A Deadly Fungus: Case of an Unidentified Severe Cryptococcal Meningoencephalitis

Abstract

A 45-year-old man with no systemic illnesses was found by his neighbor lying unconscious and with recurrent involuntary movements, reason for which he was endotracheally intubated and brought to our institution. Upon evaluation, we found an acutely ill-looking man, with decreased level of consciousness (Glasgow coma scale 11) off sedation, on mechanical ventilator support with adequate oxygenation. Physical exam was remarkable for fever, scalp lacerations with old sutures, generalized rigidity and diaphoresis, with clear lungs and no abnormal heart sounds. Laboratory results showed no leukocytosis or leukopenia, but normocytic normochromic anemia; there were no electrolyte disturbances and negative toxicology screen. Head CT without intravenous contrast showed no findings suggesting bleeding, ischemia or space occupying lesions but reported parenchymal disease, and old skull and maxillofacial fractures. Patients neighbor referred that he was hospitalized 2 weeks ago at another institution with seizures that apparently caused him a 12-feet fall at work. Re-evaluation showed a positive Kernig and Brudzinski signs. Lumbar puncture was performed. The opening pressure was markedly elevated (> 30 cm H₂O) and cerebrospinal fluid (CSF) analysis was consistent with fungal infection. He was promptly started in empiric antifungal therapy with amphotericin and flucytosine while waiting for CSF culture results. Meanwhile, serial lumbar punctures were performed to decrease intracranial pressure. HIV tests were sent and resulted positive. CSF culture showed Cryptococcus neoformans, and CSF cryptococcal antigen titer was positive in 1:32 dilutions. Diagnosis of severe cryptococcal meningoencephalitis was confirmed. Cryptococcus neoformans is one of the leading opportunistic infections seen in untreated patients with HIV and is uniformly fatal within approximately 2 weeks if untreated. Our patients prognosis was poor since admission; however, we just cannot stop thinking that maybe his prognosis could have been different if meningitis was even suspected and confirmed during patients previous hospitalization for seizures 2 weeks ago.




J Med Cases. 2015;6(9):406-408
doi: https://doi.org/10.14740/jmc2194w