Sudden hearing loss due to AIDS-related cryptococcal meningitis--a temporal bone study

Cryptococcal meningitis presented as sudden hearing loss: A case study

BACKGROUND

This case report emphasizes that cryptococcal meningitis could be uncommonly presented to otolaryngologists as sudden onset of hearing loss, especially in patients with underlying diseases that could cause immunocompromise, and highlights the importance of differentiated diagnosis on sudden hearing loss before steroid therapy. It also demonstrates that prompt and sufficient fungicidal therapy with appropriate supportive treatment is crucial for a good prognosis on cryptococcal meningitis.

CASE PRESENTATION

A diabetic adult with untreated chronic hepatitis B was admitted complaining of sudden onset of left-sided hearing loss, following unexpected aggravating headache with meningeal signs after hospitalization with days of intratympanic steroid therapy. Cryptococcal meningitis was confirmed through lumbar puncture showing positive India ink staining and microbial culture of the cerebrospinal fluid (CSF). Fortunately, the patient recovered after prompt and adequate fungicidal therapy plus appropriate supportive treatment at last, though persistent hearing loss remained.

CONCLUSIONS

Cryptococcal meningitis could be presented in a very concealed way as sudden hearing loss, especially in patients with underlying diseases that could cause immunosuppression. Differentiated diagnosis on sudden hearing loss before steroid therapy is important.

Audiologic and Otologic Complications of Cryptococcal Meningoencephalitis in Non-HIV Previously Healthy Patients

OBJECTIVE

To identify audiologic and otologic outcomes in previously healthy non-HIV patients with cryptococcal meningoencephalitis (CM).

STUDY DESIGN

Retrospective case review of a subset of patients recruited in a prospective observational study following previously healthy individuals who developed CM.

SETTING

Tertiary referral center, National Institutes of Health Clinical Center.

PATIENTS

Previously healthy adult patients with CM without immune suppressive therapy before disease onset.

INTERVENTIONS

Diagnostic evaluations included audiometry, acoustic immittance, otoacoustic emissions, and auditory brainstem response studies, in addition to neurotologic assessment.

RESULTS

Twenty-nine patients (58 years) underwent audiologic evaluation between 6 months and 3.5 years after CM diagnosis; 21 patients were seen for longitudinal assessment with an average duration of follow up of 20.3 months. Nearly three-quarters (73%) of the cohort presented with hearing loss, most commonly (90%) sensorineural in origin. The most frequent degree of loss was mild and then moderate, although some patients had severe or profound impairment. Hearing loss improved (43%) or remained stable (38%) in most cases. Ears with internal auditory canal enhancement on magnetic resonance imaging (MRI) had significantly more hearing loss than those without enhancement, although a similar finding was not observed with gyral enhancement or the presence of ependymitis or ventricular volume expansion. Hearing loss was not associated with reduced cerebrospinal fluid (CSF) glucose, CSF total protein, cryptococcal antigen, or total cell count.

CONCLUSIONS

Hearing loss is a common manifestation of cryptococcal meningitis in previously healthy patients and may involve a cochlear or neural site of lesion, or both. Routine surveillance of hearing in patients is recommended, regardless of symptomatology, to ensure early and appropriate intervention and care.

Can HIV-infected patients undergo cochlear implantation?

OBJECTIVE

HIV-infected patients have an increased risk of developing sensorineural hearing loss. Cochlear implantation can be a mean of rehabilitating such patients.

METHODS

A 36-year-old HIV-infected male with bilateral profound sensorineural hearing loss underwent cochlear implantation after exclusion of medical and radiological contraindications. The patient was followed up for 2 years to assess the audiological outcome.

RESULTS

After a follow up of 2 years, the patient has attained good functional results not experienced any complications. Conculsion: Cochlear implantation can restore hearing to HIV-infected patients with profound hearing loss due to cochlear impairment. This helps in both social and vocational rehabilitation and can improve the quality of life of such patients.

Predictors of neurocognitive outcomes on antiretroviral therapy after cryptococcal meningitis: a prospective cohort study

