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Abstract Details

Treatment Challenges of Active Multiple Sclerosis in the Setting of Cryptococcal Meningitis: A Case Report and Review of the Literature
General Neurology
P12 - Poster Session 12 (5:30 PM-6:30 PM)

The immunosuppressive effect of disease-modifying-therapies (DMT’s), routinely used in patients with relapsing-remittent MS (RRMS), poses the risk of developing opportunistic infections. Cryptococcal meningitis is among the most threatening, yet poorly described, complication associated with DMTs. Management of active MS in this context remains uncertain.

To describe the treatment challenges related to multiple sclerosis (MS) relapse in the setting of cryptococcal meningitis. 

A 31-year-old, HIV-negative, female with RRMS, who self-suspended fingolimod one month prior, was admitted to our hospital for disseminated cryptococcosis of skin and joints, and headaches. Her neurological exam was normal. Head CT unremarkable. Meningeal involvement was confirmed on cerebrospinal fluid (CSF) analysis by positive cryptococcus neoformans PCR, fungal cultures, and antigen titer (1:2560). She was started on amphotericin and flucytosine. Episodes of intracranial hypertension were managed with therapeutic lumbar punctures. After two weeks, CSF cultures negativized and antigen titer decreased (1:80). She then developed severe monocular decreased visual acuity and color desaturation in the left eye. Brain and orbits MRI revealed six new active supratentorial plaques, and peripheral enhancement of the left optic nerve. Balancing the risk of ongoing severe infection, patient was started on methylprednisolone, 1gm daily for three days, followed by oral prednisone taper. Her visual acuity rapidly stabilized, without clinical worsening of cryptococcal meningitis. She was discharged on oral fluconazole for one year, without plan to restart any disease-modifying-therapies in the foreseeable future.    

This patient presented with active RRMS and cryptococcal meningitis. High dose corticosteroids was safe and effective in our case. The decision to treat an MS relapse was based on the severity of symptomatology and the improving trajectory of the underlying infection.

There are no therapeutic recommendations for management of active MS in patients with concomitant severe infection. Therefore, use of corticosteroids should be considered on a case-by-case basis.

Crystal A. Honold, APN, CNS (Southern Illinois Healthcare)
Mrs. Honold has nothing to disclose.
Brandi L. Anderson, NP (SIH) Mrs. Anderson has nothing to disclose.
Andrea Loggini, MD, MBA (Southern Illinois Healthcare) Dr. Loggini has nothing to disclose.
Jonatan Hornik, MD (The University of Chicago, Dept of Neurology) Dr. Hornik has nothing to disclose.
Alejandro Hornik, MD (SIH) Dr. Hornik has nothing to disclose.
No disclosure on file
Tiffany Ward, MD Dr. Ward has nothing to disclose.
No disclosure on file