The enigma of transient splenial hyperintensity: In cryptococcal meningitis
A 16-year-old Hindu girl was admitted to the hospital with chief complaints of fever for 20 days, ataxia and diplopia for 3 days. The fever was low grade, intermittent, and with evening rise of temperature and was associated with headache which was holocranial, bursting, and non-throbbing. She developed acute onset ataxia over 1-2 days and diplopia associated with vomiting. She is immunocompromised (HIV positive) since birth, her parents were seropositive (both died 8-10 years ago due to AIDS-related complications). Antiretroviral therapy was started 2 months prior to admission because CD4 count was 92 cells/mm3 at that time, although she was asymptomatic then.\nOn physical examination, she was conscious, oriented, and afebrile, body mass index (BMI) was 20. Her pulse rate was 86 per minute, blood pressure was 110/70 mmHg and there was no superficial lymphadenopathy. Cranial nerve examination revealed bilateral papilloedema and bilateral lateral rectus palsy. Motor system exam revealed 4-/5 power in right proximal lower limb. Finger-nose test, heel-shin test were abnormal on both sides, and deep tendon reflexes were diminished on the right lower limb. However, sensory system examination and control of bowel/bladder were normal. Examination of respiratory, cardiovascular, and abdomen were within normal limits.\nAfter 3 days of admission she developed right-sided lower motor neuron (LMN) type of facial nerve palsy [], she also developed herpes labialis nearly the same time. Initially, she was put on mannitol and oral acyclovir to control herpes labialis.\nSubsequent investigations showed Hb 9.9 gm%, TLC 7500/mm3 (Neutrophlis 76%, Eosinophils 2%, Basophils 0%, Lymphocytes 20%, Monocytes 2%), platelet count 2,80,000 per mm3, fasting plasma glucose 90 mg/dl, blood urea 20 mg/dl, serum creatinine 1.0 mg/dl, serum billirubin 0.6 mg/dl, total protein 8.0 g/dl (albumin 4.0 g/dl), AST 33U/L, and ALT 35 U/L.\nMRI of brain revealed hyperintensity of Splenium of Corpus Callosum in FLAIR (“Boomerang sign”) [], although T2 and T1 with contrast did not show any such abnormality. On doing lumbar puncture, cerebrospinal fluid (CSF) pressure was very high (10-12 drops/sec). CSF examination showed 55 cells/mm3 (Neutrophils 4%, Lymphocytes 96%), glucose 6.0 mg/dl, protein 123 mg/dl, chloride 128 mmol/L, and adenosine deaminase 1.60 U/L (normal <5 U/L). Antitubercular drugs (ATD) were started empirically but her condition continued to deteriorate with increasing headache and sequential development of lower motor neuron (LMN) type of facial palsy on the left side [] with partial improvement of the facial palsy of the right side. CSF polymerase chain reaction (PCR) for Epstein barr virus was negative but Cryptococcus antigen became positive by enzyme immunoassay. Amphotericin B was added to the regime. Her CD4 count at this time was 246 cells/mm3. She started improving gradually, her facial palsy and sixth nerve palsy resolved. She was discharged from the hospital after 2 weeks with an advice to continue fluconazole and cotrimoxazole.\nShe came for regular follow-ups, was doing well. A repeat MRI of brain was done after 2 months, it showed complete resolution of the splenial hyperintensity in FLAIR [].