Title : Cryptococcal meningitis without headache: A case report highlighting atypical presentation
Abstract:
Background: Cryptococcus neoformans meningoencephalitis is a common manifestation of cryptococcosis and disseminated infection, often seen in immunosuppressed patients and untreated AIDS. Common immunosuppression causes glucocorticoid therapy, organ transplantation, cancer, and other conditions. Symptoms include headache, fever, vomiting, and altered mentation.
Case Presentation: We present a 61-year-old female diagnosed with autoimmune hemolytic anemia on high dose glucocorticoid therapy who presented with dyspnea and febrile episodes. The initial workup suggested community-acquired pneumonia, but further testing with blood cultures revealed yeast cells, and the serum cryptococcal antigen titer was markedly elevated (1:4096). Even if with the absence of headache or other neurological symptoms, lumbar puncture was done due to a high index of suspicion, eventually revealing an elevated opening pressure of 51 cmH2O, and a positive CALAS in cerebrospinal fluid. The patient was then treated with liposomal amphotericin B and fluconazole as per treatment protocol, and with serial lumbar punctures showing a gradual decline in antigen titers and intracranial pressure. She remained clinically stable and was transitioned to consolidation therapy with fluconazole. This case highlights the need for early CNS evaluation in immunocompromised patients with high cryptococcal antigen titers, even in the absence of classical symptoms.
Conclusion: Cryptococcal meningitis should be identified in immunocompromised patients, especially when serum antigen titers are high, even if no neurologic symptoms. Early diagnosis, comprehensive evaluations, and prompt antifungal treatment are crucial for improved patient outcomes.
