The British Journal of Radiology, 74 (2001), 83±85 E 2001 The British Institute of Radiology

Case report
Cerebral cryptococcosis: atypical appearances on CT
1
M AWASTHI, MBBS, 1T PATANKAR, MD, 1P SHAH, MD and 2M CASTILLO, MD
1
Department of Radiology, King Edward VII Memorial Hospital, Acharya Donde Marg, Parel, Bombay, India
and 2Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7510,
USA

Abstract. Cryptococccal infection is common in immunocompromised patients, often presenting

with meningitis or meningoencephalitis. We report an unusual presentation of cryptococcal
infection in an immunocompetent patient presenting with headache and hemiplegia. CT
demonstrated a large ring-enhancing lesion in the parietal region with intralesional calci®cation.

Cryptococcosis is the most common fungal
infection of the central nervous system [1, 2].
Most patients present with signs of meningitis and
less frequently meningoencephalitis [3±7]. Both
parenchymal and meningeal forms have been
described [3±6]. Most reports describe cryptococ-
cosis in immunocompromised patients [3±6]. We
report a case of Cryptococcus neoformans infec-
tion in an immunocompetent patient with an
atypical presentation of headache and gradual
onset hemiparesis. CT demonstrated a large ring-
enhancing lesion with calci®cation.
Case report
A 20-year-old man presented with right-sided
headache and vomiting for 6 months. He gave
history of pulmonary tuberculosis, which had
been treated 5 years previously. On examination,
the patient was afebrile and had no papilloedema
or focal neurological de®cit. Contrast enhanced
CT showed a sharply marginated loculated lesion
with rim enhancement in the upper right parietal
region. There were multiple intralesional calci®ca-
tions with minimal perilesional vasogenic oedema.
No meningeal enhancement was seen. A provi-
sional diagnosis of tuberculoma was considered
and the patient was started on antituberculous
chemotherapy. He showed no clinical improve-
ment and presented 3 months later with gradual
onset of left hemiparesis over a period of 1
month. He also had multiple episodes of general-
ized tonic and clonic convulsions. On clinical
examination, decreased strength was found in the
left arm and leg. Sensation was decreased on the
left side. No clinical signs of meningeal irritation
were observed. Fundoscopy showed papill-
oedema. Standard laboratory tests were normal.
Received 26 July 2000 and in revised form 20 September
2000, accepted 5 October 2000.
Tests for HIV were negative. ELISA test for
toxoplasmosis was also negative. Repeat contrast
enhanced CT showed that the lesion had signi®-
cantly increased in size (Figures 1a,b). There was
mass effect with compression of the right lateral
ventricle and subfalcine herniation to the left.
A stereotactic biopsy showed multiple refractile
yeast forms with a surrounding halo, amidst tissue
showing moderate in¯ammation composed of a
few lymphocytes and occasional neutrophils. The
appearances were typical of cryptococcoma. The
patient was treated with Amphotericin B, anti-
convulsants and intravenous steroids. He made
a gradual recovery over 2 months. Strength
improved considerably in the legs but the seizures
persisted. Contrast enhanced CT 2 months later
showed that the lesion had decreased in size with
complete resolution of the surrounding oedema
(Figure 2).
Discussion
Cryptococcosis is caused by Cryptococcus
neoformans, an encapsulated yeast-like fungus. It
is a ubiquitous organism found in mammal and
bird faeces, particularly in pigeon droppings [5, 7,
8]. Cryptococcosis is the most common mycotic
infection involving the central nervous system
(CNS) [1]. Although it can affect immunocompe-
tent patients, patients having an underlying
chronic illness such as diabetes mellitus, collagen
vascular disease, chronic renal disease, alcohol-
ism, malignancy or those on immunosuppressive
drugs are more susceptible to cryptococcosis [2, 7,
8]. It ranks third after HIV and Toxoplasma
gondii among the infectious agents causing CNS
disease in AIDS, affecting nearly 5% of HIV
positive patients [1, 2].
The lung is the primary site of cryptococcal
infection, with subsequent spread to different
organs via the haematogenous route. CNS

