After Unprotected Sex, 50-Year-Old Has Rash, Severe Weakness

Amber M. Bokhari, MD


August 22, 2022

The patient in this case had newly diagnosed HIV/AIDS, with a CD4 T-cell count of 32 cells/µL and an HIV viral load of 459,000 copies/mL. His serum cryptococcal antigen test was initially negative, but when the laboratory repeated the test with latex agglutination and pretreated with pronase, the serum cryptococcal antigen titer was ≥ 1:512. This in itself was a poor prognostic factor.

The urine Histoplasma antigen test, Aspergillus galactomannan test, Quantiferon-TB Gold test, MTB probe, and Toxoplasma serology and PCR tests were negative. Blood and sputum cultures grew C neoformans. Stool and urine cultures showed no growth.

The CSF cultures were positive for C neoformans, and the CSF cryptococcal antigen titer was > 1:512. Biopsy of the skin lesion revealed encapsulated yeast forms identified as C neoformans. The CSF VDRL test was negative. The BAL fluid MTB probe and PCP test were negative, and AFB and other bacterial staining and cultures showed no growth. The BAL fungal cultures grew C neoformans.

Because this patient had evidence of severe disseminated Cryptococcus infection, he was treated with an induction phase of 2 weeks with liposomal amphotericin B 3-4 mg/kg IV every 24 hours plus oral flucytosine 25 mg/kg four times a day. The induction phase was prolonged for another 2 weeks because he showed slow clinical improvement with gradual resolution of his headaches. The induction phase was followed by a 10-week consolidation phase with oral fluconazole 400 mg once daily. During the sixth week of therapy, a bictegravir-based one-pill regimen was started, as his HIV-1 was pansensitive on GenoSure PRIme.

After 10 weeks, the patient was switched to maintenance therapy with oral fluconazole 200 mg once daily for 1 year. His CD4 counts remained > 200 cells/µL, and his viral load was undetectable during this phase. Repeat cryptococcal antigen titers remained < 100.[45]