Cryptococcal meningitis is the most common cause of adult meningitis in Africa, yet neurocognitive outcomes are unknown. We investigated the incidence and predictors of neurologic impairment among cryptococcal survivors. HIV-infected, antiretroviral-naive Ugandans with cryptococcal meningitis underwent standardized neuropsychological testing at 1, 3, 6, and 12 months. A quantitative neurocognitive performance z-score (QNPZ) was calculated based on population z-scores from HIV-negative Ugandans (n = 100). Comparison was made with an HIV-infected, non-meningitis cohort (n = 110). Among 78 cryptococcal meningitis survivors with median CD4 count of 13 cells/μL (interquartile range: 6-44), decreased global cognitive function occurred through 12 months compared with the HIV-infected, non-cryptococcosis cohort (QNPZ-6 at 12 months, P = 0.036). Tests of performance in eight cognitive domains was impaired 1 month after cryptococcal diagnosis; however, cryptococcal meningitis survivors improved their global neurocognitive function over 12 months with residual impairment (mean z-scores < -1), only in domains of motor speed, gross motor and executive function at 12 months. There was no evidence that neurocognitive outcome was associated with initial demographics, HIV parameters, or meningitis severity. Paradoxically, persons with sterile CSF cultures after 14 days of induction amphotericin therapy had worse neurocognitive outcomes than those still culture-positive at 14 days (P = 0.002). Cryptococcal meningitis survivors have significant short-term neurocognitive impairment with marked improvement over the first 12 months. Few characteristics related to severity of cryptococcosis, including Cryptococcus burden, were associated with neurocognitive outcome.

Cryptococcal meningitis with isolated otologic symptoms

Sensorineural hearing loss (SNHL) is a known complication of cryptococcal meningitis; however, it is unusual for a patient to present with isolated otologic symptoms. We review the case of a patient who is not immunocompromised and who presented with progressive gait instability and sudden onset of left-sided SNHL followed by progression to bilateral SNHL within a 3-week period. Cryptococcal meningitis was confirmed by lumbar puncture with positive cryptococcus antigen in the cerebrospinal fluid. The patient was treated with systemic antifungals, and the hearing loss persisted. The presented report outlines this patient's unusual presentation and his treatment course and reviews the literature on the otologic manifestations of cryptococcal meningitis.

Noise-induced hearing loss in mice treated with antiretroviral drugs

The results reported here for CBA/CaJ mice describe the effects of regular dosing with a common antiretroviral drug combination on outer hair cell (OHC) function using measures of 2f1-f2 distortion product otoacoustic emissions (DPOAEs) and auditory brainstem responses (ABRs). Specifically, experimental mice were treated daily over a 3-mo period with the nucleoside reverse transcriptase inhibitors (NRTIs), zidovudine (ZDV) and lamivudine (3TC), dissolved in their drinking water, while their control counterparts received untreated water. DPOAE levels and ABR detection thresholds prior to and after 12 wk of NRTI treatment did not differ between experimental and control groups. To assess whether NRTI treatment potentiates the adverse effects of noise over-exposure on OHC function, both experimental and control mice were exposed 1 wk later, while still on the drug regimen, to a 10-kHz octave-band noise (OBN) at 105-dB SPL for 1h. A major outcome of the sound over-exposure episode was that the NRTI-pretreated mice showed significantly greater permanent OBN-induced reductions in DPOAE levels at 2 wk postexposure than were observed for the untreated control animals. These findings support the notion that a synergistic relationship exists between certain NRTIs and intense sounds in that such preexposure drug treatments produced greater noise-induced decreases in DPOAE activity than did noise exposure alone. This drug/noise interaction is consistent with the known harmful effects of NRTIs on cellular mitochondrial activity.

Bilateral Bell Palsy and Acute HIV Type 1 Infection: Report of 2 Cases and Review

Two adult patients who presented to a hospital with bilateral facial Bell palsy who were also experiencing human immunodeficiency virus type 1 seroconversion are described. Ten additional cases retrieved from the literature are also reviewed. Bell palsy appeared a median of 15 days after the beginning of the clinical disease, and aseptic meningitis was an invariable concomitant of facial neuropathy. All but 1 patient (8.3%) recovered without sequelae.

A case of AIDS associated cryptococcal meningitis with multiple cranial nerve neuropathies

Cryptococcal meningitis is a common opportunistic infection among patients with AIDS. Cranial nerve neuropathies are well-known complications that occur due to increased intracranial pressure and inflammation of cranial nerves in such patients but have not been previously reported to involve more than four cranial nerves simultaneously. Our patient had involvement of five cranial nerves resulting in the complete loss of vision and hearing as well palsies of the third, sixth and seventh cranial nerves. He was treated with multiple antifungal medications. Repeated high volume lumbar punctures and Ommaya reservoir were used to lower intracranial pressure. At the time of discharge the patient had complete recovery of the functions of third, sixth and seventh cranial nerves bilaterally and partial recovery of hearing and vision.

Cryptococcal disease and HIV infection

In the era of highly active antiretroviral therapy for the treatment of HIV infection, the dramatic reductions in mortality and morbidity associated with immune reconstitution have included a marked decline in the incidence of opportunistic infections. Cryptococcus neoformans is a yeast that causes predominantly neurological disease in immunocompromised individuals, in particular those with HIV infection. It continues to be an important diagnosis in developing areas and amongst late presenters in parts of the world with access to highly active antiretroviral therapy. This article reviews the epidemiology, clinical features and management of cryptococcal disease in HIV-infected patients, particularly focusing on the history of, current guidelines for and future developments in antifungal therapy.