The British Journal of Radiology, January 2001 83


(a)
Figure 1. (a) Contrast enhanced CT shows a sharply marginated, irregular, conglomerate, rim-enhancing lesion in
the right high parietal cortex, 5 cm in its largest diameter. Surrounding vasogenic oedema is present. (b) A higher
section shows intralesional calci®cation.
cryptococcosis has two forms: meningeal and
parenchymal. Meningitis is often the primary
manifestation and is most pronounced at the base
of the brain. Hydrocephalus often develops as a
result of meningeal scarring [5, 8]. No such
evidence was seen either clinically or on imaging
in our patient. Parenchymal involvement in
Figure 2. Contrast enhanced CT 2 months after treat-
ment with Amphotericin B shows resolution of
oedema, although ring enhancement is persists.
84
M Awasthi, T Patankar, P Shah and M Castillo
(b)
cryptococcosis may be in the form of parenchy-
mal cryptococcomas or torulomas, dilated
Virchow Robin spaces (pseudocysts), multiple
enhancing cortical nodules and a mixed variety
[4].
It is believed that meningeal spread through
subarachnoid and perivascular spaces or ventri-
cles may be the source of parenchymal invasion of
cryptococcii [2, 3]. The commonest parenchymal
sites are the midbrain and the basal ganglia [4]. A
collection of organisms, in¯ammatory cells and
gelatinous mucoid material forms a cryptococ-
coma [2]. A cryptococcoma may be focal
homogeneous nodules with or without circumfer-
ential oedema or may rarely exhibit ring-like
contrast enhancement [4, 9]. Contrast enhance-
ment of cryptococcomas or meninges is rare
because of underlying immunosuppression in
most patients or the non-immunogenic nature of
the polysaccharide capsule of the cryptococcal
organism [1]. Infection spreading along the
Virchow Robin spaces that accompany the
perforating arteries forms gelatinous pseudocysts,
or so called ``soap bubbles'' [2, 4]. They appear as
¯uid-®lled cysts mainly in the basal ganglia,
thalamus, substantia nigra and periventricular
regions [2, 4]. On MRI they are typically non-
enhancing hypointense lesions on T1 weighted
images and hyperintense lesions on T2 weighted
images [2]. Brain stem compression requiring
surgical decompression has been due to large
The British Journal of Radiology, January 2001
Case report: Atypical CNS cryptococcosis
cryptococcal cysts formed by the coalescence of
small cysts [7].
CNS cryptococcosis commonly presents with
manifestations of meningitis and encephalitis such
as headache, nausea, staggering gait, dementia,
irritability, confusion and blurred vision. Both
fever and nuchal rigidity are mild or absent [2, 7].
The course may be fulminant or chronic and
insidious. Lumbar puncture is the single most
useful laboratory investigation. CSF pressure is
often raised and may show mild to moderate
leucocytosis, decreased glucose and elevated
protein levels [7, 8]. India ink smears demonstrate
the yeast. Elevated cryptococcal antigen may be
found in the serum or CSF [2, 5, 7].
The differential diagnosis on imaging includes
infectious causes such as toxoplasmosis, cytome-
galovirus, tuberculoma, pyogenic abcess as well as
lymphoma and metastatic disease.
The clinical picture in our patient was unusual,
with an insidious onset and no evidence of
meningitis. Although parenchymal cryptococco-
mas are well described, such a large rim-enhan-
cing cryptococcoma has not been reported. The
high parietal lobe is an unusual site for CNS
cryptococcosis, the usual sites being basal ganglia
and the midbrain. Such a large lesion occurring in
an immunocompetent individual is rare in CNS
cryptococcosis. The ring enhancement was possi-
bly due to the patient's ability to mount an
immune response, which would be uncommon in
immunosuppressed patients. Another notable
feature is the multiple foci of calci®cation within
the lesion. Such parenchymal calci®cation in
cryptococcosis is rare [7] and may be attributed
to the protracted course of the disease in this
patient.
Cryptococcosis is usually treated with intrave-
nous Amphotericin B [3, 10]. Surgical drainage of
large pseudocysts has been reported [7, 10].
Surgical removal of the cryptococcoma was
The British Journal of Radiology, January 2001
performed in this patient as his convulsions
were not responding to drug therapy.
In conclusion, cryptococcosis may be consid-
ered in the differential diagnosis in immunocom-
petent patients with atypical clinical presentation
and intracranial rim-enhancing lesions, even in
the presence of intralesional calci®cation.
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