40-year-old man with headaches and dyspnea
1: Brain Pathol. 2005 Jan;15(1):89-90, 95.
July 2004: 40-year-old man with headaches and dyspnea.
Lane H, Browne L, Delanty N, Neill SO, Thornton J, Brett FM.
A 40-year-old man had a 6-week history of severe frontal
headaches and dry cough. Chest x-ray showed hilar adenopathy
with bilateral parenchymal infiltrates. A diagnosis of atypical
pneumonia was made. Four weeks later he was admitted with
persistent headache. Infectious screen was negative. Brain MR
post contrast, revealed cerebellar enhancement and swelling with
moderate tonsillar herniation; findings which precluded the
performance of a lumbar puncture. High resolution CT thorax
confirmed hilar abnormalities; shown by microscopy to represent
non caseating granulomata. A presumptive diagnosis of
sarcoidosis was reached. Despite an initial symptomatic
improvement his headache persisted. Repeat MRI, eleven days
after admission, showed reduced cerebellar enhancement and
swelling with no change in the degree of tonsillar herniation.
He deteriorated acutely and died two weeks after admission.
Autopsy revealed cerebral oedema with tonsillar herniation
secondary to cryptococcal meningitis variety neoformans. There
was no evidence of neurosarcoid. Active and inactive sarcoid was
identified in the lungs and hilar nodes with no evidence of
systemic sarcoid. Focal evidence of cryptococcal pneumonitis was
present in the lung as a necrotic focus. A strong index of
clinical suspicion is necessary to diagnose the rare association
of cryptococcus complicating sarcoidosis.