A 24-year-old woman* presents to the emergency department with headache accompanied by neck and shoulder pain of 2 weeks’ duration. She is unable to conduct normal daily activities and feels confused. She denies fever, chills, and rash.
Past medical history includes migraine, HIV infection, and a cesarean section. This headache is similar to her typical migraine pain but is much more severe.
The patient has had HIV infection for the past 6 years, but she refuses to take highly active antiretroviral therapy (HAART) because of nausea. She does not smoke or drink but previously abused drugs. She is single, has one child, and is unemployed. Family history is remarkable for maternal migraine.
The patient lies quietly in a darkened room. Temperature is 98.4ºF (36.9ºC); pulse, 87 beats/min; respirations, 19 breaths/min; and blood pressure, 152/103 mm Hg. Throat examination reveals a white exudate. She resists neck flexion. Brudzinski and Kernig signs are positive.
She is sleepy and irritable. Cranial nerve examination reveals bilateral papilledema and bilateral sixth nerve palsies. Vision is blurry; however, she cooperates poorly with acuity testing. Peripheral reflexes are brisk. Babinski signs are absent.
Laboratory and imaging studies
Results of CT of the brain with and without contrast are negative. MRI with and without contrast reveals a few nonspecific white matter lesions but no enhancement.
Total white blood cell count is low at 3800 cells/µL (normal, 4000 to 10,000 cells/µL), but red blood cell and platelet counts are normal. Chemistry panel, coagulation studies, electrolyte levels, and liver tests are normal. Rapid plasma reagin test is negative.
1. Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis. 2002;35:46-52.
2. Diaconu IA, Stratan LM, Nichita L, et al. Diagnosing HIV-associated cerebral diseases—the importance of neuropathology in understanding HIV. Rom J Morphol Embryol. 2016;57(2 suppl):745-750.
3. Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:291-322.
4. Shribman S, Noyce A, Gnanapavan S, et al. Cryptococcal meningitis in apparently immunocompetent patients: association with idiopathic CD4+ lymphopenia. Pract Neurol. 2018;18:166-169.
5. Chen J, Zhang R, Shen Y, et al. Serum cryptococcal antigen titre as a diagnostic tool and a predictor of mortality in HIV-infected patients with cryptococcal meningitis. HIV Medicine. 2019;20:69-73.