我们感谢Drs带来的利益和评论。冯和张我们的文章。1We agree that intracranial pressure often rises with CNS cryptococcosis. However, we note that the main mechanism underlying increased pressure is due to obstruction of the arachnoid villi, not from mass effect of the gelatinous pseudocysts and cryptococcomas.2 While the lesions in this case are sizable, there is no significant mass effect, ventricular obstruction, nor herniation that would preclude a safe lumbar puncture (LP). In fact, the World Health Organization (WHO) recommends (repeated) LP as mainstay treatment for intracranial hypertension in CNS cryptococcosis.3 Prior study showed therapeutic LP improved survival regardless of initial pressure.4 Rest assured, the patient was well informed. We also note that the WHO recommends LP with either antigen testing (if available) or India ink test as first line strategy of diagnosis.3 In this case, brain biopsy/evacuation would not have improved care since the lesions were not isolated to the cerebellum, but could have resulted in additional complications. Following induction therapy with amphotericin B and flucytosine, clinical improvement was noted. The patient was transferred to rehabilitation facility in stable condition on consolidation therapy.
我们感谢Drs带来的利益和评论。冯和张我们的文章。1We agree that intracranial pressure often rises with CNS cryptococcosis. However, we note that the main mechanism underlying increased pressure is due to obstruction of the arachnoid villi, not from mass effect of the gelatinous pseudocysts and cryptococcomas.2 While the lesions in this case are sizable, there is no significant mass effect, ventricular obstruction, nor herniation that would preclude a safe lumbar puncture (LP). In fact, the World Health Organization (WHO) recommends (repeated) LP as mainstay treatment for intracranial hypertension in CNS cryptococcosis.3 Prior study showed therapeutic LP improved survival regardless of initial pressure.4 Rest assured, the patient was well informed. We also note that the WHO recommends LP with either antigen testing (if available) or India ink test as first line strategy of diagnosis.3 In this case, brain biopsy/evacuation would not have improved care since the lesions were not isolated to the cerebellum, but could have resulted in additional complications. Following induction therapy with amphotericin B and flucytosine, clinical improvement was noted. The patient was transferred to rehabilitation facility in stable condition on consolidation therapy.
1。陈K, Le D,郭a教学实验:隐球菌脑膜脑炎切除和凝胶状的假性囊肿。首页神经学。5月2日在线发表2023:10.1212 / WNL.0000000000207359。doi: 10.1212 / WNL.0000000000207359
2。Loyse,温赖特H,贾维斯约,等。组织病理学的蛛网膜颗粒在艾滋病隐球菌脑膜炎和脑:相关性与脑脊液压力。艾滋病。2010;24 (3):405。doi: 10.1097 / QAD.0B013E328333C005
3所示。世界卫生组织。指南诊断、预防和管理隐球菌病成年人、青少年和儿童感染艾滋病毒。2022年。
4所示。创建人,Hullsiek KH、大黄酸J。的影响从隐球菌脑膜炎治疗腰椎穿刺对急性死亡率。感染说。2014;59 (11):1607。doi: 10.1093 / CID / CIU596
我是一个作家的工作,这项工作是准备在自己的时间里——不是我作为一个员工的职责的一部分。