Fulminant cryptococcal meningoencephalitis with adrenal involvement in an immunocompetent patient: a clinicopathologic correlation

Abstract

Cryptococcus meningoencephalitis (CM) is the most frequently encountered manifestation of cryptococcosis. We report the case of a previously healthy, human immunodeficiency virus (HIV)-negative 65-year-old man who presented with 3 days of severe holocranial headache followed by sudden psychomotor agitation, confusion, and disorganized speech, without improvement after midazolam, requiring endotracheal intubation. Initial neuroimaging suggested inactive neurocysticercosis. Early cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis with negative India ink but positive cryptococcal antigen (latex agglutination), and subsequent testing confirmed Cryptococcus neoformans. The patient received fluconazole and amphotericin B and underwent therapeutic lumbar punctures for intracranial pressure control, with opening pressures decreasing from 25 to 13 cmH2O and transient clinical improvement. Despite this response, he experienced sudden deterioration and died. Autopsy revealed diffuse cerebral edema and granulomatous adrenal involvement. This case illustrates the potential fulminant course of cryptococcal meningoencephalitis in immunocompetent individuals and reinforces the importance of early recognition and aggressive intracranial pressure management.