A Lethal Case of Cryptococcal Meningitis in an Apparently Immunocompetent Patient: A Case Report Highlighting Diagnostic Pitfalls and Therapeutic Challenges

Cryptococcal meningitis (CM) is a relatively uncommon infection among immunocompetent individuals, with high rates of morbidity and mortality. We describe a 41-year-old seemingly immunocompetent gentleman with no significant past medical history who presented with fever, altered mental status, and headache for one week. The initial lumbar puncture (LP) exhibited lymphocytic pleocytosis with elevated cerebrospinal fluid (CSF) protein. CSF samples tested negative for common bacterial and viral pathogens; however, cryptococcal antigen was not tested. The patient was subsequently intubated for airway protection due to further deterioration in his mental status. Repeated CSF analysis tested positive for cryptococcal antigen with positive Indian ink microscopy. In spite of urgent surgical CSF diversion and combination antifungal therapy, the patient subsequently succumbed to his illness. This case highlights the great challenge in ensuring early and accurate diagnosis of CM, especially in immunocompetent patients who often present with indolent clinical manifestations. Greater emphasis should be placed on the importance of early diagnosis of CM and prompt initiation of effective treatment for better prognosis. This case underscores the critical need to include point-of-care cryptococcal antigen (CrAg) testing in the initial workup of all patients with unexplained lymphocytic pleocytosis, irrespective of their perceived immune status. Future research should be conducted to refine diagnostic approaches and treatment strategies for immunocompetent patients with CM.