The diagnostic role of elevated serum cryptococcal antigen titers in patients with suspected cryptococcal meningitis when lumbar puncture is contraindicated: A case report

Cryptococcal meningitis is one of the major causes of death in sub-Saharan Africa among individuals with advanced HIV, and it is typically diagnosed through lumbar puncture (LP). However, LP may be contraindicated in some cases, causing a clinical dilemma and potential delay in treatment. We present the case of a 60-year-old female, newly diagnosed with HIV, who presented with a reduced level of consciousness and a positive serum cryptococcal antigen (CrAg) test (high titer = 1:320). Computerized tomographic (CT) brain imaging showed multiple nodular lesions, peri-lesional edema and a midline shift. Despite the contraindication for LP, a low volume lumbar puncture (1–2 mL) was performed in view of the elevated serum CrAg titers and patient's clinical symptoms, in order to rule in a definitive diagnosis of cryptococcal meningitis or exclude tuberculous meningitis. The patient was treated for cryptococcal meningitis and responded well. In patients with a positive serum CrAg test and contraindications to LP, an elevated titer (>1:160) and neurological symptoms may guide the initiation of definitive treatment for cryptococcal meningitis, however further evaluation is needed.