Acute Ischemic Stroke and Pseudosubarachnoid Hemorrhage in a HIV‐Negative Patient Presenting with Cryptococcal Meningitis

1Regions Hospital, St. Paul, MN

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 140

Case Presentation:

A 75‐year‐old man with a history of chronic myeloid leukemia presented to the emergency room with bifrontal headache, syncope, and double vision of the right eye. Physical examination was unremarkable. He was afebrile, and laboratory investigations, EKG, and chest X‐ray were normal. A CT scan of the head was normal. A cerebrospinal fluid (CSF) examination was done because of his worsening headache, which revealed clear and colorless fluid, an opening pressure of 25 H2O cm, normal glucose, and elevated protein at 72 mg/dL (normal: 15–45 mg/dL). His CSF white blood cell count was elevated at 38/mm3 (normal: 0‐5 mononuclear cells/mm3); 90% lymphocytes, 7% monocytes, and 3%granulocytes. Cryptococci were detected in the CSF by India ink staining, and CSF cryptococcal antigen titers were elevated. A serology for human immunodeficiency virus was negative. Fundoiscopic evaluation did not show any choroidal involvement A diagnosis of cryptococcal meningitis (CM) was made, and he was treated with intravenous amphotericin and oral flucytosine. On the seventh day of hospital admission, the patient developed weakness of his lower extremities bilaterally and mild slurring of his speech. On examination he showed normal mental status, decreased strength in the lower extremities bilaterally, diminished bilateral knee reflexes, negative Babinski sign, and no sensory loss. A MRI of the head was obtained, which showed multiple new small foci of restricted diffusion in the cerebral hemispheres, compatible with acute infarcts. A transesophageal esophagogram did not show any cardiac source of the emboli. The patient was continued with the above antibiotics. A few days later, he had 1 episode of a partial complex seizure with postictal confusion. There was no new change in the clinical examination. An MRI of the head showed an increase in the amount of abnormal FLAIR signal hyperintensity involving the subarachnoid spaces of both cerebral hemispheres and development of fluid/fluid levels in both lateral ventricles, suggestive of an subarachnoid bleed. The CSF study was repeated and did not show any RBC or xanthochromia, with a decrease in cryptococci titers. An EEG was performed and did not show any epileptiform activity. The patient showed slow clinical improvement and was discharged to a rehabilitation facility with lifelong oral fluconazole.

Discussion:

To our knowledge, this is the first reported case of CM in an HIV‐negative patient complicating cerebral infarction and pseudosubarachnoid hemorrhage (pSAH). Cerebral infarction is a poor prognostic sign of cryptococcal meningitis in an HIV‐negative patient. pSAH is an unusual MRI finding in cryptococcal meningitis, and prompt CSF study should be done for accurate diagnosis. Cerebral edema, vasculitis, and venous congestion are thought to be the possible etiologies of these complications.

Conclusions:

Hospitalists should be aware of these potential complications of cryptococcal meningitis in an HIV‐negative patient, even with appropriate treatment.

Author Disclosure:

I. Ahmed, none.

To cite this abstract:

Ahmed I. Acute Ischemic Stroke and Pseudosubarachnoid Hemorrhage in a HIV‐Negative Patient Presenting with Cryptococcal Meningitis. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 140. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/acute-ischemic-stroke-and-pseudosubarachnoid-hemorrhage-in-a-hivnegative-patient-presenting-with-cryptococcal-meningitis/. Accessed September 16, 2019.

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