Title : A rare case: Crytococcal menigitis presenting as recurrent stroke
Abstract:
Meningitis, a severe and potentially fatal infection of the central nervous system, can be caused by Cryptococcus neoformans, a rare fungus that often presents with unusual symptoms. While this type of infection is more frequently seen in individuals with compromised immune systems, it can also occur in those with normal immune function. Here, we present a case illustrating the complexities of cryptococcal meningitis in an immunocompetent patient, emphasizing the importance of early recognition and treatment.
Our patient, a 58-year-old male with a medical history of hypertension and diabetes, initially sought care at the emergency department (ED) with complaints of diplopia, dizziness, and gait imbalance. Magnetic resonance imaging (MRI) of the head revealed an acute ischemic stroke affecting the medial right pons, along with a small rim-enhancing lesion adjacent to the pons. Concerned about the possibility of an inflammatory process, lumbar puncture (LP) was performed, and the patient was subsequently discharged to await the results as an outpatient.
Surprisingly, the cerebrospinal fluid (CSF) analysis returned indicative of cryptococcal meningitis, a rare finding given the patient's immunocompetent status. Unfortunately, the patient was lost to follow-up for a considerable five-month period. During this time, he experienced persistent left-sided headaches, photophobia, and vertigo, prompting a return visit to the ED.
Recognizing the urgency of the situation, a repeat LP was performed, confirming the presence of Cryptococcus neoformans yeast cells in the CSF. Immediate initiation of curative antifungal therapy was imperative, and the patient was discharged with a prescription for long-term antibiotic therapy.
This case highlights several noteworthy aspects. Firstly, it underscores the elusive nature of cryptococcal meningitis, which can manifest despite the absence of traditional risk factors or compromised immunity. The delayed diagnosis due to loss to follow-up exemplifies the challenges in managing such cases, emphasizing the need for robust patient education and follow-up mechanisms.
The successful identification of the causative agent in the CSF, coupled with prompt initiation of targeted therapy, underscores the pivotal role of LP in confirming the diagnosis and guiding treatment decisions. Additionally, the case emphasizes the importance of considering infection-mediated cerebral infarcts, even in the absence of overt immunocompromising conditions.
In conclusion, this case serves as a valuable illustration of the varied and atypical presentations of cryptococcal meningitis, challenging preconceived notions about risk factors and immunocompetency. Clinicians should maintain a high index of suspicion for cryptococcal meningitis, particularly when faced with unusual neurological symptoms, to facilitate early intervention and minimize potential adverse outcomes.
