An Atypical Presentation of Culture-Negative Cryptococcal Meningitis in an Immunocompetent Host With Prior Stroke: A Case Report

TL;DR

A 55-year-old woman with no immune issues showed unusual symptoms of cryptococcal meningitis, diagnosed using a specific test when cultures failed.

Contribution

Highlights an atypical case of cryptococcal meningitis in an immunocompetent patient and the diagnostic utility of lateral flow assays.

Findings

Cryptococcal meningitis presented with cognitive decline and gait issues in an immunocompetent patient.

Diagnosis was confirmed via CSF cryptococcal antigen despite negative culture results.

Treatment with antifungal drugs improved cognition and mobility significantly.

Abstract

Cryptococcal meningitis commonly presents with acute symptoms such as fever and signs of raised intracranial pressure and usually occurs in immunocompromised hosts. A 55-year-old woman presented with worsening cognitive decline, gait disturbance and recurrent falls. Magnetic resonance imaging (MRI) of the brain revealed a prior stroke and ventriculomegaly. A lumbar puncture (LP) showed normal opening pressure. Cerebrospinal fluid (CSF) analysis revealed pleocytosis with raised protein and reduced glucose. Cryptococcal antigen in the CSF was positive; however, Cryptococcus was not cultured. The immunodeficiency screen was unremarkable. She was treated with intravenous liposomal amphotericin B and oral flucytosine induction, followed by oral fluconazole consolidation and maintenance. Her cognition and mobility improved markedly after treatment. This case illustrates an uncommon presentation of cryptococcal meningitis and highlights the need to consider this diagnosis in atypical presentations. Culture negativity complicates the determination of optimal treatment duration. This case also highlights the utility of the lateral flow assay (LFA) in diagnosing cryptococcal meningitis.

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