HIV neg Crypto Meningitis

Question

Dear Dr. Feinberg:

I am a gay physician whose partner is 45yo and just developed documented cryptococcal meningitis which responded quickly to Diflucan. He had never been previously ill, was never HIV+ and always practiced safe sex.

He was found to have a CD4 of 99, however HIV antibody testing and viral load testing done two months apart and many months after any possible exposure were negative. Lupus testing and a workup for lymphoma were negative. His past history includes Rocky Mtn Spotted Fever.

My question is: is this bout of crypto an AIDS-related opportunistic infection (in the absence of negative HIV testing)? What other possible etiologies might there be for developing crypto?

Thank you for your response.

Answer

You can be HIV- and develop crypto meningitis if you encounter a heavy inoculum, or if you have some underlying immune deficiency, like lymphoma. Other diseases can change T cell counts and ratios, but the coincidence of all these things happening to the same person raises a red flag. Did he have a direct test for HIV in addition to the standard antibody (ELISA) test? If not, he should have an HIV viral load test Roche Amplicor methodology may result in the fewest false negatives) or a p24 antigen test. I'd suspect HIV until proven otherwise.