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An unusual case of central nervous system cryptococcosis
S Schmidt1, I Reiter-Owona, M Hotz
1Department of Neurology, RLK Bonn, Germany.
Insights
Diagnosing opportunistic central nervous system (CNS) infections in immunocompromised patients is challenging. This case highlights CNS cryptococcosis mimicking toxoplasmosis, emphasizing diagnostic difficulties and characteristic findings.
Area of Science:
- Neuroscience
- Infectious Diseases
- Immunology
Background:
- Opportunistic central nervous system (CNS) infections pose significant diagnostic and therapeutic challenges in immunocompromised individuals.
- A wide array of potential infectious agents can cause CNS disease, complicating differential diagnoses.
Observation:
- A severely immunocompromised patient presented with headache, confusion, and abnormal cerebrospinal fluid (CSF) findings, including eosinophilia and elevated protein.
- Neuroimaging revealed multiple contrast-enhancing lesions in the basal ganglia, initially suggestive of toxoplasmosis based on serological markers.
- Despite initial serological findings pointing towards toxoplasmosis, the final diagnosis was CNS cryptococcosis.
Findings:
- The case underscores the diagnostic complexities in differentiating opportunistic CNS infections in immunocompromised hosts.
- Central nervous system (CNS) cryptococcosis can present with significant CSF eosinophilia and multiple cryptococcomas.
- Persistence of cryptococcomas on CT and MRI scans can occur even after successful antifungal therapy.
Implications:
- Diagnosis of toxoplasma encephalitis requires confirmation beyond serological testing, utilizing methods like PCR, mouse inoculation, or brain biopsy.
- This case highlights the importance of considering CNS cryptococcosis in immunocompromised patients, even with initial serological indicators of toxoplasmosis.
- Radiological findings of cryptococcomas may persist despite effective treatment, necessitating careful clinical and microbiological monitoring.
Abstract:
Opportunistic infections of the central nervous system (CNS) in immunocompromised patients often represent a diagnostic and therapeutic challenge due to the variety of possible infectious agents causing CNS disease. We report the case of a severely immunocompromised 43-year-old woman presenting with headache, confusion, abnormal CSF findings (cell count 237/mm3 with 50% eosinophils and elevated protein), multiple contrast enhancing lesions on CT and MRI in the basal ganglia, and serologic findings compatible with latent or reactivated toxoplasmosis with high IgA and IgG antibody titers against Toxoplasma gondii in whom a final diagnosis of CNS cryptococcosis was made. This case illustrates the considerable difficulties in the differential diagnosis of opportunistic CNS infection in the immunocompromised host. We conclude from our report that (1) the diagnosis of toxoplasma encephalitis should not be based on serological findings but rather be proven by either PCR, mouse inoculation or brain biopsy, (2) CNS cryptococcosis can be associated with marked CSF eosinophilia and multiple cryptococcomas, and (3) cryptococcomas can persist on CT and MRI despite successful antifungal treatment.