PMC7452429_01
Timeline of opening pressure and CSF results, CSF culture, visual acuity, intravitreal and systemic antimicrobial therapy and evolution cryptococcal choroiditis during cryptococcal induction therapy by diffuse fundoscopic examination and optical coherence tomography. A) Upper images represent diffuse fundus photography of the right eye at the start (12/20/18) and end (1/10/19) of induction/intravitreal therapy. Multifocal creamy choroidal lesions observed in the posterior pole and mid-periphery were noted to become more atrophic and pigmented following induction therapy. Lower images represent optical coherence tomography of the right eye at the start and end of therapy. Disruption of the outer retinal layers, outer retinal hyperreflectivity and underlying choroidal thickening in the macula (red brackets) were reduced at end of induction/intravitreal therapy. Diffuse fundus photography and optical coherence tomography results of the right eye are representative of those of the left eye.. B) CSF WBC, lymphocyte percentage, monocyte/macrophage percentage, glucose, protein, opening pressure and culture results, plus signs (+) indicate positive CSF culture and minus signs (-) indicate negative CSF culture. Each individual marker, bar graph, plus or minus signs represent an individual data point per day. The graph inset shows toxoplasma tachyzoites (yellow arrow) phagocytosed in macrophage from CSF. Scale bar (inset lower right hand corner) represents 20 mum. Pinhole occluder visual acuity of the right (OD; oculus dexter) and left (OS; oculus sinister) eye by Snellen chart are noted throughout time with each fraction representing an individual data point per day. The numerator represents the distance in feet between the subject and chart and denominator represents the distance at which a person with 20/20 acuity would discern the same optotype. Each syringe represents a single intravitreal treatment into both eyes of 5 mug/50 muL (per eye) liposomal amphotericin B per day. Daily dose in milligram per kilogram of liposomal amphotericin B (LAB), 5-Flucytosine (5-FC), and trimethoprim-sulfamethoxazole (TMP/SMX) are shown over time. LAB, 5-FC, and TMP/SMX treatment durations bars are open-ended on the right side to indicate extension of treatment duration beyond 1/8/19.
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A dilated fundoscopic examination and optical coherence tomography (OCT) were performed showing diffuse choroidal lesions bilaterally (Fig. 1A). Lumbar puncture (LP) demonstrated an opening pressure of 23 cm H2O and assessment of cerebrospinal fluid (CSF) showed a WBC of 4 cells/muL (56 % monocytes, 34 % lymphocytes), red blood cell (RBC) of 1 cell/muL, protein of 82 mg/dL, and glucose 22 mg/dL; CSF Gram-stain revealed many yeast and a cryptococcal antigen (CRAG) test was reactive (titer not obtained at our institution; Fig. 1B). A). Air dried cytospin preparation of the CSF stained with Diff-Quick revealed tachyzoites phagocytosed in macrophages (Fig. 1B) and toxoplasma was detected by polymerase chain reaction (PCR) in the CSF and blood (ARUP, Salt Lake City, UT). We initiated therapy with liposomal amphotericin B, 5-flucytosine, and trimethoprim-sulfamethoxazole therapy for the treatment of cryptococcal meningoencephalitis/choroiditis and toxoplasmic encephalitis, respectively (Fig. 1B). A vitrectomy was deferred given the apparent choroidal localization on OCT (Fig. 1A). The patient had an uncomplicated treatment course notable for improvement in his vision and regression of the choroidal lesions (Fig. 1B, bottom).
MRI brain (sagittal section, multiplanar reconstruction) demonstrating multiple ring- enhancing lesions in the left basal ganglia, inferior occipital lobe, and inferior cerebellum (yellow arrows).
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Magnetic resonance imaging (MRI) of the brain revealed multiple ring-enhancing lesions in the right frontal area, left basal ganglia, left occipital lobe and bilateral cerebellar hemispheres (Fig. 2). Given involution of parenchymal lesions on interval MRI brain (Fig. 2), the patient was treated with 6-week course of trimethoprim-sulfamethoxazole before transitioning to prophylactic therapy dosing.