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Cryptococcal meningitis is a major HIV-related opportunistic infection, occurring when CD4 counts are below 100. Ocular involvement is seen with up to 30% of patients with cryptococcal meningitis. A young HIV infected male was admitted to in patient department of School of Tropical Medicine, Calcutta with complaints of headache for two months with dimness of vision for 10 days. Examination showed decreased visual acuity on both eyes, neck rigidity with right sided extensor plantar reflex, external ophthalmoplegia in the form of left 6th cranial nerve palsy, bilaterally absent light reflex, power 5/5 in all four limbs with normal tone and right eye hypermetropic tilted disc, left eye normal on ophthalmoscopy. India Ink preparation of CSF showed encapsulated budding yeast cells. Fungal culture grows Cryptococcus sp. CSF CRAG (cryptococcal antigen measured by immunochromatographic method) was positive in high titre (1:2560). MRI of brain revealed multiple tiny hypo to isointense lesions on T1 and hyperintense lesions on T2, T2 flair sequences are seen in basal ganglia, peri & paraventricular white matter and centrum semi-ovale on both sides. He was managed with injection amphotericin B deoxycholate along with fluconazole as per WHO recommendations and treatment related complications were managed accordingly. Visual acuity was followed in the entire treatment period but vision did not improve, but GCS improved to 15/15, there was no headache, no neck rigidity. Repeat MRI of brain after three weeks of treatment showed absence of above mentioned lesions. After 12 months of follow up the patient had no perception of light in both eyes and no wave in VEP study of both eyes suggestive of permanent visual loss following cryptococcal meningitis. So, cryptococcal meningitis after completion of treatment may have irreversible visual loss.

A 52-year-old hypothyroid presented with episodes of seizures in last ten days with altered behavior. CT scan of brain showed cerebral atrophy and MRI of brain revealed non-specific changes. In EEG, there was slow wave pattern. CSF study showed increased cell count with all lymphocytes and raised protein with normal glucose. Anti- TPO Antibody was positive. All relevant investigations like HIV, HBsAg, Anti- HCV Ab, ANA (Hep2 method), ANA profile, P-ANCA, c-ANCA, VGKC (voltage gated potassium channel) Ab, NMDA Receptor/Anti- Glutamate Antibody) Ab, VDRL were negative. She was given pulse doses of methylprednisolone followed by maintenance prednisolone. Then her GCS improved followed by sudden deterioration. Repeat CSF showed marginal decrement of protein and cell count. Then she was given IV Immunoglobulin and patient improved. At discharge her CSF study normalized. Anti-TPO Ab titre came to normal level and EEG normalized. Hashimoto’s encephalopathy(HE) should be suspected in a case of sub-acute encephalopathy with high levels of anti-thyroid antibodies may be with normal thyroid functions. Here the patient did not have improvement on steroids. The patient needed immunoglobulin to improve.

Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH ) is a rare but potentially life threatening conditioncharacterized by uncontrolled activation of CD8+ T lymphocytes and macrophages that leads to organ damage. HLHcan be primary (familial or genetic) and secondary. Secondary HLH occurs due to infections caused mostly by viruses likeEbstein Barr virus, Cytomegalovirus (CMV), Parvo B19 etc. Early diagnosis and treatment is the key to management ofHLH. We present here a case of a 30 year old female who presented with fever, jaundice, cough and progressive weakness of bothlower limbs. There was no girdle like sensation, no bladder/bowel involvement. She was recently diagnosed to be seropositivefor Human Immuno-deficiency Virus (HIV)-1 and had a CD4 count of 27/μL. She had hepatomegaly, pancytopenia, hyperbilirubinemia, hypoalbuminemia, raised liver enzymes and hypertriglyceridemia. CSF had raised protein, reduced sugarand neutrophils. DNA PCR for CMV was positive and there was evidence of CMV disease on fundoscopy. Her bonemarrow revealed presence of haemophagocytes. She was treated successfully with Ganciclovir, Dexamethasone and antiretroviraldrugs and was discharged. Though often fatal and difficult to diagnose, HLH is potentially treatable disorder.

Fine needle aspiration biopsy yields a high rate of positive tissue with negligible local sequelae. We report the first instance known to us of Chiba needle tract seeding following this biopsy technique in a patient with renal malignancy.

We study zero-sum stochastic differential games in a bounded domain with reflecting boundary condition. We consider two payoff criteria: discounted and average. We establish optimal strategies for both players and characterize these strategies