The following day, her mental status is unchanged.

Lydia remains confused but afebrile. Biox reveals pulse of 84 with 96% saturation. The results of the LP are not available. The intern goes to the lab for the CSF values: Elevated protein Normal glucose Cyrptococcus seen with India ink An ELIZA for HIV is ordered.

Lydia was started on Fluconazole for her Cryptococcal meningitis

• Unlike bacterial meningitis, fungal meningitis may not have nuchal rigidity.
• Fungal meningitis may present with confusion or even cortical blindness.
• Sometimes, a 'therapeutic' lumbar puncture is done to relieve pressure.
• Changes of acute hydrocephalus may also develop if there is occlusion of the CSF outlets of the 4th ventricle. Click here to see an example.
• Unfortunatley, India ink is positive only about 80% of the times.
• May need to treat empirically if there is a high enough index of suspicion.
• CSF protein is elevated, but glucose can be normal.
• Fever may not be present

What else should you think about?