A 39-year-old man with a history of hepatitis C cirrhosis and intravenous drug use presented to the emergency department for right arm weakness and headache. Patient had mild scleral icterus and 4/5 strength on right elbow flexion. The remainder of the exam was unremarkable. CT head without contrast demonstrated a small left centrum semiovale hypodensity. CTA head and neck showed no arterial stenosis or occlusion. MRI brain with and without contrast showed multiple enhancing lesions in the left midbrain, bilateral basal ganglia, and bilateral internal capsules. Restricted diffusion within the left midbrain lesion was suggestive of abscess. Differential for these lesions included an infectious process, such as septic emboli, fungal infection, or toxoplasmosis, and less likely neoplastic or demyelinating. Lumbar puncture was performed with opening pressure of 10 cm H₂O. CSF analysis revealed glucose 54, protein 30, cell count 7 (94% lymphocytes), and positive Cryptococcal antigen with titer of 1:20. The remainder of CSF studies were negative. Serum studies revealed pancytopenia. Patient’s treatment plan for CNS cryptococcosis included induction therapy with amphotericin and flucytosine for 6 weeks, followed by consolidation therapy with oral fluconazole. Unfortunately, patient expired due to complications related to hepatic failure.

We discuss this case of CNS cryptococcosis presenting as a stroke mimic to highlight the risk factors, characteristics, and challenges in diagnosis and management of this emerging disease in the U.S.