Abstract
A 33 year-old female at 32/40 (G1P0) presented with refractory headaches. Medical history included asthma and her pregnancy had been previously uncomplicated, aside from two flares of asthma requiring brief courses of prednisone. Regular medication included inhaled fluticasone propionate/formoterol fumarate. She was diagnosed with migraines and discharged after high dose aspirin. She represented the following day with worsening headaches, nuchal rigidity and fevers. CSF evaluation showed opening pressures of 31 mmH2O and predominant mononuclear pleocytosis. Cryptococcus gattii was subsequently detected from fungal cultures. Directed treatment included liposomal amphotericin and flucytosine. Initial MRI brain showed no evidence of raised intracranial pressure or cryptococcomas. During her prolonged admission, she experienced refractory headaches and raised ICP requiring successive therapeutic lumbar punctures and later insertion of a lumbar drain. Sequential MRIs demonstrated evolution of multiple cryptococcomas throughout her basal ganglia, supratentorial brain and cerebellum without significant mass effect. Immunosuppression screening was unremarkable. After three weeks of antifungal therapy her headaches settled. Complications of induction therapy included amphotericin-induced nephrotoxicity and peripartum hypokalaemia. She delivered a healthy newborn by elective caesarean section at 37+ 5 weeks and was discharged home without neurological deficit with HITH. Progress MRIs with gadolinium (postpartum) continue to show significant improvement in her cryptococcomas and resolving leptomeningeal changes. Notably, she did not develop cryptococcal-IRIS postpartum. After six weeks she was changed to fluconazole, which she will remain on for a further 12–18 months.
Conclusions C. gattii meningitis in pregnancy is uncommon, poses many therapeutic challenges and requires a collaborative multidisciplinary approach.
