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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 3 | Page : 321-323
Cryptococcal myelitis: A rare manifestation in immunocompetent patients
Anand Kumar Rai, Baiakmenlang Synmon, Lakshya J Basumatary, Marami Das, Munindra Goswami, Ashok K Kayal
Department of Neurology, Gauhati Medical College and Hospital, Guwahati, Assam, India
|Date of Submission||22-Mar-2014|
|Date of Decision||24-Mar-2014|
|Date of Acceptance||29-May-2014|
|Date of Web Publication||18-Jul-2014|
Ashok K Kayal
Department of Neurology, Gauhati Medical College and Hospital, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rai AK, Synmon B, Basumatary LJ, Das M, Goswami M, Kayal AK. Cryptococcal myelitis: A rare manifestation in immunocompetent patients. Neurol India 2014;62:321-3
Cryptococcus neoformans is the most common central nervous system fungal infection. Spinal cord syndrome as a presenting feature of cryptococcus is rare;  hence, we are presenting this report.
Case 1: An 18-year-old male farmer presented with urinary complains in the form of hesitancy and increased frequency, followed by asymmetrical weakness of lower limbs, truncal weakness, and sensory loss up to umbilicus for 5 months. There was history of contact with pigeons. Neurological examination revealed flexor spasm of both lower limbs; muscle power 0/5 in left lower limb, right lower limb at knee and ankle joints, and 1/5 at right hip joint; exaggerated deep tendon reflexes in both lower limbs; and sensory impairment below umbilicus [right ˃ left]. Blood biochemistry was normal except raised aspartate transferase [92 IU/L]. Magnetic resonance imaging (MRI) of cervicodorsal spine with screening of whole spine showed long segment dorsal cord (D4-D13) patchy hyper intensity in T2-weighted images [Figure 1]a. Cerebrospinal fluid examination (CSF) revealed protein 142 mg%, sugar 50 mg%, total cells 95 [5% polymorphs and 95% were lymphocytes]. India ink [Figure 2]a and Gram stain [Figure 2]b preparations showed budding yeast forms of cryptococcus and positive serology for cryptococcus antigen in 1:64 titers. Based on history, examination, and investigations, the diagnosis of Cryptococcus myelitis was made. He was started on intravenous fluconazole (200 mg) two times a day for 7 days, followed by oral fluconazole (400 mg daily for 8 weeks). At the time of discharge, the patient was able to walk by himself without assistance. The patient was followed up at regular intervals of one month up to 6 months from date of discharge; he is ambulatory, continent, and performing his daily activities independently.
|Figure 1: (a) Axial section of spinal cord showing hyperintense signal intensity inside the cord (b) Cryptococcal myelitis showing long segment swelling of cord extending from D3 to D12 with T2W hyperintense signals|
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|Figure 2: Cryptococcus images under India ink stain (a) and Gram stain (b)|
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Case 2: A 39-year old male farmer presented with band-like sensation; 3 fingers above umbilicus along with radicular pain in both lower limbs for 3 months. There was history of chicken farming. Neurological examination revealed symmetrical hypotonia, motor power 4/5 at both hip and knee joints and 3/5 at bilateral ankle joints, and weakness of dorsiflexion of the great toe bilaterally. Planters were bilaterally extensor. Straight leg raising test was positive in both lower limbs. There was sensory impairment in both lower limbs in graded manner up to three fingers below umbilicus, and there was impairment of joint position sense at bilateral great toe. Laboratory investigations revealed elevated erythrocyte sedimentation rate [60 mm], aspartate transferase [88.6 IU/L], alanine transferase [92.4 IU/L], and alkaline phosphatase [208.7 IU/L]. MRI of dorsal spine with screening of whole spine was normal. CSF examination revealed protein 72 mg%, sugar 55 mg%, and 2 cells (all were lymphocytes). Cryptococcus antigen was positive in 1:4 titers. Based on history, clinical examination, and investigations, provisional diagnosis of chronic myeloradiculopathy due to Cryptococcus was considered and started on similar treatment as in the first case. Patient improved with treatment and was discharged with advice to follow-up. Six months of discharge patient was readmitted with complaints of paresthesia and pain at multiple sites. Repeat blood investigations and CSF examination, including for cryptococcal antigen, were normal. The patient was given symptomatic treatment and discharged. Patient was followed-up regularly after discharge at 1 month interval up to 8 months and he was performing well in his daily activities.
Spinal infection in Cryptococcus occurs rarely but may be seen in immunocompromised hosts and rarely in normal subjects.  Spinal cord involvement includes epidural abscess, chronic arachnoiditis, intramedullary granuloma, frank myelitis, or vasculitis with cord infarction.  There is often delay in diagnosis because of decreased host immune response. Backache is the most prominent symptom; sometime, it is associated with point tenderness, fever, and malaise.  Spinal fluid shows a lymphocytic cellular response, increased protein level, and normal to low glucose level. Fungi grow readily on Sabouraud's agar media within 2-7 days and can be distinguished from other fungi by colony morphology and microscopic appearance. India ink preparation is positive in 50% of patients in CSF with Cryptococcus infection. Cryptococcus infection is more common in men possibly because of occupational exposure or a lack of estrogens.  In this communication, we want to emphasize that in cases of non-compressive myelopathy, investigation for Cryptococcus infection should also be performed when infectious etiology is suspected. Early and aggressive medical treatment of Cryptococcus neoformans myelitis in immunocompetent patients may be life-saving.
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[Figure 1], [Figure 2]