Bilateral Cerebellar Hemispheric Ischemia in Cryptococcal Meningitis

Bilateral cerebellar hemispheric ischemia is a rare complication of cryptococcal meningitis that may lead to significant neurologic morbidity. We present the case of a 70-year-old male with asplenia who developed progressive headaches, confusion, and fever. Neurological exam and brain MRI were unremarkable. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis with elevated protein and low glucose levels. CSF polymerase chain reaction (PCR) consisted of <i>Cryptococcus neoformans</i>, and the patient was started on induction therapy. On day 12, the patient reported altered mental status with worsening confusion and dizziness. MRI revealed multiple small infarcts of the posterolateral left cerebellar hemisphere. Transthoracic echocardiogram (TTE) and computed tomography angiography (CTA) of the head and neck were normal. By weeks 3 and 4, new symptoms developed, including ataxia, left-sided facial droop, diplopia, and dysphagia. Repeat MRI showed increased diffusion-positive infarcts involving both cerebellar hemispheres. Due to concern for cryptococcal vasculitis, oral prednisone was initiated. Neurological function gradually improved over the next three to four months. This case highlights vasculitis as a potential contributor to ischemia in cryptococcal meningitis.