The MICU is able to perform an LP. Opening pressure is 40cmH2O. Per IDSA guidelines, they remove 30mL CSF and are able to obtain a closing pressure of 20cmH2O, representing a reduction of 50%. They also start IV amphotericin B and flucytosine, with ID helping to guide therapy. The patient is found to be HIV-negative, so IRIS is less of a concern.
Her exam does improve, briefly. Unfortunately, there's some trouble repeating an LP, and she still has persistent intracranial hypertension. At this point, her exam gets worse, and they are unable to drain more CSF. You evaluate her, and you and your attending agree that it's reasonable to place an EVD and hope that it can get weaned.
She is unable to get the EVD weaned over the next two weeks. Fortunately, though, her intraabdominal infection has resolved. However, you opt to place a ventriculopleural shunt as her abdomen would not be hospitable to a shunt catheter (she has bad Crohn's disease). (In patients with cryptococcal meningitis that is NOT associated with HIV, shunts tend to be necessary more often.)
She eventually gets discharged to the floor, and then gets discharged to SAR thereafter, having spent a total of 5 weeks in the hospital.
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