Cryptococcal meningoencephalitis post coronavirus disease 2019 (COVID-19) Infection Recovery

ABSTRACT

Objective: To describe a case of cryptococcal meningoencephalitis (CM) after recovery from severe SARS-CoV-2 pneumonia. Background: CM following clinical resolution of severe SARS-CoV-2 pneumonia in a previously healthy patient has not been reported before. Design/Methods: A 76-year-old patient with a past medical history of hypertension was hospitalized after presenting with 3 days of diarrhea followed by weakness and confusion. Nasal swab nucleic acid amplification test was positive for SARS-CoV-2. A non-contrast MRI brain was unremarkable. Fever and worsening hypoxic respiratory failure rapidly developed, necessitating mechanical ventilation on day 3. Remdesivir, tocilizumab and convalescent plasma were administered. She also received IV methylprednisolone and inhaled budesonide over the course of her month long hospitalization, along with empiric broad spectrum antibiotics and two weeks of micafungin for a sputum culture positive for Candida albicans. She was successfully extubated on day 19 and discharged to a skilled nursing facility on day 30. She was admitted again 19 days later with fever and progressive encephalopathy. MRI brain revealed multiple strokes in bilateral cerebral and cerebellar hemispheres. Blood and CSF cultures were positive for Cryptococcus neoformans. CSF opening pressure was normal. She was started on amphotericin B and flucytosine. Mental status worsened to a comatose state requiring intubation. At the time of this writing, she remains comatose 12 days after initiation of treatment. Results: N/A Conclusions: Cryptococcal meningoencephalitis should be considered in the differential diagnosis of encephalopathy in a patient with severe SARS-CoV-2 infection. Treatment with steroids and tocilizumab may be predisposing factors due to relative immunosuppression.