Cochlear Implantation in Human Immunodeficiency Virus–Infected Patients

OBJECTIVE

To evaluate the efficacy of cochlear implants in human immunodeficiency virus-infected individuals and correlate these results with a proposed pathophysiological mechanism of human immunodeficiency virus-associated hearing loss.

STUDY DESIGN

Retrospective case series and temporal bone analysis of deceased human immunodeficiency virus-positive patients.

SETTING

Tertiary care hospital.

PATIENTS

Seven human immunodeficiency virus-positive individuals with profound sensorineural hearing loss.

INTERVENTION

Cochlear implantation at New York University Medical Center.

METHODS

The surgical outcomes and complications were analyzed. Additionally, electron microscopic and immunohistochemical findings of cadaver temporal bone specimens of other known human immunodeficiency virus-positive individuals were reviewed. The performance results of the human immunodeficiency virus-positive cochlear implant patients were then correlated with the previously hypothesized pathophysiological mechanism of human immunodeficiency virus-associated hearing loss.

RESULTS

The patients had a varied performance with cochlear implantation, and as a group performance was good. There were no surgical complications or postoperative complications. The good performance of these patients supports the hypothesis that the mechanism of human immunodeficiency virus-associated deafness involves infiltration, malfunction, and premature degeneration of the hair cells and supportive cells of the cochlea.

CONCLUSIONS

Human immunodeficiency virus-positive individuals benefit from cochlear implantation without increased surgical risk.

Ototoxicity associated with use of nucleoside analog reverse transcriptase inhibitors: a report of 3 possible cases and review of the literature

Although a variety of adverse effects have been attributed to treatment with nucleoside analog reverse transcriptase inhibitors (NRTIs) for human immunodeficiency virus type 1 (HIV-1) infection, only 5 cases of ototoxicity have been reported in the literature. We describe 3 additional cases of possible NRTI-associated ototoxicity in HIV-1-infected patients, all of whom were aged >45 years, had a history of noise-induced hearing loss, and reported tinnitus and deterioration in hearing in the setting of antiretroviral therapy. Reductions in mitochondrial DNA content induced by NRTIs, as well as mitochondrial DNA mutations associated with aging and HIV-1 infection, all may contribute to auditory dysfunction in older patients with HIV-1 infection. Prospective studies are necessary to determine the incidence of tinnitus and hearing loss among HIV-1-infected patients and their relationship to the use of NRTIs.

Clinical Viral Infections and Temporal Bone Histologic Studies of Patients with AIDS

The brain, eye, and inner ear are each protected from blood-borne infectious agents by a barrier that has some anatomic and functional differences. In patients with AIDS, opportunistic infections of the central nervous system and eye are frequent. Little is known about the incidence of middle and inner ear infections in patients with AIDS, but deafness and severe vertigo are uncommon. We studied 14 homosexual men with AIDS, aged 28 to 55 years, for 1 to 2 years until death. No patient had deafness, but one had vertigo. Adenovirus type 6 and cytomegalovirus were isolated from the middle ear cavity in four patients. Temporal bone histology demonstrated acute otitis media in four, chronic otitis media in two, and serous otitis media in three. Adenovirus type 6 and cytomegalovirus, either alone or with herpes simplex virus type 1, were isolated from inner fluids of three patients. Histologic inner ear findings were abnormal in only one patient. Viruses were isolated or histologically identified in the brains of four patients and in the eyes of five patients. In our patients viral infections were nearly as common in the inner ears as in the brain and eye, suggesting that protection from the blood-labyrinth barrier was similar to that from the other barriers. Because the inner ear viral infections were asymptomatic and there was an absence of pathologic damage and inflammation, we suggest that some viral inner ear infections in patients with AIDS are nonpathogenic and elicit no inflammation or that the viral infections occur terminally and elicit no inflammation because of immunosuppression from the AIDS.

Cryptococcal meningitis with severe visual and hearing loss and radiculopathy in a patient without immunodeficiency

Cryptococcosis is an important cause of lymphocytic meningitis, especially but not necessarily in immunocompromised patients. We present the case of a 23-year-old man with a severe and rapid course of a cryptococcal meningoencephalitis, which led to visual and hearing loss, psychotic illness and radiculopathy. There was no evidence of immunodeficiency. Treatment with amphotericin B and flucytosine led to improvement of the symptoms but did not eradicate the micro-organisms from the cerebrospinal fluid (CSF). Maintenance therapy with fluconazole was necessary and led to improvement of the CSF pathology.