To summarize a case of cryptococcal meningitis with suspected, delayed small vessel vasculitis in an immunocompetent patient.

Cryptococcus neoformans infections are rare among immunocompetent individuals; however, roughly 220,000 cases are reported yearly, affecting patients with HIV/AIDS, organ transplant, and chronic steroid use, among other conditions. We present a healthy 23-year-old intravenous drug user seronegative for the human immunodeficiency virus with cryptococcal meningitis and findings consistent with cryptococcal small-vessel vasculitis. The patient presented with a 1-week history of headache, nausea, vomiting, nuchal rigidity, and altered mental status. The patient had 3 serial lumbar punctures, each 4 to 5 days apart, with elevated opening pressures between 37-55 cm H₂O and the presence of cryptococcal antigen. Initial magnetic resonance imaging showed an acute infarction of the splenium of the corpus callosum. The patient was treated with 6 weeks of amphotericin B and flucytosine. Despite antifungal treatment, the patient experienced a neurologic decline on day 37 with repeat magnetic resonance imaging revealing accumulation of new infarcts in the bilateral basal ganglia, head of the caudate, and bilateral cerebellar hemispheres. Conventional angiogram revealed no large-vessel vasculopathy and was consistent with cryptococcal small-vessel vasculitis. The patient was treated with intravenous dexamethasone 10mg once, followed by 4mg every 6 hours with a taper over 2 weeks. There was no further neurological worsening over the subsequent 3 weeks.

This case suggests that in appropriately treated cryptococcal meningitis, a delayed para-infectious process might be responsible for cerebral infarction. Infarcts secondary to cryptococcal vasculitis are most commonly seen in the basal ganglia. In these patients for whom antifungal therapy has already been optimized, the addition of corticosteroids may be useful in suppressing an inflammatory response.