DESCRIPTION

A 20-year-old man complained of generalised headache and personality changes (depression, anger) for 4 weeks. Neurological examination revealed only a disturbance of fine motor skills (clumsiness, reduced forefinger tapping, dysmetria, impaired writing) but no meningism.

The patient’s body temperature was 37.8°C. Blood tests were normal, for example, complete blood count and C-reactive protein (CRP). MRI showed multiple, contrast-enhancing cerebellar lesions (fig 1A, arrows) and marked contrast-enhancement of the meninges (fig 1B, arrows). Cerebrospinal fluid (CSF) showed increased leukocytes (461/μl, normal<5), protein (164 mg/dl, normal<45), IgG 17.0 mg/dl (normal<4), lactate (3.6 mmol/l, normal<2.1) and decreased glucose (27 mg/dl, normal 50–75). Indian ink stain (fig 1C), culture (fig 1D), Gram-negative capsule (fig 1E) and serotyping identified Cryptococcus neoformans var grubii with increased cryptococcal antigen but no bacteria in the CSF. HIV, tuberculosis and herpes group (HSV, EBV, CMV, VZV) tests were negative. The patient was treated with amphotericin B and flucytosine and discharged 1 month later in good health.

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Figure 1

Cryptococcal meningoencephalitis. (A) Cranial MRI shows cerebellar hyperintensities (arrows) in FLAIR sequences (fluid-attenuated inversion recovery) and (B) meningeal contrast enhancement (arrows) in T1 weighted MRI. (C) Indian ink stain, (D) fungal culture, and (E) Gram stain of cerebrospinal fluid were positive.

The following were remarkable. (A) Cryptococcal meningoencephalitis occurred without immunosuppression or other risk factors.1 (B) C neoformans var grubii caused cerebellitis. Usually, C neoformans var gattii has a predilection for non-immunosuppressed hosts and is more likely associated with brain parenchymal involvement.2 (C) CRP and leukocytes were normal and meningism was absent despite meningitis. (D) Clinical signs of increased intracranial pressure were absent despite brain parenchymal involvement in the posterior circulation. However, intracranial pressure was not measured. (E) Recovery was excellent despite parenchymal involvement, altered mental status, and Indian ink positivity (indicating high organism burden).2