Multicentric Cryptococcomas Mimicking Neoplasia in Immunocompetent Patient

Fungal mass lesions in the central nervous system are, as a group, extremely rare. In this group cryptococcomas are the most common mass lesions seen. These cryptococcomas/mucinous pseudocysts are commonly only 3-10 mm in diameter and occur almost exclusively in the basal ganglia through contiguous spread from a basal meningitis through the Virchow-Robbin perivascular spaces. In rare cases a chronic granulomatous process may lead to formation of mass lesions that have a tumoral appearance.

A 19-year-old male presented to our Neurosurgical Unit with a 5-month history of progressive morning headaches. He also complained of progressive weakness of his R upper limb of 3 months' duration. The patient was found to be human immunodeficiency virus negative with a CD4 count of 1763. The patient had no other medical problems. Examination revealed a monoplegia of his R upper limb. While being optimized for surgery, the patient demonstrated progression of his upper limb monoplegia despite preoperative steroid therapy aimed at decreasing the perilesional vasogenic edema. He was booked for emergency resection of 2 lobar mass lesions. Histopathology analysis revealed the 2 specimens had similar features. These specimens were representative of gliotic brain parenchyma involved by extensive cryptococcosis.

Diagnosing the tumoral form of cryptococcosis in immunocompetent patients is a challenge. Primary and secondary brain tumors are usually the first hypotheses in these cases. Thorough preoperative investigation through cerebrospinal fluid sampling and detailed magnetic resonance imaging may lead to consideration of this diagnosis before the histopathologic analysis has been conducted.