CASE REPORT Use of Cerebrospinal Fluid Shunt for the Management of Elevated Intracranial Pressure in a Patient with Active AIDS-Related Cryptococcal Meningitis Eleftherios Mylonakis, Nathan A. Merriman, Josiah D. Rich, Timothy P. Flanigan, Beverly C. Walters, Karen T. Tashima, Maria D. Mileno, and Charles M. van der Horst Persistently elevated intracranial pressure (ICP) is one of the most accurate predictors of a poor prognosis in patients with AIDS-related cryptococcal meningitis. We present a severe case of persistent cryptococcal meningitis in a patient with advanced AIDS, complicated by elevation of ICP. A ventricu- loperitoneal shunt was placed that successfully lowered the ICP and alleviated the associated symptoms. The elevated ICP secondary to AIDS-related cryptococcal meningitis should be treated aggressively. Despite the risk of shunt complications, cerebrospinal fluid shunts can be considered in these patients if they do not respond to other treatment. © 1999 Elsevier Science Inc. Cryptococcal meningitis is the most common life threatening fungal infection in patients with AIDS (Chuck and Sande 1989; Dismukes 1988; Powderly 1993). Several studies have shown that persistently elevated intracranial pressure (ICP) and alterations in mental status are two of the most accurate predic- tors of a poor prognosis in patients with AIDS- related cryptococcal meningitis (Denning et al. 1991; Fessler et al. 1998; Powderly 1996; Saag et al. 1992). We present a patient with persistently elevated ICP associated with AIDS-related cryptococcal men- ingitis and review the literature on the management of elevated ICP secondary to cryptococcal meningitis. A 38-year-old male diagnosed with human immu- nodeficiency virus (HIV) 6 years previously, with a recent CD4 count of 25 cells/mm 3 , presented with headaches, nausea, and vomiting. The patient had a history of recurrent Pneumocystis carinii pneumonia, wasting syndrome, chronic anemia, non-Hodgkin’s lymphoma in remission, herpes zoster, and oral thrush. Cerebrospinal fluid analysis established the diagnosis of cryptococcal meningitis (Table 1). Open- ing pressure was not measured on the first lumbar puncture because the pressure was so elevated that cerebrospinal fluid (CSF) projected out of the punc- ture needle. A subsequent magnetic resonance imag- ing did not suggest hydrocephalus, but revealed ab- normalities at the basal ganglia consistent with multiple cryptococcomas. Over the next 3 months, the cryptococcal infection was treated with several combinations of antifungal medications, including From the Department of Medicine, The Miriam Hospital, Brown University School of Medicine, Providence, Rhode Is- land; Department of Neurosurgery, The Miriam Hospital, Brown University School of Medicine, Providence, Rhode Is- land; and Division of Infectious Diseases, Department of Medi- cine, University of North Carolina, Chapel Hill, North Carolina. Address reprint requests to Dr. Eleftherios Mylonakis, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906. Received 20 November 1998; revised and accepted 11 Febru- ary 1999. DIAGN MICROBIOL INFECT DIS 1999;34:111–114 © 1999 Elsevier Science Inc. All rights reserved. 0732-8893/99/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0732-8893(99)00025-5