Q: 53 year old male with history of HIV is admitted to ICU with clinical signs of meningitis. Resident performed Lumbar Punture and called you with panic as opening pressure is noted to be 200 mm H2O. Whats your diagnosis?

Answer: Cryptococcosis

Cryptococcosisis is a systemic or central nervous system (CNS) fungal infection caused by the yeast Cryptococcus neoformans . Cryptococcal infection is usually asymptomatic and self-limited. In patients with advanced HIV infection (eg, those with CD4 counts less than 100 cells/µL), Cryptococcus may cause life-threatening illness, either from a new exposure or through reactivation of a previously acquired latent infection. One of the hallmark is elevated ICP. Elevated ICP significantly increases the morbidity and mortality of cryptococcal meningitis and should be treated by the removal of CSF. The CSF opening pressure should be checked on the initial LP. LP and CSF removal should be repeated daily as needed for ICP reduction. Ventriculostomy or a ventriculoperitoneal (VP) shunt may be needed if the initial opening pressure is more than 400 mm H2O, or in refractory cases.

Recommended Reading: EDITORIAL REVIEW: HIV-associated cryptococcal meningitis, Joseph N. Jarvis and Thomas S. Harrison, AIDS 2007, 21:2119–2129