Bilateral Cerebral and Cerebellar Strokes Secondary to Cryptococcal Meningitis-Associated Vasculitis Complicated by Immune Reconstitution Inflammatory Syndrome (IRIS): A Case Study

Case Diagnosis: A 70 year old male with bilateral strokes due to cryptococcal meningitis, complicated by immune reconstitution inflammatory syndrome (IRIS).

Case Description or Program Description: This patient with a history of asplenia presented to his primary care physician in 08/2024 with initial weakness, imbalance, and fevers, leading to hospitalization for a right middle cerebral artery stroke. Following discharge, he returned on 11/08 for recurrent headaches, fevers, ataxia, and falls. Lumbar puncture (LP) confirmed cryptococcal meningitis, prompting antifungal induction and 6 serial LP’s. His course was complicated by weakness, imbalance, and confusion with MRI showing new posterolateral left cerebellar and punctate right inferolateral cerebellar hemisphere changes. After discharge on 11/27, he returned on 11/29 with complaints of emesis, left facial droop, bilateral ataxia, and falls. MRI showed increased cerebellar infarcts and a new right hippocampal infarct with repeat LP positive for cryptococcus. MRI on 12/6 was completed due to worsening weakness and ataxia and showed new restricted diffusion in the splenium of the corpus callosum and medial subcortical region of the anterior left frontal lobe. He was subsequently diagnosed with IRIS and started high dose prednisone, completed 4 subsequent therapeutic LP’s, and was admitted to acute rehabilitation on 12/30. A normal pressure LP performed on 01/03, led to the discontinuation of future LPs.

Setting: Tertiary care hospital.

Assessment/Results: Since 12/30, the patient has showed improvement in activities of daily living, mobility, and visual perception. He was discharged on 01/14 and continued with outpatient rehabilitation.

Discussion (relevance): This is a rare case of recurrent bilateral strokes occurring secondary to cryptococcal meningitis with IRIS, leading to a complex and unique rehabilitation situation requiring multiple therapeutic LP’s and careful management of neurological deficits and immune dysfunction.

Conclusions: Cryptococcal meningitis and IRIS, significantly altered this patient's functionality and quality of life, necessitating therapeutic LP’s and extensive rehabilitation.