CNS Recovery in Severe Cryptococcal Meningitis in Advanced HIV Following Re-Establishment of Fungicidal Amphotericin-Based Therapy in an Older Adult

Abstract

Cryptococcal meningitis (CCM) remains a major cause of mortality among adults with advanced HIV disease. Globally, approximately one million cases of cryptococcosis are reported each year, with an estimated 625,000 annual deaths. Sub-Saharan Africa, where the population burden of HIV is up to 60%, accounts for nearly three-quarters (73%) of these deaths. The treatment of CCM involves the induction, consolidation, and maintenance of fungal clearance, with concurrent immune reconstitution. Rapid induction-phase fungal clearance is strongly associated with improved survival, and current guidelines recommend amphotericin-based combination therapy where feasible. Fluconazole monotherapy may be used in the induction phase, but is often associated with poor and slower fungal clearance. However, it is the backbone of the consolidation and maintenance phases of CCM treatment. This case is a report of a 69-year-old Kenyan woman, newly diagnosed with HIV, who presented with headache and progressive confusion and was diagnosed with cryptococcal meningoencephalitis. She initially received high-dose fluconazole, followed by amphotericin B deoxycholate. The treatment was complicated by severe febrile reactions and persistent hypokalemia, necessitating the discontinuation of the amphotericin. Her clinical status, especially the neurological function, subsequently deteriorated on fluconazole monotherapy. Liposomal amphotericin B was then introduced with strict pre-hydration and scheduled electrolyte supplementation, resulting in marked neurological improvement. This case emphasizes the necessity of fungicidal induction therapy, proactive mitigation of amphotericin-associated complications, and sustained clinical vigilance to ensure good patient outcomes.