Cryptococcoma mimicking a brain tumor in an immunocompetent patient: case report of an extremely rare presentation

Abstract

CONTEXT: Central nervous system (CNS) infectious diseases have high prevalence in developing countries and their proper diagnosis and treatment are very important for public health planning. Cryptococcus neoformans is a fungus that may cause several CNS manifestations, especially in immunocompromised patients. Cryptococcal meningitis is the most common type of involvement. Mass-effect lesions are uncommon: they are described as cryptococcomas and their prevalence is even lower among immunocompetent patients. The aim here was to report an extremely rare case of cryptococcoma causing a mass effect and mimicking a brain tumor in an immunocompetent patient. The literature on CNS cryptococcal infections was reviewed with emphasis on cryptococcomas. Clinical, surgical and radiological data on a female patient with this rare presentation of cryptococcoma mimicking a brain tumor are described. CASE REPORT: A 54-year-old female patient presented to the emergency department with a rapid-onset progressive history of confusion and completely dependency for basic activities. Neuroimaging showed a left occipital lesion and neurosurgical treatment was proposed. From histopathological evaluation, a diagnosis of cryptococcoma was established. She received clinical support with antifungals, but despite optimal clinical treatment, her condition evolved to death. CONCLUSIONS: Cryptococcal infections have several forms of presentation and, in immunocompetent patients, their manifestation may be even more different. Cryptococcoma is an extremely rare presentation in which proper surgical and clinical treatment should be instituted as quickly as possible, but even so, there is a high mortality rate.

Cerebral Cryptococcomas: A Systematic Scoping Review of Available Evidence to Facilitate Diagnosis and Treatment

“…Patients with C. gattii were less likely to report a significant past medical or surgical history, whereas those with C. neoformans were more likely to be HIV-infected, which is similar to findings from previous data [58,60]. A few patients reported social histories with established ecologic risk factors, including living in or traveling to Australia in the case of C. gattii [18,49], and exposure to birds and bird droppings in the case of C. neoformans [41,46]. Patients with cerebral cryptococcomas presented with a wide range of often non-specific symptoms and physical exam findings, from headache and altered mental status to vomiting, giddiness, word-finding difficulties, and cerebellar signs, which were more common among patients 50 years and older.…”

“…Few cases described recurrent disease during the follow-up period [22,[28][29][30]41,42,48], with even fewer detailing subsequent surgical or pharmacological intervention. An HIVinfected patient was asymptomatic with near complete radiographic resolution after 7 months of antifungal therapy and 5 months of ART, but then experienced a recurrence with worsening basal ganglia lesions on MRI, prompting initiation of combination antifungal therapy and corticosteroids for 6 weeks, followed by long-term fluconazole [28].…”

“…Due to resource limitations to perform species identification in many laboratories, it is likely that C. gattii may be responsible for some of the cases attributed to C. neoformans presented in this review. *, based on the 34 cases in which an organism was isolated and speciated [19,[22][23][24][26][27][28][29][30]32,34,36,37,39,41,[44][45][46][47]50,[52][53][54].…”

“…Though 40% (n = 19) of the patients did not report a past medical, surgical, or social history, of the 60% (n = 28) who did, 36% (n = 10) were HIV-infected, 21% (n = 6) had hypertension, and 18% (n = 5) had diabetes mellitus. One patient was in her second trimester of pregnancy with no other significant history [39], one patient had a history of polycythemia vera and monoclonal gammopathy of unknown significance [24], whereas two patients reported close contact with pigeons [41,46]. Of those with HIV, absolute CD4 count ranged from 0 to 157 cells/µL [9,28,36,42,43,50], whereas only three patients were noted to be on ART [36,42].…”

“…C. neoformans was responsible for 74% of the 34 cases in which an organism was isolated and speciated [19,[22][23][24][26][27][28][29][30]32,34,36,37,39,41,[44][45][46][47]50,[52][53][54]. Among the nine cases which implicated C. gattii as the infectious etiology, only four provided explicit details as to the method for identifying the organism, either via isolation from a clinical specimen or genotypic testing [18,31,40,48].…”