Covert cryptococcal meningitis in a patient with systemic lupus erythematous

Area of Science:

• Infectious Diseases
• Rheumatology
• Neurology

Background:

• Cryptococcal meningitis is a serious infection with high mortality in patients with systemic lupus erythematosus (SLE).
• Diagnosis can be challenging in the emergency department (ED) due to non-specific clinical presentations.
• Immunosuppression in SLE patients increases susceptibility to opportunistic infections like cryptococcal meningitis.

Observation:

• A 21-year-old male with SLE presented with symptoms mimicking a common illness, despite a normal initial lumbar puncture.
• The patient had recently undergone immunosuppressive therapy for lupus nephritis.
• Subsequent testing revealed a positive cryptococcal antigen in cerebrospinal fluid (CSF).

Findings:

• Normal neurological and CSF examinations do not rule out cryptococcal meningitis in immunocompromised SLE patients.
• Early diagnosis relies on a high index of suspicion and appropriate diagnostic tests.
• Treatment with amphotericin B and 5-flucytosine led to a favorable outcome.

Implications:

• Highlights the importance of considering cryptococcal meningitis in SLE patients presenting with non-specific symptoms, even with initially normal CSF.
• Emphasizes the utility of cryptococcal antigen testing (latex agglutination) and CSF fungal cultures for diagnosis.
• Underscores the need for prompt treatment to improve prognosis in this high-risk population.