SHM Converge Scientific Abstract ePoster Gallery-Too Much of a Good Thing: Immune Reconstitution Inflammatory Syndrome in a Non Hiv Patient

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This case report describes cryptococcal meningitis-associated immune reconstitution inflammatory syndrome (CM-IRIS) in a non-HIV patient, highlighting a diagnosis that can be easily missed. A 49-year-old woman with adult-onset Still’s disease had been taking prednisone 40 mg daily for three months when she presented with headache and right leg weakness. Lumbar puncture showed elevated opening pressure and lymphocytic CSF pleocytosis, and CSF PCR was positive for Cryptococcus neoformans. She was treated with amphotericin B, with flucytosine initially started but later stopped because of thrombocytopenia. Steroids were tapered over four weeks.<br /><br />Despite prolonged antifungal therapy, her course became complicated. After discharge and completion of treatment, she returned one month later with worsening mental status and new left hemiparesis. MRI showed meningoencephalitis and acute infarcts. Repeat lumbar puncture demonstrated markedly elevated opening pressure, increased CSF white cells and protein, but repeat Cryptococcus PCR and cultures were negative, arguing against active infection. Because symptoms worsened after steroid withdrawal and no pathogen was identified, clinicians diagnosed CM-IRIS. Prednisone 50 mg daily was started, leading to rapid improvement in CSF pressure and laboratory markers. Over six weeks of gradual steroid tapering, her mental status and neurologic deficits improved significantly.<br /><br />The report emphasizes that IRIS is not limited to HIV patients receiving antiretroviral therapy. It can also occur in non-HIV patients after withdrawal of immunosuppression, such as corticosteroids. In cryptococcal meningitis, new neurologic symptoms after apparent microbiologic control should prompt evaluation for IRIS once persistent or recurrent infection has been excluded. The authors stress maintaining a high index of suspicion for CNS IRIS in this setting.

Asset Subtitle

Nuzhat Batool

Meta Tag

Author List Carlos Salama, David Song, Emilie Chan, Nuzhat Batool

Category Clinical Vignettes

Concept Immune Reconstitution Inflammatory Syndrome

Concept Cryptococcal Meningitis

Concept Neurological Decline

Concept Opening Pressure

Concept Cerebrospinal Fluid Pleocytosis

Distinguished Non-Finalist

Presenter Organization NYU Langone Hospital-Long Island, Mineola, NY

Presenting Author Nuzhat Batool

Track Adult

Keywords

cryptococcal meningitis

immune reconstitution inflammatory syndrome

CM-IRIS

non-HIV patient

Cryptococcus neoformans

corticosteroid withdrawal

prednisone taper

meningoencephalitis

elevated intracranial pressure

adult-onset Still’s disease

Immune Reconstitution Inflammatory Syndrome

Cryptococcal Meningitis

Neurological Decline

Opening Pressure

Cerebrospinal Fluid Pleocytosis