Objective:
Cryptococcus meningitis is the most common fungal meningitis. Cryptococcus can affect different organ systems however has a particularly strong neurotropism therefore patient’s frequently present with headache, altered mental status, lethargy, visual symptoms, and emesis. Cryptococcal meningitis is a subacute disease normally presenting in 1-2 weeks in HIV patient’s and 6-12 weeks in non-HIV patients. This case depicts an abrupt, explosive onset case of cryptococcus meningitis developing over a 24-hour period.
Background:
A 43-year-old male with a past medical history of Cystic Fibrosis (CF) with double lung transplant was admitted for shortness of breath. Six days into the admission, Neurology was consulted urgently for acute encephalopathy with somnolence and lethargy. During the preceding 24 hours, the patient was complaining of a headache and had 1 episode of emesis mostly attributed to migraine however was at neurologic baseline. Initial neurologic evaluation was notable for somnolence with right gaze preference with inability to cross midline and right beating nystagmus. There was no evidence of meningeal signs. CTH from that morning showed evidence of subcortical hypoattenuation posteriorly however no previous images to compare . Differential diagnosis at the time included nonconvulsive status epilepticus secondary to CNS infection or PRES. Due to worsening clinical exam, lumbar puncture was completed which showed malignant ICP with opening pressure unmeasurable > 55 mm H2O with fluid analysis positive for lymphocytic pleocytosis, and later positive cryptococcus antigen. Despite quick initiation of lumbar drain for management of ICP and immediate antimicrobial coverage, the patient’s persistently elevated ICP resulted in herniation and the patient’s demise.
Conclusions:
This case depicts the importance of recognizing the signs and symptoms of abrupt onset cryptococcus meningitis and maintaining this disease on your differential for acute meningitis. The biggest predictor of a poor prognosis is an opening pressure > 25 mm H2O on the first spinal tap.
Disclaimer: Abstracts were not reviewed by Neurology® and do not reflect the views of Neurology® editors or staff.