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LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 6  |  Page : 909-911

Infectious psychosis: Cryptococcal meningitis presenting as a neuropsychiatry disorder


1 Department of Microbiology, Amrita Institute of Medical Sciences, Ponekara, Kochi, Kerala, India
2 Department of Neurology, Amrita Institute of Medical Sciences, Ponekara, Kochi, Kerala, India

Date of Submission04-Aug-2011
Date of Decision12-Aug-2011
Date of Acceptance28-Sep-2011
Date of Web Publication2-Jan-2012

Correspondence Address:
Anil Kumar
Department of Microbiology, Amrita Institute of Medical Sciences, Ponekara, Kochi, Kerala
India
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DOI: 10.4103/0028-3886.91379

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How to cite this article:
Kumar A, Gopinath S, Dinesh KR, Karim S. Infectious psychosis: Cryptococcal meningitis presenting as a neuropsychiatry disorder. Neurol India 2011;59:909-11

How to cite this URL:
Kumar A, Gopinath S, Dinesh KR, Karim S. Infectious psychosis: Cryptococcal meningitis presenting as a neuropsychiatry disorder. Neurol India [serial online] 2011 [cited 2014 Nov 23];59:909-11. Available from: http://www.neurologyindia.com/text.asp?2011/59/6/909/91379


Sir,

Among neuropsychiatry manifestations, disorders like psychosis, mania, delirium, depression and dementia are the commonest and can rarely be seen in patients with central nervous infections. One such condition is cryptococcal meningitis which can present as acute manifestation of organic brain syndrome causing impairment of cognition. [1]

A 49-year-old male, a known case of direct Coombs test-positive hemolytic anemia, presented with symptoms of psychosis, on and off fever, and headache of two months' duration. Brain computed tomography (CT) scan was normal and he was diagnosed with psychosis and was started on olanzapine 2.5 mg/day and clonazepam 0.25 mg/day. On day 10 he returned with mild resolution of psychotic symptoms, but worsening of headache and was admitted under neurology for further workup. Magnetic resonance imaging (MRI) of brain was normal and electroencephalogram EEG showed mild degree of generalized nonspecific findings. Cerebrospinal fluid (CSF) opening pressure was 410 mm and CSF was turbid with protein of 373 mg/dl, glucose of 13 mg/dl, cell count of 40/mm 3 , and cytology showed monocytic pleocytosis. Microbiological investigation for bacterial pathogens and fungi on Gram stain was negative, acid-fast staining and polymerase chain reaction for rpoB gene of Mycobacterium tuberculosis was negative and CSF Venereal Disease Research Laboratory (VDRL) test was also non-reactive. Serology for P24 antigen, HIV-1and HIV-2 antibody was also negative. Latex agglutination for cryptococcal antigen was positive while India ink preparation was negative. Routine and fungal cultures of CSF grew mucoid colonies of yeast which were identified as Cryptococcus neoformans var. neoformans by the ID 32C/mini API system (Biomerieux, France). The isolate was susceptible to amphotericin B, itraconazole, fluconazole, voriconazole and 5-fluorocytosine using ATB FUNGUS 3/mini API system (Biomerieux, France). With the confirmation of cryptococcal meningitis the patient was treated with IV amphotericin B along with psychotropic medications. By Day 20 of antifungal therapy the patient showed marked resolution of neuropsychiatry symptoms and CSF cultures were also sterile. He was discharged on Day 22 on oral fluconazole 200 mg twice daily for 12 weeks. All psychotropic medications were discontinued on discharge. He was asymptomatic with no evidence of relapse at seven months' follow-up.

