Cryptococcal meningitis mimicking cerebral infarction: a case report

Another case of cryptococcal meningitis in a person without HIV who injects drugs: A possible risk factor in need of further investigation

Cryptococcal meningitis is a fungal central nervous infection typically occurring in patients with severe immunocompromise. We present a case of cryptococcal meningitis occurring in a patient with active injection drug use (IDU) but no immunocompromising condition. This is the seventh case in the recent literature of cryptococcal central nervous involvement in an otherwise healthy young person with IDU, suggesting a possible association in need of further exploration.

Cryptococcosis Presenting as Cerebrovascular Disease

Infection plays a complex role in cerebrovascular disease and is believed to have both direct and indirect mechanisms on stroke pathogenesis. if not diagnosed and treated promptly, this may have devastating consequences. Management of infection-related strokes focuses on the treatment of the underlying infection with appropriate antimicrobial drugs and the prevention of medical complications. This can lead to devastating neurological deficits. We present two cases of cryptococcal meningoencephalitis that presented with an atypical cerebral infarction. A 55-year-old male with a history of unknown autoimmune disease presented with acute onset cognitive changes and no stroke-like symptoms. A 35-year-old male with no history of autoimmune disease or other existing immunodeficiency presented with breakthrough seizure a long with stroke-like symptoms. Both patients developed multiple cerebral infarcts in multiple vascular territories, with histologic and radiologic findings consistent with a central nervous system cryptococcosis. They were subsequently diagnosed with cryptococcal meningoencephalitis and started on the appropriate anti-fungal regimen with amphotericin B and flucytosine. Prior to discharge to an inpatient rehabilitation facility, both patients were notably improved and near their neurologic baseline. It is important to understand the pathogenesis of cryptococcal infection in the central nervous system because it produces a wide variety of clinico-radiographic features that can be overlooked. Clinicians should keep infection-mediated cerebral infarcts in mind, regardless of risk factors, in order to expedite antimicrobial therapy and minimize adverse events.

Comparison of patterns of infarction in TB and cryptococcal meningitis

BACKGROUND

To compare the frequency and patterns of stroke, the specificity of tubercular zone (TBZ) infarction and its effect on outcomes in TB (TBM) and cryptococcal meningitis (CM).

METHODS

This retrospective study was conducted at two tertiary centres in India from May 2018 to July 2020. Sixty-one patients with TBM and 22 with CM were included. The primary outcome was the proportions of TBM and CM patients with infarction. Secondary outcomes included the anatomical locations of infarction and in-hospital mortality.

RESULTS

Infarction was noted in 52.5% of patients with TBM and in 54.5% of those with CM (p=0.87), with caudate head infarcts in 9.4% vs 41.7% (p=0.01), cerebellar in 9.4% vs 33.3% (p=0.05), thalamic in 25% vs 0% and lobar in 28.1% vs 0%, respectively. In TBM, the infarcts were located in the TBZ in 3 (9.4%), in the ischaemic zone in 23 (71.9%), while 6 (18.8%) patients showed infarcts in both, while in CM, the infarcts were in 0 (0%), 6 (50%) and 6 (50%) patients, respectively. Infarcts were not associated with in-hospital mortality, either in TBM or CM.

CONCLUSION

Caudate head and cerebellar infarction was more common in CM, while thalamic and lobar infarcts were more frequent in TBM. TBZ infarcts were not specific to TBM.

Cryptococcus Meningoencephalitis With Severe Localizing Neurological Deficits Mimicking a Large Right Middle Cerebral Artery Infarct in a HIV Patient

Immunocompromised patients with Cryptococcal meningoencephalitis can develop focal neurological signs and symptoms. Stroke and abscess are usually the leading etiologies. Definitively localized non-fluctuating deficits mimicking a large middle cerebral artery (MCA) infarct without corresponding MRI findings is rare. Localized lobar cerebritis may be the underlying etiology. Despite having many different kinds of sequences, a significant pathological process can still evade MRI’s detection. Diffusion-weighted imaging (DWI) abnormality has also been seen in pathology other than ischemic stroke.

Meningitis and encephalitis management in the ICU

PURPOSE OF REVIEW

Management of patients with meningitis and encephalitis oftentimes requires ICU level of care. This article is an update on management for meningitis and encephalitis with focus on clinical care in the ICU. Information provided is based on a review of recent studies with focus on studies since 2017.

RECENT FINDINGS

Advances in diagnostic and treatment approach for different pathogens are presented. Nosocomial meningitis now constitutes a major part of brain infections seen in ICUs in the developed world. Advances in ICU care of central nervous system (CNS) infections include application of newer diagnostic methods, improved understanding and delivery of antibiotics to the CNS, infection prevention for nosocomial infections, and application of neuromonitoring where indicated.

SUMMARY

Advances in diagnostics and therapeutic approach to CNS infections are continually made. For intensivists, focus on neuromonitoring and brain resuscitation in critically ill patients with CNS infections may present a path to enhance preservation of brain function and improve outcomes. VIDEO ABSTRACT: http://links.lww.com/COCC/A22.