KRIPTOKOKNI MENINGITIS KAO DIJAGNOSTIČKI PROBLEM U BOLESNIKA SA SUSTAVNIM ERITEMSKIM LUPUSOM – PRIKAZ BOLESNIKA

Dubravka Bosnić, Mislav Cerovec, Branimir Anić, Miroslav Mayer, Mirna Sentić, Marko Barešić, Jasenka Markeljević, Nada Čikeš

Sažetak. Sustavni eritemski lupus (SLE) bolest je sa širokim spektrom kliničkih očitovanja. Prognozu bolesnika uglavnom određuje zahvaćanje vitalnih organa kao što su bubreg i središnji živčani sustav (SŽS). Bitan uzrok smrtnosti u bolesnika sa SLE-om su infekcije. One su česte zbog agresivne imunosupresivne terapije koja je potrebna radi kontrole upalne aktivnosti osnovne bolesti. U tekstu je prikazan bolesnik sa SLE-om i klinički značajnom renalnom afekcijom, ali i komplikacijama imunosupresivne terapije primijenjene u liječenju. Iako slučajno otkrivena, bolest je od početka imala težak klinički tijek. Zbog lupusne nefropatije već je u ranoj fazi bolesti započeta agresivna imunosupresivna terapija (kombinirana parenteralna primjena glukokortikoida i ciklofosfamida). Kao posljedica kombiniranog učinka osnovne bolesti i imunosupresivne terapije razvila se infektivna dijateza (ponavljane infekcije S. enteritidis – uroinfekcije i sepsa). Tijekom jedne od hospitalizacija zbog relapsa osnovne bolesti razvila se oportunistička infekcija, meningitis uzrokovan gljivom C. neoformans. Infekcija se klinički očitovala nespecifičnim simptomima i znakovima afekcije SŽS-a te se postavilo pitanje afekcije SŽS-a sistemskim lupusom. Iako je dijagnostika provedena pravodobno te je promptno uvedena odgovarajuća antimikotična i simptomatska terapija, ishod je bio fatalan. Zbog infektivne dijateze bolesnika koji boluju od SLE-a a koja se očituje obolijevanjem od uobičajenih, ali i oportunističkih infekcija, kao i zbog visoke stope mortaliteta zbog ovih infekcija, pokušali smo upozoriti na potrebu pravodobnog uzimanja/analize primjerenih uzoraka prema rijetkim uzročnicima infekcija kao što je primjerice C. neoformans. U recentnoj medicinskoj literaturi dominiraju slučajevi opisani na području Azije, rijetki su izvještaji s područja Europe, a opisani je bolesnik prvi takav slučaj u Hrvatskoj.

Summary. Systemic erythematosus lupus (SLE) is a disease with wide range of clinical manifestations, signs and symptoms. Disease outcome depends mostly on the affection of kidneys and central nervous system by the disease. Very important cause of death in patients with SLE is infection. Infections are very common among these patients due to aggressive immunosuppressive treatment that is needed for the disease inflammatory activity control. in this case report we have presented a patient with SLE who initially had severe renal affection, but also complications of immunosuppressive therapy that was administered. Even though the disease was accidentally diagnosed, it had a severe clinical progress. Because of lupus nephropathy, in the early phase of the disease we administered aggressive immunosuppressive therapy (combined parenteral therapy of glucocorticoides and cyclophosphamide). As an outcome of the combined effect of disease and immuno¬suppressive agents used in the treatment of the disease, the patient had increased infective diathesis (repeated infections caused by S. enteritidis – urinary infections and sepsis). During one of the disease flares the patient was hospitalized an opportunistic infection developed. It was meningitis caused by C. neoformans. This opportunistic mycosis infection ¬presented with clinically totally nonspecific signs and symptoms of CNS affection. Therefore, we suspected affection of CNS with SLE. Even though all diagnostic procedures were made on time and that adequate antifungal and supportive agents were applied very early after the infection onset, the outcome was fatal. Because of infective diathesis in patients with SLE, which present with common and opportunistic infections, and due to high mortality rates caused by these infections, we have tried to emphasise the importance of taking adequate specimens early after infection outcome for these rare infective agents like C. neophormans. In recent medical literature are dominant cases reported in Asia. Reports from Europe are very rare, and this case is the one of that kind in Croatia.