Keywords
Cryptoccoccal antigen titer; Cryptococcal meningoencephalitis; Neurocognitive decline; lymphocytic pleocytocis; Amphotericin B; Flucytocine; Fluconazole
Abstract
Cryptococcal meningoencephalitis in immunocompetent patients is a very rare presentation. The most common clinical manifestations are headache, nausea, vomiting, seizures and meningeal signs. Here we present an 89 year old healthy male presenting with rapid cognitive decline, ataxia, frequent falls and tremor as presenting signs which delayed diagnosis. The purpose of the article is to stimulate direction of rapid cognitive decline work up in the pathway of infectious cause’s especially indolent cryptococcal meningitis.
Case report
89 Year Old Male presented with altered behavior, unable to perform ADLs, urinary incontinence and frequent falls of six weeks duration. Prior to this, he lived independently and was highly functional. He went to an outside hospital for fever, cough, and episodes of agitation, garbled speech and disorientation. He was treated for urinary tract infection and community acquired pneumonia and was discharged to rehabilitation center. Patient did not participate in rehab due to impaired comprehension, increasing somnolence, lethargy. Neuropsychiatric evaluationshowed severe Neurocognitive and behavior dysfunction assessed through various scales. His sub-acute course ofcognitive decline prompted admission to Neurology service for evaluation of reversible causes. Examination was remarkable for attention, memory, executive dysfunction, ataxia with no meningeal signs. MRI of brain showed global cortical atrophy with small vessel disease and periventricular T2 FLAIR hyperintensities with no enhancing lesions. HIV testing, nutritional and neoplastic workup returned negative. CSF showed very high protein, low glucose, lymphocyticpleocytosis with high cryptococcal antigen titers. He was started on amphotericin B, flucytosine therapy for 3 weeks followed by suppressive prophylaxis with high dose fluconazole. Pt is currently through 12 weeks of antifungal therapy with clinical improvement.
Conclusion
This case prompts work up for sub-acute causes of neurocognitive impairment towards infectious diseases in the elderly dueto atypical clinical presentations. Early diagnosis and treatment is warranted to prevent permanent neurological sequelae.
Citation
Yerram SR and Naresh M. Cryptococcal Meningitis with Behavioral Changes as Presentation. SM J Neurol Neurosci. 2017; 3(2): 1010.