Cryptococcal Meningitis in Young, Immunocompetent Patients: A Single-Center Retrospective Case Series and Review of the Literature

Abstract

Background Cryptococcal meningitis is an uncommon but serious infection with a high mortality and morbidity. Classically described in immunocompromised patients, including those with solid organ transplants or HIV/AIDS, cryptococcosis has also been reported in young and otherwise healthy patients, albeit rarely. Methods We retrospectively searched for all cases of cryptococcal meningitis in young (≤50 years) and previously healthy patients with no known immunocompromising conditions from January 2015 to January 2022 at Indiana University Health (IU Health). Additionally, a PubMed literature review was performed with the keywords “cryptococcal meningitis” and “immunocompetent” from January 1988 to January 2022. Clinical courses, including outcomes and treatment regimens were evaluated. Results We identified 4 local cases of cryptococcal meningitis in otherwise healthy patients ≤50 years. Three cases were due to Cryptococcus neoformans with one experiencing a post-infectious inflammatory response syndrome (PIIRS). The PubMed search identified 51 additional cases with 32 (63%) being caused by Cryptococcus neoformans and 8 (17%) by Cryptococcus gattii. Of the 51 cases, only two resulted in death directly due to cryptococcosis. Fifteen (29%) had PIIRS with steroid treatment documented in 11 of 15. Antifungal induction regimens and duration were varied but predominately consisted of amphotericin and flucytosine with a mean induction duration of 5.0 weeks. Conclusions Cryptococcal meningitis in young, previously healthy patients is likely under-recognized. PIIRS (akin to IRIS observed in HIV/AIDS) with prolonged recovery should be of concern. Determining risks factors for cryptococcosis in these patients remains elusive.