# Bilateral Cerebellar Hemispheric Ischemia in Cryptococcal Meningitis

## TL;DR

A rare case of cerebellar ischemia in a patient with cryptococcal meningitis is described, highlighting vasculitis as a possible cause.

## Contribution

This case report adds to the understanding of rare neurological complications in cryptococcal meningitis.

## Key findings

- MRI revealed multiple small infarcts in the cerebellar hemisphere during treatment for cryptococcal meningitis.
- Symptoms such as ataxia and facial droop were linked to bilateral cerebellar involvement.
- Neurological improvement occurred after initiating treatment for suspected cryptococcal vasculitis.

## Abstract

Bilateral cerebellar hemispheric ischemia is a rare complication of cryptococcal meningitis that may lead to significant neurologic morbidity. We present the case of a 70-year-old male with asplenia who developed progressive headaches, confusion, and fever. Neurological exam and brain MRI were unremarkable. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis with elevated protein and low glucose levels. CSF polymerase chain reaction (PCR) consisted of Cryptococcus neoformans, and the patient was started on induction therapy. On day 12, the patient reported altered mental status with worsening confusion and dizziness. MRI revealed multiple small infarcts of the posterolateral left cerebellar hemisphere. Transthoracic echocardiogram (TTE) and computed tomography angiography (CTA) of the head and neck were normal. By weeks 3 and 4, new symptoms developed, including ataxia, left-sided facial droop, diplopia, and dysphagia. Repeat MRI showed increased diffusion-positive infarcts involving both cerebellar hemispheres. Due to concern for cryptococcal vasculitis, oral prednisone was initiated. Neurological function gradually improved over the next three to four months. This case highlights vasculitis as a potential contributor to ischemia in cryptococcal meningitis.