Case Presentation: A 56-year-old man with HIV, nonadherence to antiretroviral therapy, prior cryptococcal meningitis, and remote methamphetamine use presented with progressive bilateral lower-extremity weakness. MRI showed a 2.1-cm homogeneously enhancing intramedullary mass at T8–T9, raising concern for inflammatory versus malignant etiologies, particularly lymphoma. CSF and serum cryptococcal antigen were positive, while all other infectious studies—including bacterial, fungal, TB, meningitis panel, and toxoplasmosis—were negative. PET imaging demonstrated intense metabolic activity at T8–T9 and in cervical, thoracic, and inguinal lymph nodes. Two lymph-node biopsies revealed atypical lymphohistiocytic infiltrates with CD8-positive T cells and polytypic plasma cells, without organisms and with negative flow cytometry, making lymphoma unlikely and cryptococcoma more likely.One week after admission, the patient developed worsening weakness, paraparesis and new urinary retention. Repeat MRI demonstrated lesion expansion. After multidisciplinary review, neurosurgery determined that biopsy or resection posed an unacceptably high risk of neurologic deficits, despite oncology and infectious disease concerns for possible malignancy. Medical therapy with amphotericin B and flucytosine was initiated, followed by corticosteroids. Three weeks later, MRI showed marked improvement, with lesion size decreasing from 2.1 cm to 1.0 cm and a significant reduction in cord edema. Neurologic function progressively improved, allowing assisted standing before discharge to rehabilitation.
Discussion: Cryptococcus typically affects the CNS as meningitis or meningoencephalitis; space-occupying cryptococcomas are rare, usually located in the brain, but are extremely rare in the spinal Cord[1,2, 3]. Spinal cryptococcosis can be intradural or extradural; intradural disease may be extramedullary (arachnoiditis) or intramedullary (cryptococcoma). Interestingly, intramedullary cryptococcomas are reported mostly in immunocompetent hosts, likely because granuloma formation requires an intact inflammatory response[4]. A review of six intramedullary cases—all immunocompetent—showed all cases located in thoracic or upper-lumbar, and most symptoms are paraparesis. Surgical resection was performed in all cases due to difficulty excluding neoplasm, with concomitant antifungal therapy. 5 out of 6 cases survived and recovered eventually. In our case, the lesion’s central cord location and associated cord expansion made surgical intervention prohibitively risky, leading neurosurgery to decline operative management. This raised an important question: without mass resection, would medical therapy alone act quickly enough to relieve symptoms? Notably, antifungal therapy alone in this case resulted in rapid radiologic improvement and progressive neurologic recovery. This outcome suggests that medical management without mass removal can be effective for spinal cryptococcoma, particularly in situations where surgical risk is exceptionally high.
Conclusions: Spinal cryptococcoma is very rare disease which mimics intramedullary neoplasms in both immunocompetent and immunocompromised patients. High-risk lesions may be successfully managed with amphotericin B plus flucytosine without operative intervention which demonstrates that medical therapy alone can yield substantial clinical and radiologic improvement when surgery is contraindicated.