P3.G136: "A Misfortunate Pair”: Tuberculous and Cryptococcal Meningitis Co-infection in an Immunocompetent Child

Introduction: Tuberculous meningitis (TBM) remains the most lethal form of tuberculosis in children. Mortality is high and survivors are often left neurologically disabled. Cryptococcal Meningitis on the other hand is an opportunistic infection that causes more than 100,000 HIV-related deaths each year. Although the infection is usually HIV-related, there are few reports on cryptococcal meningitis in non-HIV-infected patients.

Case Description: A previously healthy 5-year-old male living in the inner-city presented to the pediatric emergency department with three weeks of intermittent fever, undocumented weight loss, and decreased appetite and activity. His symptoms progressed to 5-day history of generalized weakness with a new onset of neurologic deficits such as the inability to eat, speak, and ambulate. He developed generalized tonic-clonic seizures prompting the admission. Further history revealed exposure to grandfather treated for tuberculosis and potential exposure to nearby pigeon sanctuaries. On examination, he was lethargic, with no verbal output and deficits in cranial nerves: II, III, IV, VI and VII. He was also noted for spastic extremities, nuchal rigidity, bilateral Babinski, and clonus. An immediate cranial CT scan was done revealing a triad of tuberculous meningitis findings – basal enhancement, left thalamocapsuloganglionic infarcts and communicating hydrocephalus. Chest radiography and Tuberculin Skin Test were indicative of TB disease. Gastric aspirate TB Xpert has detected Mycobacterium tuberculosis. CSF analysis revealed hypoglycorrhachia and mild lymphocytosis, and the presence of encapsulated yeasts with India ink. Further immunodeficiency testing showed a non-reactive HIV test with normal CD4 levels and CD4% lymphocyte counts. As the patient's neurological status worsened, a ventriculostomy was performed followed by a ventriculoperitoneal shunt. The patient received anti-TB regimen and dexamethasone along with antifungal therapy.

Discussion: Cryptococcal Meningitis is the most common opportunistic infection in advanced HIV. TBM on the other hand is the second most common cause of HIV – associated meningitis. However, co – infection is rare, especially in non – HIV patients. In the Philippines, no report was documented for this co – infection in immunocompetent children. Reports in the adult population nonetheless showed timely initiation of anti – TB regimen, amphotericin B and high – dose oral fluconazole showed favorable outcomes.

Conclusion: This case highlights that in disease endemic areas – like the Philippines, multiple disseminated infections can occur in individuals without obvious immunocompromise. There must always be a high index of suspicion when risk arises to employ timely intervention.