Obstructive Hydrocephalus in the Setting of Cryptococcal Meningoencephalitis: A Case Report

Case Diagnosis: A 60-year-old female with a history of renal transplant, chronic immunosuppression, and systemic lupus erythematosus presented with new-onset neurological symptoms secondary to obstructive hydrocephalus due to fungal meningoencephalitis.

Case Description or Program Description: A 60-year-old female with a history of renal transplant, chronic immunosuppression, and lupus presented with headaches, nausea, dizziness, and cognitive decline. Imaging revealed obstructive hydrocephalus, requiring EVD placement. Initial CSF studies suggested bacterial meningitis, but Cryptococcus neoformans was identified. Despite antifungal treatment, EVD dysfunction persisted, worsening her condition. The patient expired after failing medical and surgical interventions.

Setting: Neuro-ICU in a Fort Worth Hospital

Assessment/Results: Initially diagnosed with bacterial meningitis, the patient showed no signs of an underlying fungal infection. She underwent EVD placement and antibacterial therapy, later switched to antifungal treatment. Despite initial CSF improvement, recurrent occlusions and poor response led to worsening cognitive and functional outcomes. Serial imaging and CSF studies showed rising fungal titers and worsening hydrocephalus. Multiple EVD replacements and antifungal treatments failed, resulting in her transition to comfort care and eventual expiration.

Discussion (relevance): This case highlights the complex interplay between cryptococcal meningoencephalitis, obstructive hydrocephalus, and intracranial pressure management in an immunocompromised patient. Cryptococcal infections are often insidious and challenging to diagnose in chronically immunosuppressed individuals. Despite early mobilization by therapy disciplines, which led to temporary motor and cognitive improvements, the relapsing and rapidly progressing nature of the disease rendered these gains short-lived. This case underscores how medical and surgical treatments influence rehabilitation outcomes, particularly when the overall trajectory remains poor.

Conclusions: Managing cryptococcal meningoencephalitis complicated by obstructive hydrocephalus, particularly in immunocompromised individuals across multiple medical and therapy disciplines, remains challenging. Early diagnosis and targeted treatment are crucial, yet the patient's rapid neurological decline despite momentary functional progress exemplifies the challenges in treating cryptococcal hydrocephalus. More effective therapeutic strategies are needed to improve outcomes in such cases.