Case Presentation: 5 59-year-old male with alcoholic cirrhosis, hypertension, COPD, and diabetes mellitus presented with a 3-month history of progressive confusion and altered mental status. His family reported memory decline, prompting multiple ER visits primarily focused on cirrhosis-related complications, overlooking the neurological symptoms’ etiology. Initial improvement following hepatic encephalopathy treatment was short-lived, leading to rapid deterioration.Further workup revealed extensive meningitis, abnormal nodular enhancement in the inferior basal ganglia, and abnormal FLAIR hyperintensity in cerebral sulci, indicative of infections/inflammatory processes. Concerns arose about empyema and an acute-on-subacute stroke in the left caudate head. Infectious disease and neurology were consulted for lumbar puncture. Vancomycin, ceftriaxone, ampicillin, and acyclovir were initiated. Negative HSV and Listeria results led to acyclovir and ampicillin discontinuation. CSF findings prompted amphotericin B for suspected fungal meningitis. Despite extensive testing, including Fungitell, CSF HSV 1 and 2 PCR, aspergillus antigen, RPR, and blood culture, a definitive diagnosis remained elusive.Cryptococcal tests in May and June were negative, complicating the case. Concerned about the elusive pathology and worsening condition, infectious disease specialists recommended tertiary care transfer. At the tertiary center, a repeat lumbar puncture confirmed cryptococcal meningitis, challenging initial negative results. Antifungal therapy was adjusted, with amphotericin B and flucytosine improving mentation. Serial lumbar punctures tracked decreasing WBC counts and Crypto titers. The patient’s unexplained hypothermia, possibly Crypto affecting adrenal glands, was unusual in a non-HIV patient, signifying community-acquired crypto. Maintenance therapy with fluconazole extended beyond initial treatment, highlighting complexities in management. Follow-up in the office was recommended.
Discussion: The delayed recognition of Cryptococcal meningitis within the context of alcoholic cirrhosis is a significant and intricate phenomenon, often escaping initial consideration. The patient’s compromised immune status, potentially influenced by the complex interplay of comorbidities, likely facilitated the opportunistic nature of the infection, introducing complexities to the clinical presentation. The prolonged time to diagnosis underscores the delicate balance required in managing patients with intricate medical histories, emphasizing the nuanced challenges inherent in navigating multifaceted clinical scenarios.
Conclusions: This case serves as a reminder of the intricate nature of clinical decision-making when confronted with complex medical histories. The twists and turns in the diagnostic journey highlight the importance of persistent exploration and collaboration among multidisciplinary teams in unraveling rare and elusive diagnoses. The insights gained from managing such intricate cases not only contribute to the evolving landscape of medical knowledge but also emphasize the ongoing need for research and awareness in navigating diagnostically challenging scenarios.