Other than AIDS cryptococcal meningitis can also occur in other immunodeficient states: diabetes, cancer, hematological malignancy, solid organ transplant, sarcoidosis, autoimmune hemolytic anemia, and steroid therapy. [2] Classically, cryptococcal meningitis is characterized by the triad of headache, fever and vomiting while altered sensorium have been reported in 13-73% of patients. [2] Patients presenting with confusional psychosis in the absence of constitutional symptoms like fever are never suspected to have an infectious etiology therefore cryptococcal meningitis was never considered as one of the differential diagnoses in this patient. Only nine such cases [Table 1] [3],[4],[5],[6],[7],[8],[9],[10] have been reported in the literature and one-third of them were seen in immunocompetent patients while confusional psychosis has been reported in only three of them. [2,6] It is hypothesized that the neuropsychiatric manifestations may be due to meningeal cryptococcosis and raised intracranial pressure. [7] Due to the unusual presentation, all these cases were initially misdiagnosed as behavioral disorders and were treated with psychotropic drugs which further extended the course of the disease. Without appropriate treatment cryptococcal meningitis is invariably fatal with a mortality of 83% in patients without neuropsychiatric manifestation and 76% in patients with neuropsychiatric manifestation. [1] Our report underlines the need to delineate organic brain syndromes by looking for subtle systemic and neurological signs before treating the behavioral disorders with psychotropic drugs.
Table 1: Reported cases of neuropsychiatric manifestations secondary to cryptococcal meningitis

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  References Top

1.De Ibanez-Valdes LF, Foyaca-Sibat H, Mfenyana K, Chandia J, Gonzalez-Aguilera H. Neuropsychiatry Manifestations In Patients Presenting Cryptococcal Meningitis. Internet J Neurology 2005;5. [ http://www.ispub.com/journal/the_internet_journal_of_neurology/...._meningitis.html ] [Last accessed on 2011 Jul 21].  Back to cited text no. 1
    
2.Satishchandra P, Mathew T, Gadre G, Nagarathna S, Chandramukhi A, Mahadevan A, et al. Cryptococcal meningitis: Clinical, diagnostic and therapeutic overviews. Neurol India 2007;55:226-32.  Back to cited text no. 2
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3.Goeb JL, Leon V, Kechid G. Cryptococcal meningitis with acute psychotic confusion in a sarcoid patient. Prim Care Companion J Clin Psychiatry 2007;9:393-4.  Back to cited text no. 3
    
4.Aharon-Peretz J, Kliot D, Finkelstein R, Ben Hayun R, Yarnitsky D, Goldsher D. Cryptococcal meningitis mimicking vascular dementia. Neurology 2004;62:2135.  Back to cited text no. 4
    
5.Tan WK, Ungvari GS, Leing CM. Cryptococcal meningitis mimicking primary mania in a young female. Gen Hosp Psychiatry 2005;27:298-303.  Back to cited text no. 5
    
6.Prakash PY, Sugandhi RP. Neuropsychiatric manifestation of confusional psychosis due to Cryptococcus neoformans var. grubii in an apparently immunocompetent host: A case report. Cases J 2009;2:9084.  Back to cited text no. 6
    
7.Thienhaus OJ, Khosla N. Meningeal cryptococcosis misdiagnosed as a manic episode. Am J Psychiatry 1984;141:1459-60.  Back to cited text no. 7
    
8.Sa′adah MA, Araj GF, Diab SM, Nazzal M. Cryptococcal meningitis and confusional psychosis: A case report and literature review. Trop Geogr Med 1995;47:224-6.  Back to cited text no. 8
    
9.Johannessen DJ, Wilson LG. Mania with cryptococcal meningitis in two AIDS patients. J Clin Psychiatry 1988;49:200-1.  Back to cited text no. 9
    
10.Johnson FY, Naragi S. Manic episode secondary to cryptococcal meningitis in a previously healthy adult. P N G Med J 1993;36:59-62.  Back to cited text no. 10
    



 
 
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This article has been cited by
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Rajesh Jacob,Zheng Zhimin,Satya Rayapureddy,Robert T. Isaacs
Asian Journal of Psychiatry. 2013;
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