Discontinuation of highly active antiretroviral therapy leads to cryptococcal meningitis/choroiditis in an AIDS patient

Bilateral Cryptococcal Choroiditis in a Human Immunodeficiency Virus-Infected Patient: A Case Report

Introduction

In this case report, we present a rare case of bilateral cryptococcal choroiditis following a diagnosis of meningitis in a 38-year-old woman with HIV.

Case Presentation

A Colombian woman, newly diagnosed with HIV, presented with respiratory distress followed by meningeal syndrome. Further evaluation revealed cryptococcal meningitis caused by Cryptococcus neoformans, confirmed through cerebrospinal fluid analysis and brain magnetic resonance imaging. The patient reported mild blurred vision, prompting an ophthalmic examination that included indocyanine green angiography. The findings revealed signs of HIV retinopathy and multifocal choroidal lesions in both eyes, suggestive of choroidal cryptococcosis. Treatment involved intravenous administration of amphotericin B and flucytosine, followed by oral fluconazole. Subsequently, the choroidal lesions gradually regressed, and regular monitoring demonstrated no signs of recurrence.

Conclusion

Cryptococcal choroiditis, though exceptionally rare, can occur in HIV-positive patients with disseminated cryptococcosis. Ophthalmologists should maintain a high index of suspicion for opportunistic infections, even in the absence of pronounced ocular symptoms, particularly in immunocompromised individuals. Early diagnosis and appropriate treatment are crucial for achieving favorable outcomes in such cases.

Potent antifungal agents and use of nanocarriers to improve delivery to the infected site: A systematic review

There are four major classes of antifungals with the predominant mechanism of action being targeting of cell wall or cell membrane. As in other drugs, low solubility of these compounds has led to low bioavailability in target tissues. Enhanced drug dosages have effects such as toxicity, drug-drug interactions, and increased drug resistance by fungi. This article reviews the current state-of-the-art of antifungals, structure, mechanism of action, other usages, and toxic side effects. The emergence of nanoformulations to transport and uniformly release cargo at the target site is a boon in antifungal treatment. The article details research that lead to the development of nanoformulations of antifungals and potential advantages and avoidance of the lacunae characterizing conventional drugs. A range of nanoformulations based on liposomes, polymers are in various stages of research and their potential advantages have been brought out. It could be observed that under similar dosages, test models, and duration, nanoformulations provided enhanced activity, reduced toxicity, higher uptake and higher immunostimulatory effects. In most instances, the mechanism of antifungal activity of nanoformulations was similar to that of regular antifungal. There are possibilities of coupling multiple antifungals on the same nano-platform. Increased activity coupled with multiple mechanisms of action presents for nanoformulations a tremendous opportunity to overcome antifungal resistance. In the years to come, robust methods for the preparation of nanoformulations taking into account the repeatability and reproducibility in action, furthering the studies on nanoformulation toxicity and studies of human models are required before extensive use of nanoformulations as a prescribed drug.

Bilateral Placoid Choroiditis in an HIV-Positive Patient With Cryptococcus neoformans Meningitis and Disseminated Cryptococcal Disease

Purpose:

We report a presumptive case of bilateral placoid choroiditis secondary to disseminated Cryptococcus neoformans infection and review the literature on choroidal involvement of C neoformans.

Methods:

A case report is presented.

Results:

A 35-year-old HIV-positive man presented with disseminated cryptococcal infection. Cryptococcal meningitis was confirmed by lumbar puncture, and skin involvement was confirmed by microscopy of scrapings from a papular, umbilicated, ulcerated lesion. Ophthalmologic examination revealed intact visual acuity, clear vitreous, and multiple yellowish, placoid-appearing choroidal lesions in the posterior pole bilaterally.

Conclusions:

Multifocal choroiditis caused by C neoformans is an uncommon manifestation of disseminated infection, and placoid yellowish choroidal lesions are an unusual variant. These findings must be differentiated from choroidal tuberculosis and other infections. Multifocal choroiditis typically occurs in AIDS patients and may precede the presentation of meningitis. In such patients, choroidal lesions warrant investigation for systemic, life-threatening opportunistic infections.

Vogt-Koyanagi-Harada disease and fungal meningitis

PURPOSE

To describe a patient who initially presented with features of Vogt-Koyanagi-Harada disease and who eventually demonstrated symptoms of mycotic meningitis.

METHODS

An 18-year-old immunocompetent boy showed a disseminated uveitis with patchy thickening of the posterior choroid. A clinical neurologic examination and a microbiological assessment revealed neck stiffness as well as pleocytosis, increased protein content, a decreased concentration of glucose and chloride, and cryptococcal fungi in the cerebrospinal fluid. It led to the diagnosis of cryptococcal meningitis.

RESULTS

Antifungal therapy was initiated and given for 2 months. After bilateral retrobulbar injections of 2.5 mg of dexamethasone and 20 mg of triamcinolone acetonide, choroidal edema regressed and visual acuity increased from 0.4 to 1.0 at 3 weeks after start of therapy. Microbiological examination of cerebrospinal fluid samples taken 30 days later was unremarkable. Ophthalmoscopy showed some fine pigment clumping and depigmentation in the macula.

CONCLUSION

According to the International Nomenclature Committee for Vogt-Koyanagi-Harada diagnosis, the patient was diagnosed with incomplete Vogt-Koyanagi-Harada because he had not suffered any ocular trauma, had not undergone ocular surgery, and presented with bilateral multifocal choroiditis accompanied by signs of meningitis without skin abnormalities. Because skin changes can occur months to years after the initial symptoms, the patient may eventually fulfill the criteria for complete Vogt-Koyanagi-Harada disease.