Opportunistic Infection — SCE Rheumatology MCQ

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HardRheumatology EmergenciesOpportunistic InfectionSCE Rheumatology

A 65-year-old man with RA on Methotrexate and Prednisolone 5 mg daily presents with acute confusion and fever. CT head is normal. Lumbar puncture shows elevated opening pressure lymphocytic pleocytosis protein 1.8 g/L and low glucose. India ink stain is positive. What is the most likely organism?

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Correct answer: D — Cryptococcus neoformans

India ink-positive CSF with lymphocytic pleocytosis, elevated protein, and low glucose in an immunosuppressed patient is diagnostic of cryptococcal meningitis (Cryptococcus neoformans). RA patients on combined immunosuppression (Methotrexate + corticosteroids) are at increased risk of opportunistic infections including cryptococcosis. Treatment involves IV Amphotericin B with Flucytosine for induction, followed by oral Fluconazole for maintenance. Immunosuppression should be reviewed and reduced. This underscores the infection risk with combined immunosuppressive therapy in RA.

Reference: BSR 2019 biologic safety guidelines; BIA/BHIVA guidelines for cryptococcal disease