Cryptococcal meningoencephalitis in a patient with HIV infection: critical analysis of diagnosis and treatment

Introduction. Cryptococcal meningitis remains one of the most lethal opportunistic infections in patients with HIV, with mortality rates ranging from 30% to 75% depending on geographic region and timeliness of treatment initiation. Timely diagnosis is challenging due to nonspecific clinical presentation and absence of classic meningeal signs in the majority of patients, requiring high clinical suspicion when managing patients with profound immunosuppression.

Objective. To conduct a prospective analysis of a clinical case of cryptococcal meningoencephalitis in a patient with profound immunosuppression due to HIV infection, with critical evaluation of diagnostic and therapeutic approaches, identification of systemic problems, and formulation of practical recommendations to prevent similar cases in the future.

Materials and methods. A detailed retrospective analysis of medical documentation was performed for a 46-year-old male patient with HIV infection stage 4B receiving antiretroviral therapy. The patient was admitted to a regional infectious disease hospital with complaints of cephalgia, fever, and altered consciousness. Comprehensive laboratory and instrumental examination was performed, including four lumbar punctures with cerebrospinal fluid analysis, magnetic resonance and computed tomography of the brain, and immunological studies. Consultations with related specialists were conducted, including telemedicine consultation with a federal center.

Results. Despite comprehensive examination and ongoing treatment including antimycotic therapy, the patient died 27 days after admission due to progressive cerebral edema secondary to cryptococcal meningoencephalitis. The diagnosis of cryptococcal infection was confirmed only at the third lumbar puncture, resulting in a 19-day delay in specific therapy. Critical deficiencies in patient management were identified, including suboptimal dosing of antifungal agents and absence of amphotericin B administration—the first-line drug for cryptococcal meningitis treatment.

Conclusion. This clinical case convincingly demonstrates the necessity of implementing routine screening for cryptococcal antigen in patients with CD4+ lymphocyte counts below 100 cells/μL, performing repeat cerebrospinal fluid examinations when initial results are negative in the setting of persistent high clinical suspicion, and strict adherence to recommended doses of antimycotic agents from the first days of suspected cryptococcal infection. Critical analysis of diagnostic and therapeutic errors enables formulation of specific practical recommendations for improving outcomes in this extremely vulnerable patient population. 

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