Case Report
Cryptococcal meningitis in an immunocompetent patient

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Abstract

Cryptococcal meningitis is a fungal infection that is most commonly thought of as an opportunistic infection affecting immunocompromised patients, classically patients with Human Immunodeficiency (HIV) infection. It is associated with a variety of complications including disseminated disease as well as neurologic complications including intracranial hypertension, cerebral infarcts, vision loss and other neurologic deficits. It is diagnosed by lumbar puncture with CSF studies, including fungal culture and cryptococcal antigen testing.

We present a case of cryptococcal meningitis and fungemia in a previously healthy male patient who presented after multiple emergency department visits with persistent headache. After multiple visits, he underwent a lumbar puncture consistent with cryptococcal infection, and he was admitted to the hospital for initiation of antifungal therapy. His workup revealed no known underlying condition leading to immune compromise.

Introduction

Uncommon presentations of diseases can be a challenging diagnostic dilemma in the emergency department. They are often identified through a more thorough history and escalation of usual evaluation. Cryptococcal meningitis is a fungal infectious disease associated with immunosuppressed patients, and is the most common cause of meningitis in patients with Acquired Immune Deficiency Syndrome (AIDS) [1]. In classic cases, it will present with typical meningeal signs including headache and neck stiffness, but also can be associated with other systemic findings of disseminated disease including pneumonia and dermatologic findings [1]. Diagnosis is typically confirmed by lumbar puncture which frequently reveals elevated opening pressures and India ink staining or CSF cryptococcal latex antigen [1].

Cryptococcal infection is often considered in immunosuppressed patients, but there are cases reported of cryptococcal meningitis in immunocompetent patients, and the number of cases has been increasing in recent years [2]. Immunocompromised cryptococcal meningitis carries with it a high morbidity and a mortality rate of greater than 80% [3]. Unfortunately, HIV-negative patients with cryptococcal infection have an even higher mortality rate than those who with underlying HIV infection [4], making early diagnosis critical.

We present a case of an immunocompetent 35-year-old-male who had presented to multiple emergency departments (ED) over the course of one month with a persistent severe headache who was ultimately found to have cryptococcal meningitis.

Section snippets

Case report

A previously healthy 35-year-old male presented to our ED with a chief complaint of headache. The patient reported that about one month prior to arrival, he first noted a headache while he was at work at a pest control company during which time he spent significant time in crawl spaces of buildings. He described the headache as a throbbing, pressure-like sensation in the center of his forehead. The headache was not worse at a certain time of day or with any certain position. Initially, it

Discussion

Cryptococcosis is an opportunistic fungal infection caused by an encapsulated yeast which is ubiquitous and found in many soil types throughout temperate regions worldwide, particularly in those enriched with decaying matter or bird or animal droppings [5]. Transmission is primarily through inhalation [5]. Most commonly, cryptococcosis is associated with HIV infection or other causes of immunosuppression such as solid organ transplant recipients, systemic immunosuppressive agents including

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