Case Presentation: A 29 year-old woman presented with three weeks of headache on a background of headaches for the last five months associated with nausea, vomiting, and photophobia. She now developed blurry vision, diplopia, and dizziness. She denied fevers, neck stiffness, focal weakness or numbness, bowel or bladder incontinence, dyspnea, recent travel, or sick contacts. She had a previous workup; MRI brain with areas of leptomeningeal enhancement in the posterior fossa; iridocyclitis, dystrophies of the retinal pigmented epithelium, and papilledema; lumbar puncture with elevated glucose and protein and lymphocytic pleocytosis; CSF negative for bacterial or fungal growth. She worked on a poultry farm.
Her neck was supple. She was alert, oriented x4, and maintained attention. Her pupillary light reflex was intact bilaterally and had no nystagmus. Visual acuity was 20/50 (left) and 20/30 (right). Bilateral optic disc edema was present. Strength, sensation, reflexes, and coordination were intact throughout.
Her white blood cell count was 8. The serum HIV and RPR were negative. An MRI of the brain had decreased leptomeningeal enhancement as compared to the outside MRI, but had new foci of enhancement in the caudate heads. A lumbar puncture opening pressure was 26 cm of water, glucose 110 mg/dL, and protein 75 mg/dL with 196 nucleated cells (94% lymphocytes). The CSF Cryptococcal antigen was positive, and the culture grew Cryptococcus neoformans. Amphotericin B and Flucytosine were started. Her headache, visual complaints, nausea, and vomiting resolved.
Discussion: Headache, nausea, and vomiting are problems commonly encountered by the hospitalist. It is important to keep a broad differential to rule out the most common etiologies and to recognize less common ones. A thorough exposure history is helpful. Although Cryptococcus is ubiquitous, based on profession and interests, some patients will have higher chances for exposure. Cryptococcal infections are typically associated with immunocompromised, rather than immunocompetent, patients. Immunocompetent patients have a longer time to diagnosis for this reason. There is also a delay in diagnosis due to an altered disease presentation as compared to an immunosuppressed patient. Immunocompetent hosts are more likely to have pulmonary manifestations than immunosuppressed hosts, but can also develop central nervous system disease. Our patient had five months to time of diagnosis. Additionally, while there is a longer time to diagnosis, there is evidence that Cryptococcal infections can have higher morbidity and mortality in immunocompetent individuals. Immunocompetent patients have a higher likelihood of permanent neurologic sequelae (stroke, blindness, deafness) and CSF shunting procedures than immunosuppressed patients. There is also a trend toward higher mortality at 90 days and one year for immunocompetent patients, further highlighting the importance of recognizing this disease.
Conclusions: Cryptococcal meningitis should remain on the differential for patients presenting with headache, nausea, vomiting, and visual complaints as the disease can be seen in both immunocompromised and immunocompetent hosts. This is particularly important to reduce time to diagnosis and morbidity and mortality associated with the disease.