J Korean Soc Radiol.  2018 Dec;79(6):359-364. 10.3348/jksr.2018.79.6.359.

Paradoxical Cryptococcal Meningitis Immune Reconstitution Inflammatory Syndrome in a Patient with Human Immunodeficiency Virus Infection: Matching Clinical Findings with MRI Findings

• Moon S
• Hahm MH

• KMID: 2427386
• DOI: http://doi.org/10.3348/jksr.2018.79.6.359

Abstract

There are two forms of cryptococcal meningitis immune reconstitution inflammatory syndrome (CM-IRIS): paradoxical CM-IRIS and unmasking CM-IRIS. It is important to distinguish paradoxical CM-IRIS and CM relapse because mortality of CM-IRIS is higher than that of CM without IRIS, and paradoxical CM-IRIS and CM relapse requires different treatment. We report a case of paradoxical CM-IRIS that well matches the clinical findings with MR findings during three years follow-up of a HIV infected patient and new MRI finding is also introduced to help distinguish them.

MeSH Terms

Acquired Immunodeficiency Syndrome
Antiretroviral Therapy, Highly Active
Follow-Up Studies
HIV*
Humans
Humans*
Immune Reconstitution Inflammatory Syndrome*
Iris
Magnetic Resonance Imaging*
Meningitis, Cryptococcal*
Mortality
Recurrence

Figure

• 

  Fig. 1 Paradoxical CM-IRIS in a 26-year-old HIV-infected male patient. A. Trend graph of patient's laboratory results. (Upper left) HIV RNA burden is rapidly decreased after ART initiation and CD4+ T cell counts tend to increase steadily. (Upper right) Before events of CM-IRIS, Cryptococcus neoformans was already eradicated in the order of blood culture, CSF indian ink staining and CSF culture. (Lower left) While baseline levels of CSF and serum cryptococcal antigen titer are as high as 1:512, these levels tend to be lower at the events of CM-IRIS (grey squares). (Lower right) Baseline levels of CSF WBC counts and total protein are low as 12 cells/μL and about 58 mg/dL respectively. Although in first event of CM-IRIS, both increased than baseline, in second events of CM-IRIS, total protein only increased than baseline. However, it closely coincides with period of events of CM-IRIS (grey squares). CM-IRIS = cryptococcal meningitis immune reconstitution inflammatory syndrome, CSF = cerebrospinal fluid, WBC = white blood cell B. Brain MRI in May 2016. (Upper row) FLAIR imaging shows high signal intensity at the bilateral basal ganglia and thalamus, white matter of left occipital lobe, left hippocampus and left cerebellum (not shown). (Middle row) Contrast enhanced MRI showed prominent leptomeningeal enhancement at the left occipital convexity, perivascular enhancement in bilateral thalamus and basal ganglia and bilateral choroid plexus enhancement. (Lower row) Prominent enhancement of deep medullary veins that seems like connecting with choroid plexus is shown and right side is predominant. C. Brain MRI in November 2016. (Upper row) FLAIR imaging shows newly appeared extensive high signal confluence at the periventricular white matter and dilatation of occipital horn of left lateral ventricle due to adhesion associated with previous inflammation. (Middle and lower rows) Contrast enhanced MRI shows prominent perivascular enhancement in right parietal sulci and leptomeningeal enhancement at the new sites. Enhancement of deep medullary veins that seems like connecting with choroid plexus is shown again. CM-IRIS = cryptococcal meningitis immune reconstitution inflammatory syndrome, FLAIR = fluid attenuated inversion recovery

Reference

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