Immunocompromised patient meningitis

L. monocytogenes is a gram-positive, diphtheroid-like organism and is responsible for 8% of all reported cases of meningitis. The disease affects primarily neonates, alcoholics, immunocompromised patients, and the elderly. 

In immunocompromised patients pulmonary infection can lead to disseminated forms of the disease where the eyes, skin and bones become infected. Cryptococcal meningitis is particularly associated with AIDS patients, where it is a major cause of death. While cryptococcosis may be controlled by antifungal therapy, in AIDS patients there is a danger of relapse unless antifungal therapy is constantly maintained. 

Cryptococcosis is caused by Cryptococcus neoformans and occurs primarily in immunocompromised patients. Patients with acute meningitis are treated with amphotericin B with flucytosine. Patients infected with HIV require long-term suppressive therapy with fluconazole or itraconazole. 

In the case of opportunistic candidal infections in the immunocompromised patient, no prophylactic drugs have been shown to be effective. Prophylaxis against other fungi may be effective in some instances, including suppression of cryptococcal meningitis in AIDS patients with fluconazole. However, prophylactic use of azoles may be contributory to the development of fungal resistance. The answer is (E). 

Glucocorticoids are also used in the treatment of a number of HIV-related disorders, including Pneumocystis carinii pneumonia, demyelinating peripheral neuropathies, tuberculous meningitis, and nephropathy. Glucocorticoids are used as adjunctive therapy in Pneumo cystitis carinii pneumonia to decrease the inflammatory response and allow time for antimicrobial agents to exert their effects. In patients who are immunocompromised because of HIV infection, adjunctive steroids may be less beneficial in promoting survival. 

Lumbar puncture is considered mandatory in patients with suspected bacterial meningitis but the procedure can be hazardous with a risk of brain herniation in patients with raised intracranial pressure, and imaging with computed tomography or MRI is recommended for selected patients to detect brain shift. Patients who are in an immunocompromised state, have new-onset seizures, moderate-to-severe impairment of consciousness or signs that are suspicious of space-occupying lesions (e.g. papilloedema - oedema of the optic disk) should undergo neuroimaging prior to lumbar puncture. 

Peak plasma levels occur around 2 hours after oral administration, with a terminal half-life of around 8 hours. Ketoconazole is extensively bound (>95%) to plasma proteins, mainly albumin, which results in relatively low free dmg concentrations. Therefore, with clinical dosing schedules, ketoconazole tends to be fungistatic rather than fungicidal, which is a potential concern if the patient is immunocompromised. Ketoconazole is widely distributed throughout the body but penetration into CSF is low, excluding its use in the treatment of fungal meningitis. 

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