Title : Cryptococcal meningoencephalitis present as a stroke mimic in ICL patient
Cryptococcus neoformans infection predominantly occurs in the immunocompromised patients. However, it may infect apparently immunocompetent hosts and present as stroke mimic. We are reporting a case of elderly gentleman who presented with acute onset right upper limb weakness, ataxia and impaired awareness. He had no history of fever, headache, vomiting, convulsions, recent travel or vaccination. CT head showed left frontal lobar hypodensity which was not corresponding to a vascular territory. CEMRI brain was done which showed focal left frontal leptomeningeal enhancement with focal cerebral edema. Blood workup including HIV and HTLV was negative. CSF examination showed lymphocytic pleocytosis with raised protein and low glucose. He was started on antitubercular treatment with steroid. He developed altered sensorium and fever. A repeat CEMRI brain revealed a new diffuse leptomeningeal enhancement with mild improvement in the left frontal focal leptomeningeal enhancement and cerebral edema. Repeat CSF examination showed raised cell count with polymorphic predominance with very high protein and very low glucose concentration. Budding yeast cells with pseudocapsule were seen and cryptococcal antigen was positive. CD 4 count was low on two occasions (106 and 259 cells/cumm). He was started on liposomal amphotericin B and flucytosine following which he had clinical improvement. Follow up CSF examination showed clearance of all fungal elements and MRI brain showed multiple vasculitic infarcts with mild hydrocephalus. Cryptococcal infections are common in patients with idiopathic CD4+ T lymphocytopenia (ICL). This was present in approximately one fourth of the patients with ICL in one series. Case reports have been documented where it has presented as stroke mimic. It may present atypically without any preceding fever or headache. Also, the initial presentation may be focal leptomeningeal enhancement on neuroimaging prior to its more common manifestation of diffuse leptomeningeal enhancement. A high index of suspicion of cryptococcal meningoencephalitis must be kept in ICL patients with neurological manifestations.
Audience Take Away
- We should actively search for other causes of immunodeficiency in HIV negative patients with cryptococcal meningoencephalitis
- Cryptococcal meningoencephalitis may present as stroke mimic