Cryptococcal Meningitis Without Headache: A Case Report Highlighting an Atypical Presentation

Cryptococcus neoformans meningoencephalitis is a prevalent manifestation of cryptococcosis and disseminated infection, frequently observed in immunosuppressed individuals and untreated acquired immunodeficiency syndrome (AIDS) patients. Prevalent causes of immunosuppression encompass glucocorticoid medication, organ transplants, malignancies, and various other disorders. Symptoms include headache, fever, vomiting, and altered mentation. We present a 61-year-old Filipino female diagnosed with autoimmune hemolytic anemia on high-dose glucocorticoid therapy who presented with dyspnea and febrile episodes. The initial workup suggested community-acquired pneumonia, but further testing with blood cultures revealed yeast cells, and the serum cryptococcal antigen titer was markedly elevated (1:4096). Even with the absence of headache or other neurological symptoms, a lumbar puncture was done due to a high index of suspicion, eventually revealing an elevated opening pressure of 51 cmH₂O and a positive CALAS (Cryptococcal Antigen Latex Agglutination System) in cerebrospinal fluid. The patient was then treated with liposomal amphotericin B and fluconazole as per treatment protocol, with serial lumbar punctures showing a gradual decline in antigen titers and intracranial pressure. She remained clinically stable and was transitioned to consolidation therapy with fluconazole. This case illustrates the importance of early CNS evaluation in immunocompromised patients with high cryptococcal antigen titers, even in the absence of classical symptoms. Cryptococcal meningitis should be identified in immunocompromised patients, especially when serum antigen titers are high. High-dose corticosteroids may mask symptoms of headache through multiple mechanisms of action, and the absence of symptoms should not exclude the diagnosis. Early diagnosis, comprehensive evaluations, and prompt antifungal treatment are crucial for improved patient outcomes.