Unusual Presentation of Cryptococcal Meningitis in an Immunocompetent Patient on Hemodialysis

Cryptococcal meningitis (CM) is an invasive fungal disease that poses a global health threat, particularly in immunocompromised individuals. CM mainly occurs in HIV-positive patients and other immunocompromised patients and is rare in immunocompetent persons. The clinical presentation and disease course of CM in an immunocompetent patient remain poorly understood due to limited data. We present the case of a 60-year-old woman with multiple comorbidities, including hypertension, burnt-out diabetes mellitus, chronic kidney disease on hemodialysis, heart failure with preserved ejection fraction, who was brought to the emergency department with a change in her mentation. Initial evaluation suggested a differential of uremic encephalopathy, cerebrovascular accident, or hypertensive emergency. Despite hemodialysis and supportive care, the patient's lethargy and confusion did not improve. Neuroimaging revealed leptomeningeal enhancement, and lumbar puncture confirmed the diagnosis of cryptococcal meningitis through positive cerebrospinal fluid (CSF) PCR and cryptococcal antigen testing. Notably, the patient had no obvious immunosuppressive conditions, highlighting an atypical presentation of CM in an apparently immunocompetent host. This case underscores the importance of considering CM in the differential diagnosis of altered mental status, even in patients without overt immunosuppression. Understanding such atypical presentations is crucial for timely diagnosis, guiding effective treatment strategies, and improving outcomes in immunocompetent individuals affected by CM.