Central Nervous System Cryptococcosis in Non-Immunosuppressed Patient

Abstract

Cryptococcus is a fungus related to bird droppings (especially pigeons). It is described as an opportunistic pathogen. The leading defense against this fungus is the T-cell immunity, reason why it is related to immunocompromised patients (human immunodeficiency virus (HIV), organ transplant patients among others). The annual incidence is 0.4 -1.3 per 100,000. The central nervous system (CNS) involvement is the most common manifestation in an immunocompromised patient; conversely it is a very uncommon manifestation in non-immunocompromised patients. A 32-year-old Hispanic male patient with no medical history, heterosexual and no toxics habits visited our institution, after visiting three emergency rooms for 1 week, complaining of general malaise, constant non-throbbing holocephalic headache 4/10 and low-grade fever of 12 days of evolution. Labs were unremarkable and vital signs showed fever of 38.6 °C. Physical exam was remarkable for neck stiffness. Patient was admitted with suspected meningitis. HIV test was negative and lumbar puncture showed increased opening pressure and India ink stain was positive. Patient was managed successfully with fluconazole. CNS cryptococcosis in non-immunosuppressed patients is extremely unusual. Diagnosis could be delayed because of low suspicious index in healthy population. Most experts recommend amphotericin B combined with flucytosine. Our patient was managed successfully with fluconazole IV followed with oral fluconazole. Patients from countries where flucytosine is unavailable and cannot tolerate amphotericin B can benefit from fluconazole.