human immunodeficiency virus: 2020 update by the HIV medicine association of the infectious diseases society of America." Clin Infect Dis 73 (2021): e3572-e3605.
  35. Google Scholar, Crossref

  36. Doblecki-Lewis, Susanne, Stephanie Cohen, and Albert Liu. "Clinical treatment options infectious diseases: Update on PrEP implementation, adherence, and advances in delivery." Curr Treat Options Infect Dis 7 (2015): 101-112.
  37. Google Scholar, Crossref, Indexed at

  38. Newton, Paul N., Le Hung Thai, Nguyen Quoc Tip and Jennifer M. Short, et al. "A randomized, double-blind, placebo-controlled trial of acetazolamide for the treatment of elevated intracranial pressure in cryptococcal meningitis." Clin Infect Dis 35 (2002): 769-772.
  39. Google Scholar, Crossref, Indexed at

  40. Beardsley, Justin, Marcel Wolbers, Freddie M. Kibengo and Abu-Baker M. Ggayi, et al. "Adjunctive dexamethasone in HIV-associated cryptococcal meningitis." N Engl J Med 374 (2016): 542-554.
  41. Google Scholar, Crossref, Indexed at

  42. World Health Organization. Regional Office for South-East Asia. Regional Dissemination Workshop on Guidelines for HIV and Hepatitis B & C, New Delhi, India, 09 - 11 May 2018. World Health Organization. Regional Office for South-East Asia; 2018. (2022).
  43. National Institute of Allergy and Infectious Diseases (NIAID). Dexamethasone in cryptococcal meningitis. clinicaltrials.gov. (2021).
  44. Day, Jeremy, Darma Imran, Ahmed Rizal Ganiem and Natriana Tjahjani, et al. "CryptoDex: A randomised, double-blind, placebo-controlled phase III trial of adjunctive dexamethasone in HIV-infected adults with cryptococcal meningitis: Study protocol for a randomised control trial." Trials 15 (2014): 441.
  45. Google Scholar, Crossref, Indexed at

  46. Flucytosine completed phase 2 trials for meningitis, cryptococcal/human immunodeficiency virus (HIV) infections treatment. DrugBank Online. (2022).
  47. Martin-Blondel, Guillaume, Pierre Delobel, Antoine Blancher and Patrice Massip, et al. "Pathogenesis of the immune reconstitution inflammatory syndrome affecting the central nervous system in patients infected with HIV." Brain J Neurol 134 (2011): 928-946.
  48. Google Scholar, Crossref, Indexed at

  49. Ng, C.W., M.S. Lam and N.I.J. Paton. "Cryptococcal meningitis resulting in irreversible visual impairment in AIDS patients-a report of two cases." Singapore Med J 41 (2000): 80-82.
  50. Google Scholar, Indexed at

  51. Zhu, Li-Ping, Ji-Qin Wu, Bin Xu and Xue-Ting Ou, et al. "Cryptococcal meningitis in non-HIV-infected patients in a Chinese tertiary care hospital, 1997–2007." Med Mycol 48 (2010): 570-579.
  52. Google Scholar, Crossref, Indexed at

  53. Loye, Ayomide, Onyinye Gabriel, and Xiao Chi Zhang. "A case report: tragic death in a young patient with human immunodeficiency virus due to cryptococcal meningitis." Cureus 11 (2019): e4652.
  54. Google Scholar, Crossref, Indexed at

  55. Terada, Tadashi. "Cryptococcosis in the central nervous system in a 36-year-old Japanese man: An autopsy study." Tohoku J Exp Med 222 (2010): 33-37.
  56. Google Scholar, Crossref, Indexed at

  57. Brouwer, Annemarie E., Adul Rajanuwong, Wirongrong Chierakul and George E. Griffin, et al. "Combination antifungal therapies for HIV-associated cryptococcal meningitis: A randomised trial." Lancet Lond Engl 363 (2004): 1764-1767.
  58. Google Scholar, Crossref, Indexed at

  59. Graybill, John R., Jack Sobel, Michael Saag and Charles Van Der Horst, et al. "Diagnosis and management of increased intracranial pressure in patients with AIDS and cryptococcal meningitis." Clin Infect Dis 30 (2000): 47-54.
  60. Google Scholar, Crossref, Indexed at

  61. Fessler, Richard D., Jack Sobel, Lisa Guyot and Lawrence CrJoane, et al. "Management of elevated intracranial pressure in patients with Cryptococcal meningitis." J Acquir Immune Defic Syndr Hum Retrovirol 17 (1998): 137-142.
  62. Google Scholar, Crossref, Indexed at

  63. Bollela, Valdes Roberto, G. Frigieri, F.C. Vilar and D.L. Spavieri, et al. "Noninvasive intracranial pressure monitoring for HIV-associated cryptococcal meningitis." Braz J Med Biol Res 50 (2017): e6392.
  64. Google Scholar, Crossref, Indexed at

  65. Shetty, Avinash K., Bonnie C. Desselle, Randall D. Craver, and Russell W. Steele. "Fatal cerebral herniation after lumbar puncture in a patient with a normal computed tomography scan." Pediatrics 103 (1999): 1284-1287.
  66. Google Scholar, Crossref, Indexed at

  67. Antinori, Spinello, Anna Lisa Ridolfo, Erica Gianelli and Manuela Piazza, et al. "The role of lumbar puncture in the management of elevated intracranial pressure in patients with AIDS-associated cryptococcal meningitis." Clin Infect Dis 31 (2000): 1309-1311.
  68. Google Scholar, Crossref, Indexed at

  69. Kambugu, Andrew, David B. Meya, Joshua Rhein and Meagan O'Brien, et al. "Outcomes of cryptococcal meningitis in Uganda before and after the availability of highly active antiretroviral therapy." Clin Infect Dis 46 (2008): 1694-1701.
  70. Google Scholar, Crossref, Indexed at

  71. Cryptococcosis.” NIH. (2022).
  72. Sun, Hsin-Yun, Chien-Ching Hung, and Shan-Chwen Chang. "Management of cryptococcal meningitis with extremely high intracranial pressure in HIV-infected patients." Clin Infect Dis 38 (2004): 1790-1792.
  73. Google Scholar, Crossref, Indexed at

  74. Cherian, Jacob, Robert L. Atmar and Shankar P. Gopinath. "Shunting in cryptococcal meningitis." J Neurosurg 125 (2016): 177-186.
  75. Google Scholar, Crossref

  76. Rajasingham, Radha, Rachel M. Smith, Benjamin J. Park and Joseph N. Jarvis, et al. "Global burden of disease of HIV-associated cryptococcal meningitis: an updated analysis." Lancet Infect Dis 17 (2017): 873-881.
  77. Google Scholar, Crossref, Indexed at

  78. Boulware, David R., David B. Meya, Conrad Muzoora, Melissa A. Rolfes, et al. "Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis." N Engl J Med 370 (2014): 2487-2498.
  79. Google Scholar, Crossref, Indexed at

  80. Chang, Christina C., Afton A. Dorasamy, Bernadett I. Gosnell and Julian H. Elliott, et al. "Clinical and mycological predictors of cryptococcosis-associated immune reconstitution inflammatory syndrome." AIDS Lond Engl 27 (2013):2089-2099.
  81. Google Scholar, Crossref, Indexed at

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