Monday, October 1, 2012

A 32-year-old HIV+ male presenting with mental status changes

 Soon after admission, the patient lapsed into a coma and died.

Minimal edema (brain weight: 1500 grams)

Some hypoxic-ischemic damage as evidenced by Purkinje red neuron change
"Soap bubble" changes around some vessels (sample from basal ganglia)
Giant cells among mixed inflammatory infiltrate in the meninges
Inflammation appears to extend minimally into brain parenchyma
Organisms consistent with crytopcoccus neoformans amid inflammation
Mucicarmine-positive fungi capsules highlighted in red, with some capsules partially deficient
Diagnosis: Cryptococcal meningoencephalitis with early hypoxic-ischemic encephalopathy.


Anonymous said...

How slippery was it? I have never had one of these, but anecdotes I have heard point towards them being very slippery. Great case!

Brian E. Moore, MD, MEd said...

Thanks for taking a look at the case, anonymous! Upon gross examination, I did not note that the brain specimen was especially slippery. But, maybe I would have convinced myself that it was had I known the diagnosis before-hand! I suspect that more fulminant cases are more obviously slippery because of the preponderance of capsular material surrounding the brain.

Michael Rodriguez said...

Hi Brian,
Nice case.
Was this man treatment naive? The cases I've seen where there has been no treatment are devoid of inflammation and certainly of multinucleated giant cells (and yes some were slippery/slimy). Of course if he had been immune reconstituted or had some residual immune function the giant cells would be fine..

shipcolldoc said...

I saw many such cases in New York in the 1980s and early 1990s, but none in AIDS patients recently. I did recently see a primary CNS lymphoma in an AIDS patient who had been on HAART for years. I wonder if we are seeing the tip of a new iceberg, with a recrudescence of opportunistic diseases after long periods on HAART.

jd said...

Fascinating. The "soap bubble" stuff in the basal ganglia is usually evident grossly.

Brian E. Moore, MD, MEd said...

This is an unusual case in that that patient had refused any therapy. He never received HAART. Nevertheless, he was able to mount a giant cell immune response.

Brian E. Moore, MD, MEd said...

Updated and corrected information on this case: The patient did in fact received HAART, but stopped in 2009 since he could no longer afford it. It was not mentioned in the chart how long he was on HAART.

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