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Cryptococcal meningoencephalitis in an immunodeficiency virus positive patient coinfected with tuberculosis

  • Hendy Wirantara ,
  • Musofa Rusli ,
  • Muhammad Vitanata Arfijanto ,
  • Bramantono ,


Background: Cryptococcal meningitis is an inflammation of the meninges due to Cryptococcus fungal infection which commonly invades people living with immunodeficiency virus (PLHIV) with impaired immunity. The disease has a high mortality rate and is frequently misdiagnosed in the early stages due to vague symptoms. This case report aimed to provide information regarding diagnosing and managing cryptococcal meningoencephalitis in patients with acquired immunodeficiency syndrome (AIDS) and tuberculosis.

Case presentation: We reported a case of 34-year-old woman that complained of headache and fever from one month ago. There were also oral white patches in the last two weeks. The patient was diagnosed with lung TB and human immunodeficiency virus (HIV) in February 2021, but the TB was just being treated in the past two months and HIV in last two weeks. Head CT-scan with contrast showed meningoencephalitis, brain edema, left frontal, left ethmoidal, left and right maxillary and left sphenoid sinusitis. On the 9th day of hospitalization, the patient had seizures. Analysis of the cerebrospinal fluid culture revealed Cryptococcus neoformans. The patient’s comorbidities were leucopenia, hypoalbuminemia, pneumonia, brain edema which led to poor prognosis. On the 10th day, the seizures relapsed, followed by the drastically reduced SpO2 and death. Septic shock and multiorgan failure were considered the cause of the case's death.

Conclusion: This case highlights the importance of early diagnosis and management to avoid unfavorable outcome.


