Cryptococcal Meningitis in a Patient with Multiple Sclerosis on Fingolimod

Authors

Syed Hassan Amir, HCA HealthcareFollow
Teena Mathew

Files

Division

North Texas

Hospital

Medical City Arlington

Specialty

Internal Medicine

Document Type

Poster

Publication Date

2025

Keywords

opportunistic infections, cryptococci bacteria, meningitis, cryptococcal meningitis, immunocompromised

Disciplines

Bacterial Infections and Mycoses | Internal Medicine | Medicine and Health Sciences | Nervous System Diseases

Abstract

Background: There are a host of pathogens that thrive only when the host is weakened enough to be susceptible – Cryptococcus is one such organism that causes fatal meningitis, primarily in HIV patients. Those immunocompromised by other means are also susceptible. Among them, patients with multiple sclerosis (MS) pose a significant challenge as what may initially be considered an MS flare could mask a serious underlying infection. Objective: This case study discusses an MS patient on Fingolimod, an immunosuppressant, that likely made them vulnerable to cryptococcal meningitis. Pathogenesis: Cryptococci are encapsulated yeast that enter the body via inhalation of spores from sources such as bird droppings. They travel to the lungs and colonize it – in some hosts, they may form latent granulomas; while in susceptible hosts, they spread hematogenously, eventually crossing the blood-brain barrier to infect the brain. Case Presentation: A 58-year-old Caucasian female with PMHx MS presented with a change in her mental status. She displayed odd behaviors -- a case in point where she took an unusual driving route that culminated in a motor vehicle collision. On presentation, CBC and CMP were unremarkable. Alcohol/ammonia levels and urine drug screen were all negative. CT head showed no hemorrhage, but possible ischemic changes in basal ganglia. MRI confirmed an abnormal signal of the basal ganglia, midbrain and left meningeal enhancement. A lumbar puncture showed elevated WBC with lymphocytic pleocytosis, elevated protein, and low glucose. CSF studies were positive for cryptococcus antigen with an elevated cryptococcus CSF titer. CSF fungal cultures returned negative. Patient was started on induction therapy with liposomal Amphotericin B alongside Flucytosine. A repeat lumbar puncture confirmed normal opening pressure. The patient was transitioned to Fluconazole for consolidation therapy prior to discharge. Discussion: Besides HIV patients with CD4 counts of less than 100 cells/microL, CM may also occur in patients immunosuppressed by other means, such as in this case with Fingolimod. The immunosuppressant nhibits S1P receptors and thus prevents lymphocytes from leaving lymphatic tissue. Further research could delineate the relationship between lymphocytes and immunity against cryptococcus. Future studies could also help to elucidate whether MS patients are more susceptible to CM than the general population infected by the disease, while exploring possibilities of whether certain immunosuppressants put MS patients at a higher risk of infection. Conclusion: Cryptococcal meningitis should therefore be considered as part of a differential for an MS patient on immunosuppressants presenting with neurological symptoms.

Original Publisher

HCA Healthcare Graduate Medical Education

Recommended Citation

Amir, Syed Hassan and Mathew, Teena, "Cryptococcal Meningitis in a Patient with Multiple Sclerosis on Fingolimod" (2025). North Texas Research Forum 2025. 73.
https://scholarlycommons.hcahealthcare.com/northtexas2025/73