Case Presentation:
A 67‐year‐old male with metastatic colon cancer on treatment with irinotecan and bevacizumab presented with failure to thrive and ongoing weight loss not amenable to nutritional interventions. He denied headache, fever, chills, night sweats, meningismus, specifically neck pain, photophobia, or visual disturbances. Physical Examination revealed a cachectic male with supple neck. Kernig's and Brudzinski's signs were negative. No photophobia was noted. No thrush was seen in the oral cavity. Neurological exam showed no deficit. Heart sounds were regular, and lungs were clear to auscultation. CBC showed a WBC count of 4.7 K with ANC of 1.5 K. MRI brain with contrast showed no abnormally enhancing lesions. A lumbar puncture was obtained to evaluate for meningitis as an etiology of his failure to thrive. CSF analysis showed pleocylosis with WBC of 10K, differential 69% lymphocytes, protein 148, and glucose 28. A CSF cryplococcal antigen was positive at 1:16 dilution. EIA from CSF was positive for cryplococcus. CSF culture was positive for C. neoformans. Treatment for presumed cryptococcal meningitis with liposomal amphotericin and flucytosine was initiated. The treatment course was complicated by reactive thrombocytopenia with a decline in platelets from 150‐50 K after 2 days of therapy. The flucytosine was discontinued and fluconazole started in combination with amphotericin. The patient tolerated the new regimen well and showed a response to therapy, gaining 12 pounds in next 3 months.
Discussion:
Cryplococcus is an encapsulated yeast known to cause opportunistic infection in immunocompromised and rarely in immunocompetent population. Most patients without HIV present with symptoms of subacute meningitis including headache, fever, and memory loss. It has not often been considered a potentially treatable cause of failure to thrive. This case illustrates the presentation of subacute cryptococcal meningitis presenting without any focal neurologic symptoms or classic symptoms of meningitis, which was responsive to treatment. One can speculate whether the concomitant treatment with chemotherapy, in particular irhotecan and bevacizumab, attenuated the symptoms of acute cryplococcal meningitis and obscured the diagnosis.
Conclusions:
This case emphasizes the need to consider a broad differential diagnosis in patients on chemotherapy with failure to thrive, including subacute meningitis with opportunistic organisms.
Author Disclosure:
S. Jha, none; E. Linden, none; M. Melees, none.