Abstract
BACKGROUND: The incidence rate of myelofibrosis is 6 in 100,000 people in Australia. There are only a few reports of cryptococcal meningitis associated with ruxolitinib use in patients with myelofibrosis. The exact prevalence of fungal infections in patients with myelofibrosis is unknown. Furthermore, anti-NMDAr encephalitis has a prevalence of one in 1.5 million people per year. The concomitant findings of cryptococcal meningitis and anti-NMDAr encephalitis have rarely been documented with the first case of an individual presenting with both documented in 2020. The pathophysiology of both, to date, is poorly understood. AIMS & OBJECTIVES: This case presentation hopes to highlight the subtleties in presentation in a highly functional individual who was eventually diagnosed with both cryptococcal meningitis and anti-NMDAr encephalitis, as well as ways to mitigate the risk of misdiagnosis. METHOD: Signed consent was provided by the patient and next of kin. The lead study investigator had sole access to the patient’s records on Electronic Medical Record (EMR), stored notes on the hospital’s secure drive, before translating a de-identified copy of the notes into a case report. RESULTS: A 66-year-old man presents to ED with a one-week history of subjective fevers, sweats and lethargy on a background of myelofibrosis, which under CSF analysis was later diagnosed as cryptococcal meningitis & anti-NMDAR encephalitis. To emphasise, there were no meningoencephalitic changes on CT or MRI brain. The patient was initially managed locally at a regional hospital with flucytosine and amphotericin B. They were transferred back to local hospital for rehabilitation. However, patient’s confusion continued to worsen and the patient exhibited symptoms of psychosis, resulting in multiple Code Greys as an inpatient and a few episodes of abscondence. The patient’s kidney function continued deteriorating on the regime of flucytosine and amphotericin B despite continued infectious diseases input virtually. Patient was transferred to a tertiary centre for multidisciplinary input between infectious diseases, neurology and psychiatry. From a psychiatric standpoint, it was difficult to consider the addition of psychotropics given the patient's deteriorating physical health despite the concurrent deterioration of their mental health. After a 30-day admission and extensive input from specialists, two cryptococcomas were discovered on the patient's repeat MRI brain. After discussion with the patient's next of kin, a decision to palliate the patient was decided on. DISCUSSION & CONCLUSIONS: MRI brain did not reveal any significant changes in 3 of 29 instances of cryptococcal meningitis. While this does not warrant a routine consideration of lumbar puncture, in the case of immunocompromised patients, there should be perhaps a lower threshold to consider performing a lumbar puncture. This may, however, present a challenge in more remote areas without access to experienced clinicians. Whilst worsening confusion is not specific to anti-NMDAr encephalitis, despite the rarity of the condition, clinicians should consider ordering a broader encephalitic screen on CSF analysis, particularly in immunocompromised patients. From a psychiatric and psychopharmacology standpoint, further research is required to develop novel treatments that seek to improve symptoms of psychosis and mental health deterioration without complicating existing comorbidities.