A 38‐year old Ethiopian man with a history of HIV, tuberculosis, and malaria was admitted to our institution for evaluation of progressively altered mental status. The patient immigrated from Ethiopia 2 weeks prior to presentation and developed symptoms within a day of his arrival. In addition to his confusion, nausea/vomiting, imbalance and incontinence were noted. The patient was on highly active antiretroviral therapy with effective viral suppression (undetectable viral load, CD4 count > 600). MRI of the brain revealed a calcified frontal lobe mass, with associated peri‐ventricular edema, communicating hydrocephalus, and lepto‐meningeal enhancement. Lumbar puncture was performed on 3 occasions, all demonstrating lymphocytic predominance and elevated protein. Initial therapy was directed at toxoplasmosis, with tuberculosis therapy added in response to the MRI findings and the patient's history of questionably treated tuberculosis. However, follow‐up acid‐fast bacilli staining of the cerebrospinal fluid (CSF) failed to confirm tuberculosis. Instead, Cryptococcus neoformans was isolated on CSF cultures, and cryptococcal antigen was detected in the third lumbar puncture sample. Therapy for cryptococcal meningitis was initiated, and the tuberculous meningitis and toxoplasmosis therapies were discontinued. The patient responded well to these measures, with gradual improvement in cognitive and physical function.
In the HIV‐infected population, cryptococcal meningitis is considered an opportunistic infection usually diagnosed in the setting of advanced HIV disease. This case is unusual with respect to the patient's intact immunologic status and the slow progression of his neurologic symptoms. Cryptococcal meningitis in the immunocompetent host is rare but has been reported in isolated cases affecting individuals in underdeveloped countries. In 1 report, MRI findings consistent with tuberculous meningitis confounding the diagnosis was described, similar to the circumstances with our patient. The absence of serum cryptococcal antigen in 1 case of cryptococcal meningitis in an immunocompetent patient has also been reported. These data demonstrate the diagnostic challenges associated with uncommon presentations of cryptococcal meningitis. This potentially devastating infection in immunocompetent hosts should be considered when assessing a patient who has recently relocated from a developing nation.
This case emphasizes the importance of considering a broad differential diagnosis when evaluating a patient with altered mental status and abnormalities on central nervous system imaging. A multidisciplinary approach involving hospitalist coordination of infectious disease, neurology, and neurosurgical consultations permitted the rapid diagnosis of a rare condition presenting in a particularly unusual manner. This permitted timely adjustment of therapy that prevented the development of permanent neurologic injury.
J. N. Welch ‐ none
To cite this abstract:Welch J. Cryptococcal Meningitis in an Immunocompetent Patient. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 428. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/cryptococcal-meningitis-in-an-immunocompetent-patient/. Accessed April 4, 2020.