Case Presentation: A 51-year-old man was brought in by family for confusion and unsteady gait for a few days. Medical history was significant for alcoholic cirrhosis and prior (2018) cardioembolic strokes with no deficits. Social history was pertinent for drinking multiple beers daily for years. In ED, patient was oriented to name only, tachycardic otherwise afebrile and normotensive. Physical exam showed no focal neurological deficits, though notable for wide based gait. A non-contrast head CT showed new increased size of lateral and third ventricles out of proportion to sulcal prominence, encephalomalacia from remote infarcts, and significant increase in nonspecific confluent deep white matter hypo-attenuation. Patient was given thiamine and admitted for encephalopathy workup. A lumbar puncture was performed from suspicion of normal pressure hydrocephalus given CT findings; however, CSF fluid results were significant for low glucose, elevated protein, and lymphocytic predominance, which was most concerning for fungal or tuberculosis etiology. HIV and RPR were tested negative. Ultimately, cryptococcal antigen resulted positive (titers 1:20) on CSF fungal culture. As a result, patient was started on amphotericin and flucytosine for a two-week course, with later down-titration to fluconazole 400mg daily. Given signs of continued hydrocephalus, ventriculoperitoneal (VP) shunt was performed to improve drainage and indirectly, patient’s mentation.
Discussion: Cryptococcal meningitis in non-HIV patients is rare with only a few cases published on cryptococcal infection in immunocompetent hosts. While Cryptococcus neoformans is classically associated with bird dropping exposures, the relationship from exposure to disease is not well defined. Subsequent meningitis is thought to potentially result from inhalation of the organism with hematogenous spread into the central nervous system.For immunocompetent hosts, the pathophysiology is even less understood. Some evidence suggests isolates are of increased pathogenicity, while other papers postulate subtle defects in host immunity may lead to disease. While HIV and malignancy are known causes of immunosuppression, other comorbidities, ie alcoholism, diabetes, cirrhosis, certain autoimmune diseases, may precipitate mild states of immunosuppression, predisposing hosts to opportunistic infections. In our case, the exact predisposing factor is unknown, but may be in part due to his alcoholic cirrhosis.As to radiographic imaging, head CT is frequently unremarkable though may demonstrate hydrocephalus. For lumbar punctures, most notably patients with cryptococcal meningitis show marked elevation of opening pressure, which was present in our patient (OP 23). Lymphocytic predominance with low glucose and elevated protein are also commonly found, while CSF culture is considered the gold standard in diagnosis. Management usually entails both antifungal therapy and intracranial pressure control, especially to reduce opening pressures <= 20cm H20, via serial lumbar punctures or VP shunt if refractory.
Conclusions: While Cryptococcal meningitis is commonly found in immunocompromised patients, it should also be considered in immunocompetent hosts with symptoms of altered mental status, gait instability, hydrocephalus, and lymphocytic predominance on CSF findings. This case illustrates the importance of broadening the differential when otherwise healthy patients present with nonspecific or common symptoms.