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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 21  |  Issue : 2  |  Page : 97-99

Cryptococcal meningitis presenting as sixth nerve palsy


Department of Microbiology, Government TD Medical College, Alappuzha, Kerala, India

Date of Submission23-May-2019
Date of Acceptance14-Oct-2019
Date of Web Publication17-Jan-2020

Correspondence Address:
Dr. Anitha Madhavan
Department of Microbiology, Government TD Medical College, Alappuzha, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacm.jacm_10_19

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  Abstract 


Clinical features of cryptococcal meningitis can often be non-specific in immunocompetent without neurological deficit. We present a case of a middle-aged female with no known co-morbidities who presented with sub-acute onset of occipital headache, vomiting and isolated 6th nerve palsy, photophobia and double vision of 2 weeks. It progressed with development of multiple nerve palsies, bilateral lower limb paresis and complete loss of vision. She had no evidence of immunosuppression.

Keywords: Cryptococcal meningitis, immunocompetant, nerve palsy


How to cite this article:
Venunath M, Madhavan A, Sobha B. Cryptococcal meningitis presenting as sixth nerve palsy. J Acad Clin Microbiol 2019;21:97-9

How to cite this URL:
Venunath M, Madhavan A, Sobha B. Cryptococcal meningitis presenting as sixth nerve palsy. J Acad Clin Microbiol [serial online] 2019 [cited 2020 Apr 7];21:97-9. Available from: http://www.jacmjournal.org/text.asp?2019/21/2/97/276116




  Introduction Top


Majority of patients with cryptococcosis have a clearly identified underlying immunocompromised condition – the most common being AIDS, prolonged corticosteroid therapy, advanced malignancy, organ transplantation and diabetes.[1] Approximately 20% of patients with cryptococcosis without HIV infection have no apparent underlying disease or risk factor.[2] As clinical features can often be non-specific without neurological deficit, cryptococcal meningitis should be included in the differential diagnosis of chronic or subcutaneous meningoencephalitis.[3],[4]


  Case Report Top


A 59-year-old female who was a homemaker with no known co-morbidities presented to our institution with sub-acute onset of occipital headache, vomiting, isolated 6th nerve palsy, photophobia and double vision of two weeks duration. It progressed with the development of multiple nerve palsies, bilateral lower limb paresis and complete loss of vision. The patient was afebrile throughout. She had no history of travel abroad. At the time of admission, the patient was conscious, oriented and all vitals were stable. Reduced visual field, as well as impaired abduction with downbeat nystagmus, was present in the right eye. Terminal neck stiffness was present on examination, although other meningeal signs were absent. The rest of the central nervous system examination were unremarkable. On further examination, a vague mass was palpable per abdomen.

Her routine haematological parameters were within the normal limits. Although her C-reactive protein was positive, the tumour markers and autoantibody analysis showed no abnormalities. She was seronegative for HIV and syphilis. USG Abdomen showed large solid cystic lesion in left lumbar region close to anterior abdominal wall, following which CT-abdomen was done which revealed a Left adnexal solid lesion and a hypo dense ill-defined area in left kidney. Although CT brain was normal, magnetic resonance imaging of the brain revealed chronic lacunar infarcts in the right medial temporal lobe and right capsuloganglionic region. A hypodense-enhancing lesion in the left lower lobe was also detected in CT chest.

Cerebrospinal fluid (CSF) received in the laboratory was clear; no coagulum formation was noted on standing. Cell count of CSF: 25 cells/mm 3 - all lymphocytes, total protein: 5 mg/dl, sugar value was unavailable, ADA: 4.9. Bacterial culture of CSF was sterile. Gram staining showed no pus cells or organisms. India ink staining was found to be negative for capsulated organisms. Ziehl–Neelsen staining was negative for acid-fast organisms. CB-NAAT was negative. Fungal culture on SDA without cycloheximide incubated at 22°C showed off white, creamy, yeast-like colonies after one week of incubation. Gram staining showed spherical yeast cells 5–10 μ diameter with narrow-based budding. Repeat India ink from the CSF sample showed spherical yeast cells with halo around them. The isolate gave a positive urease test. MALDI-TOF ID: Cryptococcus gattii.

Differential diagnosis under consideration was disseminated cryptococcosis and cryptococcal meningitis secondary to undiagnosed malignancy. The complete workup could not be completed as the patient was discharged against medical advice before the culture reports were available and lost to follow-up.


