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Occult cryptococcal meningitis presenting as myelopathy from an arachnoid cyst
Sebastian Leon1, Aryaa N Karkare2, Jacob Gluski2
1Department of Neurosurgery, Northwell Health Institute for Neurology and Neurosurgery, Manhasset, New York, USA SLeon4@northwell.edu.
Abstract:
An immunocompromised patient presented with acute-on-chronic back pain following minor trauma. The pain was accompanied by worsening right-sided weakness, paraesthesias, progressive gait impairment and hyperreflexia concerning for compressive myelopathy. The patient's spouse also reported months of increasing forgetfulness. Imaging revealed a thoracic arachnoid cyst, which was treated by fenestration and resection of the cyst via laminoplasty. At the time of surgery, the thickened cyst wall was sent off for pathological evaluation. Postoperatively, pathology identified yeast consistent with cryptococcus; a subsequent lumbar puncture confirmed the diagnosis. Aside from mild cognitive impairment and a transient episode of delirium, the patient had no prior cognitive nor cranial nerve deficits. This case highlights the importance of considering subacute, low-grade infection in the differential diagnosis of de novo arachnoid cysts in immunocompromised patients.
Insights
This case highlights a rare presentation of cryptococcosis mimicking an arachnoid cyst in an immunocompromised patient. Early diagnosis and treatment are crucial for managing this serious fungal infection.
Area of Science:
- Neurology
- Infectious Diseases
- Neurosurgery
Background:
- Immunocompromised patients are susceptible to opportunistic infections.
- Spinal arachnoid cysts can cause compressive myelopathy.
- Cryptococcosis can present with diverse neurological manifestations.
Purpose of the Study:
- To report a case of cryptococcosis presenting as a thoracic arachnoid cyst.
- To emphasize the importance of considering infections in immunocompromised patients with new-onset cysts.
- To highlight diagnostic challenges and management strategies.
Main Methods:
- Case report of an immunocompromised patient with back pain and neurological deficits.
- Diagnostic imaging (MRI) revealing a thoracic cyst.
- Surgical intervention (laminoplasty, cyst fenestration/resection) with pathological analysis.
- Cerebrospinal fluid analysis (lumbar puncture) for diagnosis.
Main Results:
- Pathological examination of the cyst wall revealed yeast consistent with Cryptococcus.
- Subsequent lumbar puncture confirmed cryptococcal meningitis.
- The patient experienced neurological improvement after surgical decompression and antifungal treatment.
- Cognitive impairment and delirium were noted postoperatively.
Conclusions:
- Subacute, low-grade infections like cryptococcosis should be considered in the differential diagnosis of de novo arachnoid cysts in immunocompromised individuals.
- Prompt diagnosis and multidisciplinary management are essential for favorable outcomes.
- This case underscores the atypical presentations of opportunistic infections in immunocompromised hosts.
