Cryptococcal meningitis-associated cerebrovascular injury presenting with sequential multifocal cerebral infarctions and prominent autonomic dysfunction in a non-HIV patient: a case report and focused literature review

Abstract

Cryptococcal meningitis (CM) can occur in patients without human immunodeficiency virus (HIV) infection and may be complicated by genuine cerebral infarction, creating a powerful diagnostic anchor toward primary cerebrovascular disease. We report a 66-year-old non-HIV man with type 2 diabetes mellitus and no documented major immunosuppressive condition who initially presented with dizziness and mild headache. Brain MRI showed restricted diffusion in the left brainstem, and acute ischemic stroke was diagnosed. Over the following weeks, neurological deterioration continued despite stroke-directed treatment. Repeat MRI demonstrated new infarctions involving the left cerebellar vermis, corpus callosum, and left thalamus, while the patient developed rapid cognitive decline and prominent autonomic manifestations, including orthostatic hypotension, urinary retention, constipation, vomiting, and severe sleep disturbance. Cerebrospinal fluid (CSF) examination revealed an opening pressure >300 mmH 2 O, leukocytes 128 × 10 6 /L, protein 964 mg/L, and glucose 1.28 mmol/L. India ink staining was suspiciously positive, and Cryptococcus neoformans was confirmed by fungal culture and metagenomic next-generation sequencing. Serial lumbar punctures and antifungal treatment with amphotericin B and fluconazole were followed by substantial clinical improvement. To contextualize the case, we conducted a focused review of published non-HIV or apparently immunocompetent reports of CM-associated cerebral infarction. The literature shows a recurring pattern of deep perforator, brainstem, cerebellar, callosal, and multifocal ischemic injury, with both small- and large-vessel mechanisms reported. However, sequential infarctions across multiple territories accompanied by a prominent progressive autonomic syndrome remain poorly documented. This case supports early CSF investigation when recurrent infarction, encephalopathic progression, and multisystem neurological features are discordant with an isolated vascular diagnosis.