Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

An Unusual Presentation of Hepatocellular Carcinoma: Cryptococcal Meningitis in
an HIV Seronegative Patient
Riviere, AE., MA, OMSIII; Qureshi, ML DO; Abriola, KL. MD; Boynton, G, MD
Eastern Connecticut Health Network, Manchester Memorial Hospital, Manchester, CT
Introduction: Historically, cryptococcal meningitis is a rare diagnosis and most often
associated with immune suppression in HIV seropositive patients. Other presentations
of cryptococcal meningitis have been identified in a small population of patients with
other forms of immune compromise such as liver disease, recent organ transplant,
malignancy or corticosteroid use. This patient had a complicated hospital course due to
the severe side effects of the key treating agent, liposomal amphotericin B, which
ultimately revealed a solitary mass in his liver and subsequent work-up for hepatocellular
carcinoma.
Case: A 55 year-old male with a history of alcohol abuse and no other medical problems
presented to the emergency department for a third visit at our hospital after being
contacted to return immediately for treatment for a fungal meningitis when laboratory
results showed a growth of yeast in his cerebrospinal fluid culture. The patient had
recently been discharged from the hospital. Initially, he presented with a history of
severe headaches, nausea, vomiting, neck and back pain and associated gait instability
for a few weeks in duration. At his first visit, the patient’s only laboratory abnormality was
an elevated erythrocyte sedimentation rate and a CT scan did not show any acute
findings. At his second visit, he was diagnosed and treated for aseptic meningitis when
his physical exam showed meningeal signs and the laboratory studies of the
cerebrospinal fluid showed a WBC of 130, RBC of 12 with a repeat of 950, cell count
was 4, neutrophils were 6, lymphocytes were 87, monocytes were 7, glucose was
decreased at 23 and total protein was 90. A repeat lumbar puncture was performed and
the cerebrospinal fluid of both samples was confirmed to be cryptococcus neoformans.
Patient was admitted and began a planned 4-week course of liposomal amphotericin B.
He was seronegative for HIV and showed no other signs of immune suppression. The
patient recalled exposure to a bird-infested worksite. The patient experienced a
challenging hospital course and developed acute renal failure, electrolyte abnormalities,
superficial phlebitis and a lower gastrointestinal tract bleed. The GI bleed prompted a
work-up with further imaging, endoscopy and colonoscopy, which led to discovery of a
solitary liver mass in the setting of cirrhosis. The patient completed his course of antifungal
treatment and was discharged with follow-up care with infectious disease,
gastroenterology and hepatology consultants while preparing for a liver transplant in the
near future.
Discussion: The pathogenesis and intermittent clinical presentation of cryptococcal
meningitis in this patient made the initial diagnosis difficult. This case highlights the
importance of a thorough evaluation of a seemingly healthy patient diagnosed with an
opportunistic infection such as cryptococcal meningitis for further causes of immune
suppression. This patient’s hepatocellular carcinoma demonstrated one of the rare
findings of the pathogenesis of cryptococcal meningitis and its association with immune
suppression due to a hepatic malignancy and cirrhosis. The rigorous course of the
amphotericin B treatment brought to light significant underlying features in this patient,
and ultimately identified the cause of the immune suppression.