Multiple Dimensions of Neurological Injury in A Liver Transplant Recipient with Cryptococcal Meningitis

Shmuel Shoham; Sabin Thapaliya; Robin Avery; John Baddley; Veronica Dioverti; Christine Durand; Ahmet Gurakar; Andrew Karaba; Olivia Kates; Nicholas Maragakis; Nitipong Permpalung; William Werbel; Arturo Casadevall;

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ABSTRACT

Meningitis due to continues to cause substantial morbidity and mortality in victims of this infection. Worldwide, immunosuppression due to uncontrolled HIV disease is the main risk factor. In the United States, however, a substantial percentage of cryptococcal meningitis cases occur in people with non-HIV immune compromising conditions such as solid organ transplantation. Neurological damage in cryptococcal meningitis can be caused by direct fungal-induced injury, as a consequence of elevated intracranial pressure, and by immune-mediated injury. An understanding of these pathophysiological processes and an appreciation for the roles of specific treatments to address them are necessary for optimal care of patients with cryptococcal meningitis. In this report, we present a case of cryptococcal meningitis in a liver transplant recipient whose disease manifestations were due to (i) fungal invasion, (ii) elevated intracranial pressure, and (iii) an over-exuberant immune response that blossomed soon after reduction of immunosuppression and clearance of cerebrospinal fluid culture. This patient's course exemplifies the multidimensional nature of neurological injury in cryptococcal meningitis and the diverse treatment strategies required to address the infection and complications. An understanding of the pathophysiological processes that cause neurological damage in cryptococcal meningitis is critical for optimal management of patients with this infection. This case highlights three such processes so that they can be quickly diagnosed and treated before irreversible damage occurs.

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