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Chronic Steroid Use in Asthma: A Fatal Case of Cryptococcal Meningitis
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A1264 - Chronic Steroid Use in Asthma: A Fatal Case of Cryptococcal Meningitis
Author Block: H. Rehman1, S. Verga1, W. Khan2; 1Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States, 2University Medical Center of Princeton at Plainsboro, Plainsboro, NJ, United States.
Intro: Cryptococcus neoformans meningoencephalitis commonly occurs in developing countries, particularly in patients infected with the human immunodeficiency virus (HIV). It is rare in the United States and occurs even less frequently in HIV seronegative patients. Immunosuppression from chronic glucocorticoid therapy can predispose patients to Cryptococcus meningoencephalitis. It can present over weeks or more acutely with signs and symptoms such as fever, headache, and lethargy. As the use of systemic steroids has increased for a multitude of disorders, clinical suspicion must be high to diagnose this potentially fatal infection. Even with prompt recognition and early initiation of antimicrobial therapy, mortality is high. With the increasing use of steroids in chronic lung disease, such as asthma, the identification of risk factors and signs/symptoms of cryptococcal infection is important. We present the case of a patient on chronic oral prednisone for severe persistent asthma who developed cryptococcal meningitis.
Case Report: The patient was a 37-year-old female with severe persistent asthma on chronic oral prednisone for several years. She presented to the emergency room for nausea and vomiting, as well as photosensitivity and blurred vision. She was admitted to the critical care unit where she developed tonic-clonic seizures with associated fever and altered mentation. Lumbar puncture was performed and cerebrospinal fluid stain and antigen studies were positive for Cryptococcus. Treatment with amphotericin was initiated. A ventricular drain was placed for elevated intracranial pressures. The patient ultimately died despite aggressive treatment.
Discussion: Although cryptococcal meningitis is rare in non-HIV infected individuals, the clinician should maintain a degree of suspicion in patients on chronic glucocorticoid therapy. Risk appears to be dose dependent. Therefore, it is prudent for providers to minimize systemic glucocorticoid use.
Author Block: H. Rehman1, S. Verga1, W. Khan2; 1Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States, 2University Medical Center of Princeton at Plainsboro, Plainsboro, NJ, United States.
Intro: Cryptococcus neoformans meningoencephalitis commonly occurs in developing countries, particularly in patients infected with the human immunodeficiency virus (HIV). It is rare in the United States and occurs even less frequently in HIV seronegative patients. Immunosuppression from chronic glucocorticoid therapy can predispose patients to Cryptococcus meningoencephalitis. It can present over weeks or more acutely with signs and symptoms such as fever, headache, and lethargy. As the use of systemic steroids has increased for a multitude of disorders, clinical suspicion must be high to diagnose this potentially fatal infection. Even with prompt recognition and early initiation of antimicrobial therapy, mortality is high. With the increasing use of steroids in chronic lung disease, such as asthma, the identification of risk factors and signs/symptoms of cryptococcal infection is important. We present the case of a patient on chronic oral prednisone for severe persistent asthma who developed cryptococcal meningitis.
Case Report: The patient was a 37-year-old female with severe persistent asthma on chronic oral prednisone for several years. She presented to the emergency room for nausea and vomiting, as well as photosensitivity and blurred vision. She was admitted to the critical care unit where she developed tonic-clonic seizures with associated fever and altered mentation. Lumbar puncture was performed and cerebrospinal fluid stain and antigen studies were positive for Cryptococcus. Treatment with amphotericin was initiated. A ventricular drain was placed for elevated intracranial pressures. The patient ultimately died despite aggressive treatment.
Discussion: Although cryptococcal meningitis is rare in non-HIV infected individuals, the clinician should maintain a degree of suspicion in patients on chronic glucocorticoid therapy. Risk appears to be dose dependent. Therefore, it is prudent for providers to minimize systemic glucocorticoid use.
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