Cryptococcal Meningitis: Opportunistic Vagrant

There are many bad ways to die. I’ve seen some of them.

But one that perhaps haunts me most is the CLAT+ patients.

The Human Cell Line Activation Test (CLAT) is one of the most common tests utilised to diagnose Cryptococcal Meningitis. Cryptococ is in itself quite commonly found throughout nature – for example in bird faeces – and is then inhaled and eventually sent to the CSF.

Generally our immune systems react quite well and eliminate the offending spore from the body.

Unless you’re severely immunocompromised. Unless your CD4-count has dropped to below 50.

I’ve seen a few of these patients now. They come in obviously sick. Their necks are stiff. They have unremitting headaches such that they refuse to lie down.

Stained with India Ink, their CSF invariably darkens with the characteristic haloed clusters of the Cryptococcal yeast (although whether or not it is a yeast is always debatable).

I’ve seen so few of these patients survive. Maybe I’ve just been unfortunate enough to have seen the worst cases.

The pain makes them different people. They become rude, obstinate.

It’s easy to forget that it’s the pain speaking.

They slam their heads against the wall, hoping that one pain will relieve the other. It doesn’t seem to help. Then the nurses restrain them; bind them such that they cannot harm their own skulls more than the microscopic war within them.

I think it must be the very worst to feel that pressure build-up within your skull. I think perhaps you don’t require physics in your résumé to know that the pressure can only increase to a certain point until something budges.

And something budging within your skull is rarely a good thing.

I dream of their screams sometimes. I see the pleading in their eyes when we attempt yet another therapeutic lumbar puncture. I see the resignation when the strongest medication does not relieve their pain.

Invariably, I enter the ICU the next morning to find that a new patient is on the bed.  I wait for the day that we can discharge one of these patients in a state better than what they were.

*Amphotericin B is an excellent and available remedy for Cryptococcal Meningitis. However, in the socio-economic setting of our service population, these patients very rarely present with a straight-forward picture. One such example is the lady whose Diabetes Insipidus reduced her Potassium levels such that we could not administer the medication (it tends to deplete Potassium stores).