The challenges in the management of Cryptococcal meningitis in resource poor settings: Case report

Background: Human immune-deficiency virus (HIV) infection continues to be an important risk factor for the development of central nervous system opportunistic infections (OI) especially cryptococcal meningitis which is an AIDS defining illness. Cryptococcal meningitisis an important contributing factor to morbidity and mortality in HIV infected individuals. It is a life threatening disease with a 100% case fatality in the absence of an appropriate treatment regimen. In high income countries, advances in diagnosis and anti-retroviral (ARV) options, availability of recommended antifungals and monitoring has reduced markedly the mortality and morbidity associated with cryptococcal meningitis when compared to morbidity and mortality indices in low income countries. In this case, a 40year old newly diagnosed retroviral disease patient presented with a two weeks history of recurrent headache, projectile vomiting and neck stiffness. She had an associated history of blurring of vision, gradual weakness of the right upper and lower limbs. She was afebrile, not pale or icteric. She had marked neck stiffness. The power on the left upper and lower limbs was 4/5 and 3/5 on the right upper and lower limbs. Her baseline CD4 was 34cells/mm3. Serum Cryptococcal antigen (CrAg) screening and baseline viral load were not done. The cerebrospinal fluid (CSF) Indian ink staining showed yeast cells of cryptococcal neoformans>30cells per high power field. The CSF chemistry and hematology were normal. She was managed as a case of cryptococcal meningitis. She was admitted and commenced on intravenous fluconazole 1.2g daily, tablets cotrimoxazole 960mg daily. She however became progressively restless, lapsed into coma and died on the fifth day on admission. The challenges of managing cryptococcal meningitis in resource poor settings are a cascade of events ranging from late patient presentation, challenges with early diagnosis using modern test kits, cost and availability of recommended anti-fungal as well as monitoring of side-effects. Others are government policies where health sector funding is low and lack of health insurance schemes targeted at lowering cost of care for the low income earners and the disadvantaged in the society.