Atypical cryptococcal meningitis complicated by probable larger vessels vasculitis in an immunocompetent host: a case report

Abstract

Case Presentation: A 56-year-old male with a history of diabetes presented with sudden decreased consciousness and anisocoric pupils, progressing rapidly to respiratory failure. Urgent head computed tomography (CT) suggested a brainstem vascular event. Shortly after admission, he developed fever, prompting lumbar puncture and empirical treatment for bacterial meningitis. Cerebrospinal fluid showed normal opening pressure, hypoglycorrhachia, hyperproteinorrachia, pleocytosis and a positive test for Cryptococcus sp., with negative viral and bacterial panels. Therefore, induction therapy for neurocryptococcosis was initiated. Screening for immunosuppression, including human immunodeficiency virus (HIV), was negative. The only prior symptom was mild headache over the previous year, and he had a history of poultry exposure. The patient remained unresponsive, with progressive loss of brainstem reflexes. Brain magnetic resonance imaging (MRI) demonstrated diffusion restriction with a pattern of involvement of both small and larger vessels, with the main areas in the brainstem and left occipitotemporal region. Echocardiography showed no cardioembolic source. In this scenario, cryptococcal meningitis complicated by small and larger vessels vasculitis was considered the main hypothesis. The patient died shortly after admission due to systemic complications of a pulmonary infection. Discussion: Cryptococcal meningitis is uncommon in immunocompetent individuals but remains a major fungal infection in immunocompromised hosts in Brazil. Poultry and eucalyptus exposure are recognized epidemiological risk factors. Clinical presentation is variable, frequently involving headaches, cranial nerve deficits, and cognitive impairment. Among its complications, central nervous system vasculitis, particularly of small vessels, is a rare one, resulting typically in ischemic injuries in the basal ganglia, internal capsule, and thalamus. This case is notable due to several peculiar features, including the absence of a clear immunosuppressive factor, except for possible diabetes-related risk, and for an oligosymptomatic course, with only mild headache, preceding a severe acute deterioration that prompted investigation. There are few cases described in the literature in which vasculitis involves larger vessels - an extremely atypical pattern that may lead to differential diagnoses that must be ruled out, such as the presence of cardioembolic sources. Final Comments: This case is of particular interest because it highlights multiple atypical features of a serious and epidemiologically relevant disease in Brazil, contributing to an expanded understanding of its clinical spectrum. In this context, it is important that attending physicians are aware of the possibility of vasculitis of larger vessels as a complication of cryptococcal meningitis to enable early recognition and timely directed treatment.