  1. Creamer A, Ioannidis S, Wilhelm T, Mahungu T, Lipman M. Headache in an HIV positive patient: diagnostic challenges and approach to treatment . Clin Med. 2016;16(6):548–50. Available from:
  2. Nelson M, Dockrell DH, Edwards S. British HIV Association and British Infection Association guidelines for the treatment of opportunistic infection in HIV-seropositive individuals 2011. HIV Med. 2011;12:1–5. Available from:
  3. Bramantono B, Danial A, Hadi U. A case of an AIDS patient with Cryptococcus neoformans infection. Pan African Medical Journal 2020; 36(1)1-8.
  4. Williamson PR, Jarvis JN, Panackal AA, Fisher MC, Molloy SF, Loyse A, et al. Cryptococcal meningitis: epidemiology, immunology, diagnosis and therapy. Nat Rev Neurol. 2016;13(1):13–24. Available from:
  5. Haddad N, Powderly W. The changing face of mycoses in patients with HIV/AIDS. The AIDS reader. 2001;11(7):365-8.
  6. Kaplan JE, Hanson D, Dworkin MS, Frederick T, Bertolli J, Lindegren ML, et al. Epidemiology of Human Immunodeficiency Virus–Associated Opportunistic Infections in the United States in the Era of Highly Active Antiretroviral Therapy. Clin Infect Dis. 2000;30(s1):S5–14. Available from:
  7. Graybill JR, Sobel J, Saag M, van der Horst C, Powderly W, Cloud G, et al. Diagnosis and Management of Increased Intracranial Pressure in Patients with AIDS and Cryptococcal Meningitis. Clin Infect Dis. 2000;30(1):47–54. Available from:
  8. Mirza SA, Phelan M, Rimland D, Graviss E, Hamill R, Brandt ME, et al. The Changing Epidemiology of Cryptococcosis: An Update from Population‐Based Active Surveillance in 2 Large Metropolitan Areas, 1992–2000. Clin Infect Dis. 2003;36(6):789–94. Available from:
  9. Thakur R, Sarma S, Kushwaha S. Prevalence of HIV-associated cryptococcal meningitis and utility of microbiological determinants for its diagnosis in a tertiary care center. Indian J Pathol Microbiol. 2008;51(2):212. Available from:
  10. Kotaki T, Khairunisa SQ, Sukartiningrum SD, Arfijanto MV, Utsumi T, Normalina I, et al. High prevalence of HIV-1 CRF01_AE viruses among female commercial sex workers residing in Surabaya, Indonesia. PLoS One. 2013;8(12):e82645–e82645. Available from:
  11. Kurniawati R, SUGIANTO P. Relationship between High Sensitivity-C Reactive Protein Level and Impaired Cognitive Function in HIV Patients. Folia Medica Indones. 2021;57(1):63. Available from:
  12. Budi Apsari PI, Supadma IN, Kumara Wati KD, Dharma Artana IW. Cognitive, Motor, and Language Assessment in Children with Human Immunodeficiency Virus. Folia Medica Indones. 2022;58(2):162–7. Available from:
  13. Antinori S. New Insights into HIV/AIDS-Associated Cryptococcosis. ISRN AIDS. 2013;2013:471363. Available from:
  14. Maziarz EK, Perfect JR. Cryptococcosis. Infect Dis Clin North Am. 2016;30(1):179–206. Available from:
  15. French N, Gray K, Watera C, Nakiyingi J, Lugada E, Moore M, et al. Cryptococcal infection in a cohort of HIV-1-infected Ugandan adults. AIDS. 2002;16(7):1031–8. Available from:
  16. Resch S, Ryckman T, Hecht R. Funding AIDS programmes in the era of shared responsibility: an analysis of domestic spending in 12 low-income and middle-income countries. Lancet Glob Heal. 2015;3(1):e52–61. Available from:
  17. Rajasingham R, Smith RM, Park BJ, Jarvis JN, Govender NP, Chiller TM, et al. Global burden of disease of HIV-associated cryptococcal meningitis: an updated analysis. Lancet Infect Dis. 2017/05/05. 2017;17(8):873–81. Available from:
  18. Aditya A, Indrati A, Ganiem A. Cryptococcal Antigen of Acquired Immune Deficiency Syndrome with Lateral Flow Assay and Cryptococcus Antigen Latex Agglutination System. Indones J Clin Pathol Med Lab. 2018;21(1):45. Available from:
  19. Chastain DB, Henao-Martínez AF, Franco-Paredes C. Opportunistic Invasive Mycoses in AIDS: Cryptococcosis, Histoplasmosis, Coccidiodomycosis, and Talaromycosis. Curr Infect Dis Rep. 2017;19(10). Available from:
  20. Boulware DR, Bonham SC, Meya DB, Wiesner DL, Park GS, Kambugu A, et al. Paucity of initial cerebrospinal fluid inflammation in cryptococcal meningitis is associated with subsequent immune reconstitution inflammatory syndrome. J Infect Dis. 2010;202(6):962–70. Available from:
  21. Abassi M, Boulware DR, Rhein J. Cryptococcal Meningitis: Diagnosis and Management Update. Curr Trop Med reports. 2015;2(2):90–9. Available from:
  22. Srichatrapimuk S, Sungkanuparph S. Integrated therapy for HIV and cryptococcosis. AIDS Res Ther. 2016;13(1):42. Available from:
  23. World Health Organization Clinical Staging of HIV/AIDS for Adults and Adolescents Clinical Classification. In: Definitions. Qeios; 2020. Available from:
  24. Patterson TF, Donnelly JP. New Concepts in Diagnostics for Invasive Mycoses: Non-Culture-Based Methodologies. J fungi (Basel, Switzerland). 2019;5(1):9. Available from:
  25. Xia S, Li X, Li H. Imaging characterization of cryptococcal meningoencephalitis. Radiol Infect Dis. 2016;3(4):187–91. Available from:
  26. Shoham S, Cover C, Donegan N, Fulnecky E, Kumar P. Cryptococcus neoformans Meningitis at 2 Hospitals in Washington, D.C.: Adherence of Health Care Providers to Published Practice Guidelines for the Management of Cryptococcal Disease. Clin Infect Dis. 2005;40(3):477–9. Available from:
  27. Kambugu A, Meya DB, Rhein J, O’Brien M, Janoff EN, Ronald AR, et al. Outcomes of cryptococcal meningitis in Uganda before and after the availability of highly active antiretroviral therapy. Clin Infect Dis. 2008;46(11):1694–701. Available from:
  28. Antinori S, Ridolfo AL, Gianelli E, Piazza M, Gervasoni C, Monforte A d. The Role of Lumbar Puncture in the Management of Elevated Intracranial Pressure in Patients with AIDS-Associated Cryptococcal Meningitis. Clin Infect Dis. 2000;31(5):1309–10. Available from:
  29. Teo Y. Cryptococcal meningoencephalitis with fulminant intracranial hypertension: an. Singapore Med J. 2010;51(8):e133-e6.
  30. Palupi IR, Sugianto P. Accuracy of Meningitis Bacterial Score (MBS) as an indicator in establishing the diagnosis of acute bacterial meningitis in adults. Narra J. 2021;1(3). Available from:
  31. Pramana S, Hardiyanta IKY, Hidayat FY, Mariyah S. A comparative assessment on gene expression classification methods of RNA-seq data generated using next-generation sequencing (NGS). Narra J. 2022;2(1). Available from:
  32. Triwicaksana AAF, Rusli M, Arfijanto MV, Bramantono, Nasronudin, Hadi U. A patient with CD4+ T cells deficiency and HIV negative with pulmonary tuberculosis, tuberculous pleuritis and meningitis tuberculosis. Bali Med J. 2022;11(2):597–601. Available from:

How to Cite

Wirantara, H., Rusli, M. ., Arfijanto, M. V. ., & Bramantono. (2023). Cryptococcal meningoencephalitis in an immunodeficiency virus positive patient coinfected with tuberculosis. Bali Medical Journal, 12(2), 1490–1496.




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