A Rare Case of Consequential Cryptococcal Meningoencephalitis Following Nemtabrutinib in Chronic Lymphocytic Leukemia presenting with normal intracranial pressure
Sebastian Camargo1, Elizabeth Baumann1, Andrea Siguenza1, Sadia Waheed2, Fajar Fawad1, Fawad Yousuf1
1Memorial Hospital West, 2Florida Atlantic University
Objective:
Introduction/Objective:
Cryptococcal meningoencephalitis is an opportunistic infection that typically presents with headache, encephalopathy, fever, and symptoms of increased intracranial pressure (ICP). Serial lumbar punctures are indicated in cases of elevated ICP and sometimes require the placement of a lumbar drain. We report a rare case of cryptococcal meningoencephalitis with normal opening pressure in a patient with chronic lymphocytic leukemia (CLL) receiving the investigational Bruton’s tyrosine kinase (BTK) inhibitor, Nemtabrutinib.
Background:
Case:
A 79-year-old female with chronic lymphocytic leukemia presented with a one-week history of fever, generalized weakness, fatigue, and visual disturbance after starting combination therapy with Venetoclax/Nemtabrutinib. The patient was found to have elevated serum white blood cells and underwent leukapheresis. Treatment with Nemtabrutinib was held due to persistent encephalopathy. An electroencephalogram was consistent with diffuse slowing and encephalopathy. Magnetic resonance imaging of the brain was negative for an acute process. Serological work-up was notable for cryptococcal antigen. Cerebrospinal fluid (CSF) was positive for cryptococcal antigen and had elevated protein. Interestingly, the opening pressure for CSF was normal, at 5 cm H2O. The patient was promptly started on Amphotericin B and Flucytosine. Subsequently, Nemtabrutinib was held indefinitely.
Conclusions:
Conclusion:
This case emphasizes the need for increased awareness and prompt investigation of opportunistic infections in CLL patients, particularly those treated with novel BTK inhibitors like Nemtabrutinib. Furthermore, the atypical presentation with normal ICP in cryptococcal meningoencephalitis highlights the potential for an unusual disease course. Clinicians should maintain a high index of suspicion for fungal infections, such as cryptococcal meningoencephalitis, in CLL patients with normal intracranial pressure receiving immunosuppressive therapy.
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