Hemophagocytic syndrome in a patient with acute human immunodeficiency virus infection.

tion of a lumbar drain, or implantation of a VP shunt is recommended if neither focal neurologic signs nor obtunded consciousness with space-occupying lesions visible by radiographic imaging were observed [2, 9]. However, frequent lumbar punctures and large-volume drainage in the presence of elevated ICP have raised concerns among clinicians about the risk of brain herniation [6]. Antinori and colleagues [6] reported 2 cases of cryptococcal meningitis in patients who experienced loss of consciousness and died soon after lumbar puncture. At autopsy, brain herniation was considered by Antorini et al. [6] to be the cause of death; however, inadequate CSF drainage and the resultant brain herniation—not the lumbar puncture—was suspected by Graybill and Sobel [10] to be the cause of death. In our patients with cryptococcal meningitis who had extremely high ICP and poor prognostic predictors of death during initial therapy (i.e., abnormal mental status, a CSF antigen titer of 11:1024, and a CSF WBC count of !20/mL [11]), we found that, with frequent, multiple lumbar punctures combined with antifungal therapy consisting of amphotericin B and fluconazole, 7 patients survived the disease. The condition of the patient who developed visual loss because of extremely high ICP improved with our aggressive external CSF drainage. The 2 deaths were most likely caused by delayed presentation for appropriate HIV care. In 1 of the 2 patients, signs of increased ICP resolved gradually, and altered consciousness returned to normal after multiple procedures. However, extremely high ICP recurred and resulted in death. This case should alert clinicians to the possibility of recurrent high ICP despite antifungal therapy, and careful monitoring of the ICP is indicated. In conclusion, the findings of our study support the recommendation of aggressive use of lumbar puncture for the management of elevated ICP to reduce the risk of early mortality and late morbidity, even for patients with extremely high ICP. Multiple lumbar punctures and large-volume CSF drainage in HIV-infected patients with elevated ICP due to cryptococcal meningitis is safe after the presence of space-occupying lesions is excluded.