We’ve had really exciting cases at ID report this month! Will highlight a few points about Cryptococcal meningitis in non-HIV patients and the infamous entity of epididymitis, with which our story begins…
Hx: <6 wks of (unilateral) pain, swelling, and inflammation of the epididymis (most patients won’t say that their epididymis hurts, but scrotal/testicular pain may be mentioned).
- Occasionally involving the testis (epididymo-orchitis, like in 12% of patients w/ Behcets dz) or accompanied by urethritis which is usually asymptomatic
- Among sexually active men aged <35 years, C. trachomatis or N. gonorrhoeae.
- If pt is insertive partner in anal sex, consider sexually transmitted enteric organisms (e.g., Escherichia coli and Pseudomonas spp.)
- If >35 years of age, don’t forget CT/GC though bacteriuria is usually 2/2 obstructive urinary disease, urinary tract instrumentation or surgery, systemic disease, and immunosuppression.
Ddx: R/o STI, torsion, abscess, hydrocele, hernia, testicular cancer, drug reaction (AMIODARONE-induced epididymitis, self-limited situation w/ onset 4-71 months after introduction of amio, whoknew?!)
- Suspect epididymitis by physical exam, tenderness around posterior testicle/epididymis
- Use (urine) NAATs for the detection of N. gonorrhoeae and C. trachomatis
- Gram stain & culture of urethral secretions
- ≥5 WBC/oil immersion field is highly sensitive & specific urethritis; can see intracellular Gram-negative diplococci on Gram stain to dx gonococcal infxn
- Positive leukocyte esterase test on first-void urine or urine w/ ≥10 WBC/hpf
- Other STI’s: RPR, HIV
- Sono—do this to r/o torsion as the ultrasound findings in epididymitis are of minimal utility in dx/tx and include epididymal hyperemia and swelling
Tx: CTX 250mg IM x1 + Doxy 100mg BID x10d OR if considering enteric organisms, Levofloxacin 500mg daily x10d.
- For sexual partners: refer all sexual partners (within 60d prior to sx onset) for eval and tx; avoid sex until pt and all sexual partners have completed tx
- Adjunct therapy:
- Bed rest, ice, scrotal elevation (scrotal sling, perhaps)
- Re-examine in 72hr to reassess dx and abx selection. FAILURE TO IMPROVE WARRANTS RE-EVAL OF DX/TX
- If swelling and pain persists (like in the patient presented this morning), do a comprehensive eval for tumor, abscess, TB**, infarction, fungal infxn
Dx by hx: ≥6 wks of discomfort and/or pain in the scrotum, testicle, or epididymis. The CDC recommends we divide this entity into inflammatory chronic epididymitis, obstructive chronic epididymitis, and chronic epididymalgia, but let’s not get crazy.
- Consider entities w/ granulomatous reaction, specifically Mycobacterium tuberculosis (TB) is the most common granulomatous disease affecting the epididymis
The case today ended up being GU TB, which brings up that in culture negative recurrent epididymitis (or really culture-negative anything), consider TB!
- Up to 25% of patients w/ TB epididymitis have bilateral disease
- Ultrasound shows enlarged hyperemic epididymis with multiple cysts and calcifications
- Consider **Tuberculous epididymitis in pt’s w/ exposure to (this pt lived in India for 30yrs, left 5yrs ago) or h/o TB infxn or in pt’s who worsen clinically despite approp abx
At a separate, equally exciting ID report, we discussed the (Short) Ddx for high protein level in CSF:
We also spent some time discussing Cryptococcal Meningitis in non-HIV patients:
-The patient presented had a negative serum CrAg, though a positive CSF CrAg. This is a rare, but observed entity…
-There is a group of patients who are non-HIV, non-transplant who get cryptococcal infections. Usually, they are more likely to get pulmonary crypto as the sole manifestation, though meningoencephalitis is also common. A few diagnostic pearls in this scenario:
- Serum CrAg titers in immunocompromised hosts tend to be higher than titers in immunocompetent patients
- Immunocompetent patients have higher mean CSF leukocyte counts, higher CSF protein, and lower CSF glucose
- Immunocompetent patients are less likely to be India ink-positive
- Higher 90-day and 1-year mortality for immunocompromised patients
- CrAg test characteristics are pretty great (see table below) in HIV-patients, and there’ve been recent studies suggesting the sensitivity of the lateral flow assay (LFA) is just as good in non-HIV patients (PMCID: PMC4733170)
The false negative serum CrAg pearls below come from our 2003 UCSF Chief foremothers and forefathers! https://medicine.ucsf.edu/education/resed/Chiefs_cover_sheets/crypto.pdf
*Causes of a false negative serum cryptococcal antigen test*: tests for antigen against crypto surface polysaccharide
- The serum CrAg is often negative in non-HIV patients
- Low titers of cryptococcus
- Early infection
- Presence of immune complexes
- Poorly encapsulated strains with low production of polysaccharide
- Prozone phenomenon of high titers
Sadek I, Biron P, Kus T: Amiodarone-induced epididymitis: report of a new case and literature review of 12 cases. Can J Cardiol 9:833, 1993 [PMID:8281484]https://medicine.ucsf.edu/education/resed/Chiefs_cover_sheets/crypto.pdf
Pappas PG. Cryptococcal Infections in Non-Hiv-Infected Patients. Transactions of the American Clinical and Climatological Association. 2013;124:61-79.
Jitmuang A, Panackal AA, Williamson PR, Bennett JE, Dekker JP, Zelazny AM. Performance of the Cryptococcal Antigen Lateral Flow Assay in Non-HIV-Related Cryptococcosis. Diekema DJ, ed. Journal of Clinical Microbiology. 2016;54(2):460-463. doi:10.1128/JCM.02223-15.