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[Chronic Cryptococcal meningitis with CSF oligoclonal IgG band in a patient with Claude syndrome]
R Kawanishi1, T Mizutani, S Takahashi
1Department of Neurology, Nihon University School of Medicine.
Insights
This case study details a patient with chronic cryptococcal meningitis presenting atypically without fever or meningeal signs. The study highlights the diagnostic challenge of cryptococcal meningitis and its association with neurological syndromes.
Area of Science:
- Neurology
- Infectious Diseases
- Immunology
Background:
- Chronic meningitis can present with subtle or absent typical symptoms.
- Cryptococcal meningitis is a significant opportunistic infection, particularly in immunocompromised individuals.
- Claude syndrome is a rare midbrain disorder characterized by specific neurological deficits.
Observation:
- A 61-year-old man presented with acute gait disturbance and symptoms consistent with Claude syndrome.
- Cranial imaging revealed a midbrain lesion and cerebral arteriography showed posterior cerebral artery stenosis.
- Cerebrospinal fluid analysis was negative for Cryptococcus on initial testing but positive for cryptococcal antigen and showed an oligoclonal IgG band.
Findings:
- The patient was diagnosed with chronic cryptococcal meningitis co-occurring with Claude syndrome.
- An oligoclonal IgG band in the cerebrospinal fluid was absorbed by Cryptococcus neoformans antigen in vitro, suggesting a link.
- Treatment with fluconazole was ineffective, but 5-flucytosine and amphotericin B showed moderate improvement in cerebrospinal fluid abnormalities.
Implications:
- This case underscores the importance of considering atypical presentations of cryptococcal meningitis, especially when associated with neurological syndromes.
- The presence of an oligoclonal IgG band in CSF, linked to cryptococcal infection, offers a potential diagnostic marker.
- The study contributes to understanding the complex interplay between cryptococcal meningitis, vascular events, and immune responses in the central nervous system.
Abstract:
We described a 61-year-old man who was diagnosed as having chronic cryptococcal meningitis, while he was hospitalized with Claude syndrome. The patient was admitted because of acute onset of gait disturbance. He had a tendency to fall down to his left side since he awoke in the morning of August 12, 1995. On admission, he was mentally alert, showing a right oculomotor nerve palsy, gaze-evoked horizontal nystagmus in the left eye on the left lateral gaze, and incoordination of the left upper and lower extremities. In addition, he fell to the left side on standing up with feet together and with eyes closed. He had mild wild-based gait with a tendency to fall down to the left on tandem gait. Babinski sign was present on the left side. He did not have fever, nor meningeal signs, nor sensory abnormalities. X-ray films of the chest showed multiple nodular shadows consistent with pneumoconiosis. Cranial X-ray computed tomography and magnetic resonance imaging revealed a small lesion in the paramedian area of the midbrain on the right, consistent with an infarct. Cerebral arteriography revealed a stenosis in the proximal portion of the right posterior cerebral artery. Cerebrospinal fluid (CSF) showed a moderate mononuclear cell predominant pleocytosis, a moderate elevation of total protein, slightly reduced glucose values. Although the culture and India ink preparation of CSF were negative for cryptococcus in repeated studies, its antigen was positive both in the serum and CSF. In addition, the CSF showed an oligoclonal IgG band which was predominantly K type. After the antigen of Cryptococcus neoformans was added to the CSF in vitro, the oligoclonal IgG band was absorbed completely. The patient was treated with fluconazole (FLCZ), which did not cause any improvement of the CSF abnormalities, so that FLCZ was replaced by 5-flucytosine (5-FC). Since the CSF abnormalities moderately improved with 5-FC, he was discharged on December 21, 1995. After the 5-FC was discontinued, the CSF results slowly worsened over several months without any signs and symptoms of meningitis. He was hospitalized again on October 28, 1996 for treatment with both 5-FC and amphotericin B. Although the CSF abnormalities improved markedly, the meningitis was not cured. After he was discharged on February 1, 1997, he was treated with both 5-FC and FLCZ. Although his CSF abnormalities worsened mildly, he remained afebrile without meningeal signs and symptoms and led an ordinary life. In our patient it remained undetermined whether the Claude syndrome was caused by arteriosclerotic infarction, or vasculitis due to cryptococcal meningitis, or both. Asymptomatic chronic cryptococcal meningitis as observed in our patients is unusual. In addition, this is the second case after Porter et al (1977) that the oligoclonal IgG band in CSF proved to be related to cryptococcal infection.