(Kiosk 4) Cryptococcal Meningitis in Myasthenia Gravis and Chronic Inflammatory Demyelinating Polyneuropathy: A Case Report

Case Diagnosis: Cryptococcal meningitis

Case Description or Program Description: A 73-year-old male with a past medical history of myasthenia gravis (MG) and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) developed confusion, lethargy, and significant generalized weakness over the course of 7 days. Upon initial presentation, there was a concern for myasthenic crisis in the setting of CIDP. However, his respiratory status remained stable and other etiologies were investigated. An infectious workup including a lumbar puncture was initiated.

Setting: Acute Inpatient Rehabilitation Hospital

Assessment/Results: Cerebrospinal fluid studies were consistent with fungal meningoencephalitis and cryptococcal antigen was positive. The patient was started on antifungal treatment with amphotericin and induction therapy with flucytosine along with fluconazole. Given his significant weakness and functional decline, he was subsequently admitted to inpatient rehabilitation. On admission to rehabilitation, his functional level was moderate assist and following an appropriate therapy program for 20 days he was discharged to home at contact guard to minimum assist level.

Discussion (relevance): Cryptococcal meningitis is thought to be quite rare in human immunodeficiency virus (HIV) negative individuals and is usually seen in immunocompromised patients. Although MG patients are typically immunocompromised, cryptococcal meningitis is still quite rare in MG as only a few case reports are reported in the literature. This patient was on multiple immunosuppressive agents likely putting him at increased risk. Diabetes mellitus is another factor that increases the risk for cryptococcal meningitis, but this patient was not a diabetic. This patient greatly benefitted from acute inpatient rehabilitation as he received therapy to improve his strength and functional mobility along with concomitant medical oversight as he received antifungal therapy which is known to cause serious side effects.

Conclusions: Cryptococcal meningitis should be recognized as a possible cause of meningitis even in HIV-negative patients and especially in patients with underlying immunocompromised conditions such as MG. Early recognition and initiation of antifungal treatment may improve clinical outcomes.