Teaching Neuro Image : Cryptococcal brain pseudocysts in an immunocompetent patient

Abstract

A 52-year-old man developed fever, meningismus, and decreasing level of consciousness over 2 days. On arrival he was minimally responsive to external stimuli and was profoundly rigid. There was no history of immunosuppression; however, he worked as a vacuum truck operator and reported exposure to chicken and pigeon feces in the weeks prior to his illness. CSF opening pressure was Ͼ30 cm of H 2 O with a mild lymphocytic pleocytosis (239 ϫ 10*6 cells/L) with protein at the upper limit of normal (0.45 mmol/L), and normal glucose (4.1 mmol/L). HIV serology was negative. ELISA and India ink stain were positive for cryptococcus. CSF cultures identified Cryptococcus neoformans var Gatti as the pathogenic species. Other infectious causes, including hepatitis B and C viruses, herpes simplex virus, mycobacterium tuberculosis, and other fungal sources, were all excluded. Brain MRI showed bilateral pseudocysts predominantly involving the basal ganglia, and post-gadolinium sequences showed little enhancement of the cysts or surrounding parenchyma (figure). The patient received IV amphotericin B and flucytosine for 3 weeks followed by maintenance therapy with fluconazole. A lumbar CSF drain was inserted to treat raised intracranial pressure. Serial chest x-rays performed to monitor for pulmonary disease or complications showed no evidence of cryptococcal pulmonary infection. At the time of discharge, the patient had only mild residual bilateral bradykinesia and rigidity.This case highlights the potentially dramatic imaging appearance of cryptococcal meningoencephalitis. Post-gadolinium MRI sequences showed little to no enhancement of the cysts or surrounding parenchyma, a feature that differentiates this disorder from other inflammatory or malignant processes, which are usually associated

Cerebellar cryptococcosis characterized by a space-occupying lesion in an immunocompetent non-HIV patient

“…Different sites, pathological types, and stages of CNS cryptococcosis may show different computed tomographic (CT) and MRI findings. 12 Early stages of cryptococcosis may not show any abnormal CT findings, but a few nonspecific manifestations, including diffuse cerebral atrophy, hydrocephalus, and diffuse cerebral edema, can be found. 3 , 13 Cryptococcoma can appear as a localized tumor-like mass when the fungus has involved brain parenchyma.…”

Comparison and Correlation of Magnetic Resonance Imaging and Clinical Severity in Nonhuman Immunodeficiency Virus Patients with Cryptococcal Infection of Central Nervous System

“…Different immunology, localization and stages of CNS cryptococcosis may result diverse imaging findings. [1314] Therefore, patients without immunodeficiency may show different imaging appearances. Until now, there are limited literatures that reported the imaging appearances of CNS cryptococcal infection among immunocompetent patients and majority of them are case reports.…”

“…Until now, there are limited literatures that reported the imaging appearances of CNS cryptococcal infection among immunocompetent patients and majority of them are case reports. [1415] One study with 19 cases of cryptococcal infection showed that leptomeningitis and intraventricular cystic lesions were more commonly seen than intraparenchymal involvement in immunocompetent patients. [16] Another similar study with 18 cases found that the parenchymal involvement, meningitis, enlarged Virchow-Robin space and ventricular lesions are equally common among immunocompetent patients.…”