Clinical History:

A 28-year-old woman developed an increasingly severe headache over a two day period of time and came to the emergency room of the hospital. Vital signs showed respirations 25, pulse 82, temperature 37.4 C, and blood pressure 145/80 mm Hg. Physical examination revealed generalized lymphadenopathy, and needle tracks 2 cm long were noted on the antecubital fossa skin of her left arm. She did not have papilledema. A lumbar puncture was performed which showed increased opening pressure. The cerebrospinal fluid (CSF) obtained was fairly clear. Examination of the CSF showed no RBC's and only a few WBC's, all mononuclear cells.

Answers:

1. What is the diagnosis?

The findings are those of Cryptococcus neoformans infection. These fungal organisms have a thick capsule (sometimes the capsule is missing with infections in AIDS) which gives the clear space around the nucleus on the India ink preparation. As is the case in AIDS, the inflammatory response is blunted due to a failure of the immune system, so few inflammatory cells are present. Since so few inflammatory cells are present, there is only slight cloudiness to the meninges.

2. How do these findings account for the clinical presentation?

The infection of the meninges has led to a meningitis. This results in increased intracranial pressure with headache. Meningitis may also cause irritation of spinal nerve roots with neck stiffness. The lymphadenopathy suggests a systemic infection, in this case HIV infection. An HIV test should be done. If positive, this patient has AIDS because of the presence of this opportunistic infection.

3. What is the significance of the needle tracks in the arm?

This suggests a history of intravenous drug abuse, which is the risk factor for HIV infection in this case. Persons with risk factor of IVDA account for about 20 to 25% of AIDS cases in the U.S.