Objective: To report a case of cryptococcal meningitis in a person living with Human immunodeficiency virus (HIV) presented with lower body parkinsonism and subsequent generalized chorea.

Background: Chorea is a continuous, flowing and unpredictable movement disorder. In people living with HIV, several conditions may cause chorea. This case report describes cryptococcal meningitis, a common opportunistic infection, presented with an unusual movement disorder.

Method: A 60-year-old man with type 2 diabetes presented with a 3-month history of non-resolving pneumonia. Over the ensuing month, the patient developed progressive gait instability consistent with lower body parkinsonism and urinary incontinence. Initial contrast-enhanced brain CT showed non-obstructive hydrocephalus and leptomeningeal enhancement at right occipital area as shown in Figure 1. CSF analysis revealed elevated opening pressure of 25 cmH₂O with otherwise unremarkable CSF profile. The patient experienced transient improvement in gait following three serial therapeutic CSF drainages. Subsequently, the patient developed altered mental status and acute generalized chorea.

Results: Further investigation revealed reactive HIV with severely reduced CD4+ count of 26 cells/µL. Metabolic profiles were unremarkable, including blood glucose and thyroid function test. Brain MRI did not demonstrate any parenchymal abnormalities, including basal ganglia region. Repeat CSF analysis showed WBC count of 3 cells/µL, elevated protein of 95 mg/dL and low CSF/serum glucose ratio of 0.38 (CSF glucose 60 mg/dL; serum glucose 159 mg/dL). Both CSF and serum cryptococcal antigen tests were positive. CSF studies for Mycobacterium tuberculosis were negative. Regarding the pneumonia, chest CT revealed a cavitary lesion in the right lung, but no causative pathogen was identified. The patient was diagnosed with cryptococcal meningitis with non-obstructive hydrocephalus. Amphotericin B and flucytosine were initiated and haloperidol was given for symptomatic control of generalized chorea. The abnormal movements improved significantly in a following week. However, the patient later succumbed to nosocomial sepsis.

Conclusion: Cryptococcal meningitis should be considered in people living with HIV with a new onset lower body parkinsonism and generalized chorea. Prompt initiation of antifungal therapy may mitigate movement disorder.

Figure 1.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/cryptococcal-meningitis-presenting-with-lower-body-parkinsonism-and-generalized-chorea-a-case-report/