Case Presentation: A 34 year-old male fence installer presented with one week of progressively severe headache. His headaches were associated with blurred vision, dizziness, fevers and nausea. He had been seen previously and was treated for sinusitis but his symptoms did not improve with a steroid taper and antibiotics. He developed lethargy and mild confusion, and presented with photophobia and neck stiffness on exam. Computerized tomography of the head was negative for acute pathology. Lumbar puncture revealed an inflammatory fluid analysis with a positive cryptococcus antigen with a titer of 1:20. Opening pressure on initial lumbar puncture was not obtained, but was never elevated on subsequent exams. The patient denied intravenous drug use and did not have risk factors for human immunodeficiency virus, HIV. A workup for immunocompromise including HIV antibody, lymphocyte enumeration panel, flow cytometry and cancer screening, was negative. He was treated with a fourteen-day course of amphotericin and flucytosine induction, which improved his symptoms; he was discharged on fluconazole consolidation therapy with infectious disease follow-up.
Discussion: Headache with fever and altered mentation is a common presentation encountered by the hospitalist and should raise clinical suspicion for meningitis. Complete cerebrospinal fluid analysis including cell count, protein, glucose and culture is essential part of the work-up. In our patient, the cerebrospinal fluid analysis was consistent with meningitis and a positive Cryptococcus antigen led us to the proper diagnosis. Cryptococcus is an endemic fungi found in the air, water and soil. It is a relatively common pathogen in the immunocompromised patient population, but rare in patients with an intact immune system. Because it is rare, physicians should look for causes of immunocompromised including HIV and other immunodeficiencies, hematologic malignancy and solid-organ tumors. Generally, immune-competent patients who develop crypotococcal infection have been exposed to an abnormally large spore load, as is the case in our patient whose job entailed digging ditches without wearing a protective mask. In addition, Cryptococcus is more likely to cause a cryptococcoma in immune-competent patients, as they are able to wall-off the organism from the rest of the central nervous system; therefore, these patients will need a longer consolidation and suppressive therapy after their initial treatment.
Conclusions: Although rare in patients with an intact immune system, Cryptococcus meningitis should be considered in all patients who present with subacute to acute signs of meningitis and an occupational exposure. Cryptococcus infection in the immunocompetent carries a high risk of complications such as a cryptococcoma or cerebral edema due to the inflammatory response to the organism, and requires a longer treatment course.