# The Diagnostic Challenge of a False-Positive Cryptococcal Antigen in Chronic Meningitis with Suspected Indolent CNS B-Cell Lymphoproliferative Neoplasm

## TL;DR

A woman with chronic meningitis had a false-positive cryptococcal antigen test, leading to a misdiagnosis and highlighting the need for comprehensive evaluation.

## Contribution

Highlights the diagnostic challenge of false-positive cryptococcal antigen tests in chronic meningitis cases.

## Key findings

- Cryptococcal antigen test was false-positive despite negative cultures and imaging.
- CSF flow cytometry revealed a monoclonal B-cell population, suggesting a lymphoproliferative process.
- Symptoms persisted despite 15 months of antifungal treatment.

## Abstract

A 47-year-old woman presented with a two-year history of progressive visual symptoms and headaches. Lumbar puncture revealed lymphocytic pleocytosis, elevated protein, low glucose, and a CSF CrAg titer of 1:256. She was treated empirically for cryptococcal meningitis with amphotericin B, flucytosine, and fluconazole for 15 months. Her symptoms persisted, and repeated CSF and serum CrAg, fungal cultures, and an extensive infectious workup were negative. CSF flow cytometry eventually demonstrated a monoclonal B-cell population suggestive of a lymphoproliferative process. Imaging, including MRI and PET scans, did not reveal systemic disease. A ventriculoperitoneal (VP) shunt was placed for symptom management. This case emphasizes the limitations of CrAg testing and the potential for false positives. It underscores the need for integrating clinical, laboratory, and imaging data when evaluating chronic meningitis.