Intraventricular cryptococcal cysts masquerading as racemose neurocysticercosis.

BACKGROUND: Cryptococcal infections of the CNS are infrequent in immunocompetent hosts. When present, they usually present as meningitis and hydrocephalus or as fungal masses called cryptococcomas. We report a case in which intraventricular cryptococcal cysts clinically and radiologically simulated the racemose form of neurocysticercosis.

CASE DESCRIPTION: A 23-year-old man presented to the emergency department with a 1-week history of severe headache, dizziness, nausea, vomiting, and some lethargy. A computed tomography scan revealed significant hydrocephalus. The patient was admitted to the hospital and immediately underwent a right ventriculostomy tube placement. CSF examination showed a meningitic pattern. Magnetic resonance imaging, including FLAIR images, showed multiple large cysts in the temporal horns of both lateral ventricles in addition to hydrocephalus. When an endoscopic left temporal cyst fenestration failed to decompress his trapped right temporal horn, he underwent placement of a left lateral ventricle to peritoneal shunt and a right temporal cyst to peritoneal shunt. ELISA test results for HIV-1 and -2 antibodies in the patient's serum were negative. His CD4 and CD8 counts were within normal limits. Multiple tests for CSF anticysticercal antibody using IgG ELISA gave unequivocally negative results. Latex agglutination tests detected Cryptococcus neoformans antigen in his CSF in titers of 1:1024, which progressively decreased in response to antifungal therapy. The patient underwent treatment with IV amphotericin B for 7 weeks, IV 5-FC for 2 weeks, and oral fluconazole for 5 weeks. At discharge, 3 consecutive CSF cultures were negative for bacteria and fungi. His neurologic status returned to baseline.

CONCLUSIONS: Cryptococcal CNS infections in immunocompetent hosts can mimic the intraventricular form of racemose neurocysticercosis. Distinguishing between the two is essential because the medical management of the 2 conditions is distinct from each other.