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Título

Neurocryptococcosis in a young immunocompetent patient: a case-based update

RESUMO

CASE PRESENTATION: A 19-years-old female presented 3 months ago an episode of an intense occipital pulsatile headache with irradiation to the frontal region, associated with vomiting, photophobia, phonophobia, right arm paresthesia and dysarthria. After 20 days, she evolved with a return of this condition, with additional lower limb paraparesis, fever and low back pain, which demanded hospitalization for 4 days. After partial improvement of the condition, she was discharged, still unable to walk. At her home, she evolved with worsening headache and low back pain, also appearing diplopia and left convergent strabismus. Admitted to the emergency, a skull Computed Tomography and Magnetic Resonance Imaging were performed, both without alterations. The cerebrospinal fluid (CSF) analysis showed hypoglycorrhachia and hyperproteinorrhachia, then antibiotic therapy was performed for 12 days, without improvement. A new lumbar puncture was performed, which showed cells suggestive of cryptococcosis, in the strong suspicion of this fungus, multiplex Polymerase Chain Reaction (PCR) was requested, which confirmed the infection by Cryptococcus Neoformans/Gattii.

DISCUSSION: Neurocryptococcosis is a fungal infection caused by two species of Cryptococcus, C. neoformans and C.gattii. It represents an important opportunistic infection related to AIDS, being uncommon in immunocompetent patients. The clinical presentation includes signs and symptoms such as headache, fever, nauseas/vomiting, cranial neuropathies, mental disorder, lethargy, diplopia, intracranial hypertension and signs of meningeal irritation. The CSF analysis can include elevated white cell count, with lymphocyte predominance, elevated CSF protein, and low CSF glucose. The definitive diagnosis is made by isolation of Cryptococcus or direct detection of the fungus by means of India ink staining of the CSF. Other forms of diagnosis include histopathology, serological and molecular methods. Amphotericin B deoxycholate and flucytosine is the main treatment for severe cryptococcal infection, including meningoencephalitis. Liposomal amphotericin B is a second option with less nephrotoxicity, and other antifungals or combinations can be used in particular cases.

FINAL COMMENTS: Early diagnosis of neurocryptococcosis in immunocompetent patients can be challenging. Being aware of this infection in this group of patients is necessary for rapid and appropriate management.

Palavras Chave

Neurocryptococcosis, meningoencephalitis, immunocompetent patient