Objective:

To describe a case of cryptococcal cerebellitis in a patient on Fingolimod with atypical findings of generalized dystonia and imaging findings mistaken for bilateral subacute cerebellar strokes.

Background:

Fingolimod is used for multiple sclerosis and is often associated with lymphopenia with prolonged use. Opportunistic infections, particularly cryptococcus neoformans in patients on Fingolimod, have been rarely described.

Design/Methods:

Case report and review of literature.

Results:

44-year-old man with multiple sclerosis in remission treated with Fingolimod since 2014, and poorly controlled type-II diabetes mellitus (A1c 10.4), transferred to our facility for stroke work-up with brain MRI findings reportedly consistent with subacute bilateral cerebellar ischemic strokes. On physical exam, he was somnolent and intermittently followed simple commands. He also had nuchal rigidity and positive Kernig and Brudzinski signs. Meningitis was suspected and empiric treatment was initiated. MRI findings on DWI/ADC/FLAIR sequences were inconsistent with any vascular territory. Additionally, extensive leptomeningeal enhancement was noted in the cerebellar folia, basal cisterns, suprasellar cistern, and the surface of the brainstem. Labs were remarkable for lymphopenia (Lymphocyte count 250), and both cerebral spinal fluid (CSF) and blood culture grew cryptococcus neoformans so treatment with liposomal amphotericin B and flucytosine was started. On day 4 of admission, patient developed generalized dystonia that resolved with diphenhydramine. Unfortunately, patient did not respond to therapy as evident on repeat LP on day 6 of admission. His physical exam continued to worsen, and he was intubated 2 days after. Repeat MRI was consistent with tonsillar herniation and patient expired

Conclusions:

Cryptococcal cerebellitis is a rare opportunistic infection occurring in multiple sclerosis patients on Fingolimod. Early recognition is crucial given rapidly worsening neurological outcomes and atypical presentation of generalized dystonia.