A 34‐year‐old Guatemalan man with unknown medical history presented with headache. He was seen in the ED 3weeks prior to admission with headache and nausea. He was discharged after physical examination (PE), neurological examination, laboratory results and spine radiograph were unremarkable. After 1 week, he went back to ED due to worsening headache, nausea, fever, vomiting, and photophobia. Laboratory and computed tomography (CT) of the brain results were unremarkable. He was discharged with diagnosis of sinusitis. His headache continued worsening, associated with visual hallucinations, intractable vomiting, poor appetite, generalized weakness, and a 30‐pound weight loss. He was brought back to the ED and was admitted for further evaluation. PE showed a cachectic and confused man Neurologic examination was positive for nuchal rigidity and generalized weakness. CT Scan of head was normal. Lumbar puncture showed a high opening pressure, overwhelming the manometer. Cerebrospinal fluid (CSF) analysis was significant for low glucose, positive encapsulated yeast and positive cryptococcal antigen with a titer of 1:2048, a low CD4 count of 2 mm3 and reactive HIV screen. Treatment for cryptococcal meningoencephaitis was started with amphotericin B lipid and flucytosine. Therapeutic spinal taps were done until CSF opening pressure normalized. Patient completed the course of amphotericin B lipid and flucytosine, followed by fluconazole. He was discharged with remarkable clinical improvement after a complicated 3‐month hospital course.
Recognizing the small number of patients with secondary, life‐threatening headaches from the overwhelming majority with benign primary headaches is an important problem in the ED. Careful history and PE are important to determine whether the patient needs urgent evaluation with LP and neuroimaging. Our patient presented with worsening headache for 3 weeks and had multiple ED visits with lumbar puncture (LP) done only after admission. Cryptococcal meningoencephalitis causes a life‐threatening headache in HIV patients and presents indolently with fever, malaise and headache, making diagnosis difficult. Most deaths occur within the first 2 weeks of therapy, related to increased intracranial pressure. Treatment is started with Amphotericin B. 0.7 mg/kg per day IV and Flucytosine 100 mg/kg daily orally during the two‐week induction phase, followed with fluconazole 400 mg per day orally during the consolidation phase. At the completion of 8 weeks, maintenance therapy with fluconazole 200 mg daily can be continued for chronic suppression. Therapeutic LP is done to relieve increased intracranial pressure.
Cryptococcal meningoencephalitis usually presents with a worsening headache and has a 20% 3‐month mortality rate in HIV patients; therefore, early recognition and insightful management is very critical to a successful outcome.
To cite this abstract:Cirilo I, Cheriyath P. Life‐Changing Headache. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 404. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/lifechanging-headache/. Accessed April 5, 2020.