PMID- 30326861 OWN - NLM STAT- MEDLINE DCOM- 20181211 LR - 20220129 IS - 1471-2334 (Electronic) IS - 1471-2334 (Linking) VI - 18 IP - 1 DP - 2018 Oct 16 TI - Ischemic stroke as a complication of cryptococcal meningitis and immune reconstitution inflammatory syndrome: a case report. PG - 520 LID - 10.1186/s12879-018-3386-0 [doi] LID - 520 AB - BACKGROUND: Cryptococcal meningitis remains the leading cause of adult meningitis in Sub-Saharan Africa. Immune Reconstitution Inflammatory Syndrome (IRIS) following anti-retroviral therapy (ART) initiation is an important complication. Here we report the first documented case of a IRIS reaction presenting as an ischemic stroke. CASE PRESENTATION: A 38 year old newly diagnosed HIV-infected, ART naive Malawian male presented to a tertiary referral hospital in Blantyre, Malawi with a 2 week history of headache. A diagnosis of cryptococcal meningitis was made and the patient was started on 1200 mg fluconazole once daily and flucytosine 25 mg/kg four times daily as part of the Advancing Cryptococcal Treatment for Africa (ACTA) clinical trial. There was an initial clinical and microbiological response to anti-fungal treatment and anti-retroviral therapy was started at week 4. The patient re-presented 16 days later with recurrence of headache, fever, and a sudden onset of left sided weakness in the context of rapid immune reconstitution; peripheral CD4 count had increased from a baseline of 29 cells/mul to 198 cells/mul. Recurrence of cryptococcal meningitis was excluded through CSF examination and fungal culture. Magnetic Resonance Imaging (MRI) of the brain demonstrated multi-focal DWI (diffusion weighted imaging) positive lesions consistent with an ischemic stroke. Given the temporal relationship to ART initiation, these MRI findings in the context of sterile CSF with raised CSF protein and a rapid immune reconstitution, following an earlier favorable response to treatment is most consistent with a paradoxical Immune Reconstitution Inflammatory Syndrome. CONCLUSIONS: Stroke is an increasing cause of morbidity and mortality amongst HIV infected persons. Ischemic stroke is a recognized complication of cryptococcal meningitis in the acute phase and is thought to be mediated by an infectious vasculitis. This is the first time an ischemic stroke has been described as part of a paradoxical IRIS reaction. This report adds to the spectrum of clinical IRIS presentations recognized and highlights to clinicians the potential complications encountered at ART initiation in severely immunocompromised patients. FAU - Ellis, Jayne P AU - Ellis JP AUID- ORCID: 0000-0002-7009-9144 AD - Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Chichiri, Blantyre, Malawi. j.ellis@doctors.org.uk. AD - Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK. j.ellis@doctors.org.uk. FAU - Kalata, Newton AU - Kalata N AD - Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Chichiri, Blantyre, Malawi. FAU - Joekes, Elizabeth C AU - Joekes EC AD - Department of Radiology, The Royal Liverpool University Hospitals NHS Trust, Liverpool, UK. FAU - Kampondeni, Samuel AU - Kampondeni S AD - Blantyre Malaria Project, Blantyre, Malawi. FAU - Benjamin, Laura A AU - Benjamin LA AD - Brain Infections Group, Walton Centre NHS Foundation Trust, and Institute of Infection and Global Health, University of Liverpool, Liverpool, UK. FAU - Harrison, Thomas S AU - Harrison TS AD - Institute for Infection and Immunity, St George's, University of London, London, UK. FAU - Lalloo, David G AU - Lalloo DG AD - Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK. FAU - Heyderman, Robert S AU - Heyderman RS AD - Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Chichiri, Blantyre, Malawi. r.heyderman@ucl.ac.uk. AD - Division of Infection and Immunity, University College London, London, UK. r.heyderman@ucl.ac.uk. LA - eng GR - WT_/Wellcome Trust/United Kingdom GR - G1100814/MRC_/Medical Research Council/United Kingdom PT - Case Reports PT - Journal Article DEP - 20181016 PL - England TA - BMC Infect Dis JT - BMC infectious diseases JID - 100968551 RN - 0 (Antifungal Agents) RN - 8VZV102JFY (Fluconazole) RN - D83282DT06 (Flucytosine) SB - IM MH - AIDS-Related Opportunistic Infections/diagnosis/pathology MH - Adult MH - Antifungal Agents/therapeutic use MH - Brain Ischemia/*etiology/pathology MH - Cryptococcus neoformans/immunology/isolation & purification MH - Fluconazole/therapeutic use MH - Flucytosine/therapeutic use MH - HIV Infections/complications/drug therapy/pathology MH - Humans MH - Immune Reconstitution Inflammatory Syndrome/*complications/diagnosis/pathology MH - Immunocompromised Host MH - Malawi MH - Male MH - Meningitis, Cryptococcal/*complications/diagnosis/pathology MH - Stroke/drug therapy/*etiology/pathology PMC - PMC6192067 OTO - NOTNLM OT - Cryptococcal meningitis OT - HIV OT - Immune reconstitution inflammatory syndrome OT - Stroke COIS- ETHICS APPROVAL AND CONSENT TO PARTICIPATE: Not applicable. CONSENT FOR PUBLICATION: The study participant has signed a written consent form giving his consent for publication of this case in an academic journal. COMPETING INTERESTS: The authors declare that they have no competing interests. PUBLISHER'S NOTE: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. EDAT- 2018/10/18 06:00 MHDA- 2018/12/12 06:00 PMCR- 2018/10/16 CRDT- 2018/10/18 06:00 PHST- 2017/10/17 00:00 [received] PHST- 2018/09/14 00:00 [accepted] PHST- 2018/10/18 06:00 [entrez] PHST- 2018/10/18 06:00 [pubmed] PHST- 2018/12/12 06:00 [medline] PHST- 2018/10/16 00:00 [pmc-release] AID - 10.1186/s12879-018-3386-0 [pii] AID - 3386 [pii] AID - 10.1186/s12879-018-3386-0 [doi] PST - epublish SO - BMC Infect Dis. 2018 Oct 16;18(1):520. doi: 10.1186/s12879-018-3386-0.