Butterfly lesion on MRI: Cryptococcus meningoencephalitis wi
In immunocompromised patients, including patients with AIDS, with neurologic complaints, it is proposed to include Cryptococcus meningoencephalitis in the differential diagnoses when the butterfly pattern is encountered on MRI.

A 37-year-old right-handed man presented to our emergency room with new-onset progressively worsening seizures. His past medical history included congestive heart failure, hypertension, AIDS (untreated), and end-stage kidney disease (ESKD) on hemodialysis three days weekly for the past 10 years. The patient had 2 episodes of seizures within 1 week in the days leading up to admission into the hospital. He also complained of acute on chronic 4/10 generalized headache. The patient had not been taking medication and had inconsistent follow-up. CD4 count was unknown on admission.

Vital signs revealed a temperature 38 degrees Celsius, heart rate of 119 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 126/82. Physical examination revealed a thin male with normal mentation. He was alert and oriented x 4, coherent, and free of psychosis. His neck was supple; cranial nerves II-XII were intact bilaterally. Motor examination revealed 5/5 strength in bilateral upper and lower extremities without tremor, myoclonus, asterixis, abnormal tone nor dystonia. Sensation to light touch was intact, and deep tendon reflexes were 2/4 throughout. Finger-nose-finger was intact with no dysmetria nor dysdiadochokinesia. While observed frequently pacing in hallways, the patient had normal gait.

Serum studies revealed a WBC count of 7.4 × 109 cells/L and lactic acid of 0.7 mmol/L while liver and kidney function tests were within normal ranges. The initial noncontrast head CT demonstrated increased white matter in the bilateral temporal lobes. Cerebrospinal fluid (CSF) examination was intended to further delineate findings on CT. Lumbar puncture was therefore performed with an opening pressure of 42 cm CSF. Fluid color was pale-yellow, and clarity was slightly hazy.

There was an RBC count of 330 per mm3, WBC count was 60 per mm3 (with cell differential count showing 30 segmented neutrophils per mm3 and 70 lymphocytes per mm3), glucose was found to be 3 mg/dL, and protein was 406 g/dL. Microscopic examination revealed 3 + yeast/high powered field. CSF Cryptococcus titer resulted as 1:2560. CSF was negative for Coccidioidomycosis, HSV, and West Nile. MRI brain on hospital day 2 revealed no DWI abnormality. However, on FLAIR sequence, there were symmetric confluent signal densities involving the medial temporal lobes, hippocampal bodies, parahippocampal gyri extending upward, and joining at the splenium of the corpus callosum and crossing the midline.

An Infectious Disease specialist was consulted who restarted highly active antiretroviral therapy (HAART), and immediately placed the patient on Amphotericin B and flucytosine. The patient was also started on Levetiracetam 500 mg per oral twice daily. Patient did not have witnessed seizures while inpatient. Unfortunately, the patient signed out against medical advice and left the hospital on hospital day 3. Per Patient's nephrologist, patient presented sporadically for dialysis with intermittent ED visits in a neighboring hospital in the months to follow. Eventually, the patient was unfortunately lost to follow-up.

Source: https://onlinelibrary.wiley.com/doi/10.1002/ccr3.3952?af=R
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