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oregon; portland; ppmc


Internal Medicine


Background Cryptococcal infection is an infection caused by encapsulated yeasts of the Cryptococcusfungi that primarily manifests in the CNS or lungs in immunocompromised hosts. Our case describes disseminated Cryptococcus neoformansinfection and cerebral cryptococcomain an immunocompetent individual.

Case History •A 64 year-oldmale with no pertinent medical history presented to his PCP for worsening headaches for the past 2 months. •MRI: new ring enhancing lesion of the left thalamus •CT chest: bilateral upper lobe tree-in-bud nodules and a right upper lobe nodule with stippled calcification. •Lung biopsy, complicated by pneumothorax, was unremarkable. •2 days later developed headaches and nausea, became non-verbal, and exhibited seizure activity. Had to be intubated and sedated after this and taken to ICU. Physical Exam •Lungs: Clear. •Neuro: Does not follow commands. Opens eyes spontaneously but not to verbal stimuli. PERRL. Face appears symmetrical. Withdraws to pain in all extremities. Moves all 4 limbs spontaneously. Labs •Leukocytosis: 16.6: 88.8% neutrophils, 4.5% lymphocytes, •HIV negative •CSF: WBC 107, glucose 23, protein 79, opening pressure 23 •Cryptococcal neoformans Ag, serum EIA positive •Cryptococcal neoformans Ag, CSF EIA positive •CSF culture: Cryptococcus neoformans Management •Started on amphotericin B and flucytosine. •1 week after treatment repeat MRI brain showed improvement of the lesion, presumed to be cryptoccoma. •Required multiple LPs and drain placement due to increased ICP causing agitation and altered mental status that improved with CSF drainage. •Patient improved and discharged on 18 months of fluconazole.

Conclusions C. neoformans should still be in the considered as potential diagnosis for patient with altered mental status, regardless of immune status. •Patients can have normal radiological findings. •Consider early serum CrAg testing to expedite diagnosis. •Cryptococcomas are rare. •Treatment duration can be up to 20 months, especially for cryptococcomas. •Monitoring and reducing intracranial pressures may be key components of care.


Internal Medicine


Graduate Medical Education

Conference / Event Name

Academic Achievement Day, 2021


Providence Portland Medical Center

Cryptococcoma from disseminated Cryptococcus neoformans infection in an immunocompetent patient