  Discussion Top


Worldwide an estimated 220,000 new cases of cryptococcal meningitis occur annually leading to 181,000 deaths.[5] The most important risk factor for cryptococcosis caused by Cryptococcus neoformans is AIDS. C. gattii and Cryptococcus deuterogatti are more often reported in immunocompetent patients.[6] Cranial nerve palsies are seen as a presenting feature in about 25% of the patients and usually affects a single nerve, most commonly the abducens nerve. Previous reports of cryptococcal meningitis presenting with nerve palsies are given in [Table 1].[7]
Table 1: Published reports of cases of cryptococcal meningitis presenting as nerve palsies

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Clinical presentation of cryptococcal meningitis in human immunodeficiency virus – seropositive and seronegative participants also vary from an acute presentation in HIV-positive patient to a subacute to chronic presentation in immunocompetent participants [Table 2].[8]
Table 2: Comparison of presenting features of cryptococcal meningitis in human immunodeficiency virus seropositive patients and immunocompetent patients

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Among the newer diagnostic methods, lateral flow assay with excellent sensitivity, being rapid and having minimal requirements have been increasingly used as a 'point of care' test. A baseline high titre of polysaccharide antigen in serum or CSF carries prognostic significance in that a very high titre has been used as a predictor of mortality during systemic antifungal treatment. Also since the elimination kinetics of polysaccharide antigen is not constant, therapeutic decisions are to be made in caution while using polysaccharide antigen testing.[9] Sensitivity of various diagnostic methods is discussed in [Table 3].[10],[11]
Table 3: Sensitivity of various diagnostic tests for cryptococcal meningitis

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  Conclusion Top


  • Clinicians and clinical microbiologists have to be aware of the possibility of cryptococcal infection in patients with sub-acute onset of meningoencephalitis irrespective of their immune status
  • Inclusion of cryptococcal antigen rapid test in the initial panel of serum and CSF testing is highly recommended.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Perfect JR. Cryptococcosis. In: Bennet JE, Dolin R, Blaser MJ, editors. Mandell, Douglas and Bennet's Principles and Practice of Infectious Diseases. 8th ed. Philadielphia: Saunders Elsevier; c2015. Ch. 264. p. 2933-48.  Back to cited text no. 1
    
2.
Pappas PG, Perfect JR, Cloud GA, Larsen RA, Pankey GA, Lancaster DJ, et al. Cryptococcosis in human immunodeficiency virus-negative patients in the era of effective azole therapy. Clin Infect Dis 2001;33:690-9.  Back to cited text no. 2
    
3.
Bicanic T, Harrison TS. Cryptococcal meningitis. Br Med Bull 2004;72:99-118.  Back to cited text no. 3
    
4.
Zimmermann B 3rd, Spiegel M, Lally EV. Cryptococcal meningitis in systemic lupus erythematosus. Semin Arthritis Rheum 1992;22:18-24.  Back to cited text no. 4
    
5.
Disease Prevention and Control. Fungal Diseases. Preventing Deaths from Cryptococcal Meningitis. Disease Prevention and Control; 2017.  Back to cited text no. 5
    
6.
Amburgy JW, Miller JH, Ditty BJ, Lune PV, Muhammad S, Fisher WS, III. Cryptococcus gattii in an Immunocompetent Patient in the Southeastern United States. Case Reports in Infectious Diseases 2016;2016:4. Avaliable from: https://doi.org/10.1155/2016/8280915. [last accessed on 2019 Nov 19].  Back to cited text no. 6
    
7.
Krishnamoorthy A, Joel A, Abhilash KP. Cryptococcal meningitis with multiple cranial nerves palsies: A review of literature. J Glob Infect Dis 2015;7:123-4.  Back to cited text no. 7
    
8.
Satishchandra P, Mathew T, Gadre G, Nagarathna S, Chandramukhi A, Mahadevan A, et al. Cryptococcal meningitis: Clinical, diagnostic and therapeutic overviews. Neurol India 2007;55:226-32.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Perfect JR, Bicanic T. Cryptococcosis diagnosis and treatment: What do we know now. Fungal Genet Biol 2015;78:49-54.  Back to cited text no. 9
    
10.
Sorrell TC, Chen SC-A, Phillips P, Marr KA. Clinical perspective on Cryptococcus neoformans and Cryptococcus gattii: implications for diagnosis and management. In: Heitman J, Kozel TR, Kwon-Chung KJ, Perfect J, Casadevall A, editors. Cryptococcus: from human pathogen to model yeast. Washington, DC: ASM; 2011. p. 595-606.  Back to cited text no. 10
    
11.
Severance PJ, Kauffman CA. Diagnosis of cryptococcosis: Comparison of various methods to detect Cryptococcus neoformans. Mykosen 1983;26:29-33.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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