Cryptococcal Cerebellitis in the Setting of Fingolimod Use for Multiple Sclerosis: Atypical Presentation of Dystonia and Imaging Finding Misinterpreted as Subacute Ischemic Stroke
Raman Singh MD1* and Ahmad Al-Awwad MD1
1 The University of Oklahoma Health Sciences Center, Oklahoma, United States.
*Corresponding Author: Raman Singh, MD, The University of Oklahoma Health Sciences Center, Oklahoma, United States.
DOI: https://doi.org/10.58624/SVOANE.2024.05.0131
Received: March 04, 2024 Published: March 25, 2024
Abstract
Objective: Describe a case of cryptococcal cerebellitis in a patient on Fingolimod with atypical findings of generalized dystonia and imaging findings mistaken for bilateral subacute cerebellar strokes.
Background: Fingolimod is used for multiple sclerosis (MS) and is often associated with lymphopenia with prolonged use. Cryptococcal opportunistic infections in patients on Fingolimod, have been rarely described.
Design/Methods: Case report and review of literature.
Results: 44-year-old man with MS in remission treated with Fingolimod for the last 8 years, and poorly controlled type-II diabetes mellitus (A1c 10.4), transferred to our facility for stroke work-up with brain MRI findings reportedly showing subacute bicerebellar ischemic strokes. On exam, he was somnolent and intermittently followed commands. He had nuchal rigidity and positive Kernig and Brudzinski signs. Meningitis was suspected and empiric treatment was initiated. MRI findings on DWI/ADC/FLAIR sequences were inconsistent with any vascular territory. Leptomeningeal enhancement was noted in the cerebellar folia, basal cisterns, suprasellar cistern, and brainstem surface. Labs were remarkable for lymphopenia (250), cerebrospinal fluid (CSF) and blood culture grew cryptococcus neoformans, so treatment with liposomal amphotericin B and flucytosine was started. On day 4, patient developed generalized dystonia that resolved with diphenhydramine. Unfortunately, patient did not respond to therapy as evident on repeat LP on day 6. His physical exam worsened, and he was intubated 2 days after. Repeat MRI showed with tonsillar herniation and patient expired.
Conclusion: Cryptococcal cerebellitis is a rare opportunistic infection occurring in MS patients on Fingolimod. Early recognition is crucial to avoid rapidly worsening neurological outcomes.
Keywords: Multiple Sclerosis; Cryptococcal Cerebellitis; Fingolimod; Subacute Ischemic Stroke
Citation: Singh R, Al-Awwad A. Cryptococcal Cerebellitis in the Setting of Fingolimod Use for Multiple Sclerosis: Atypical Presentation of Dystonia and Imaging Finding Misinterpreted as Subacute Ischemic Stroke. SVOA Neurology 2024, 5:2, 73-77.
