Cryptococcal meningitis with cryptococcemia in a multiple sclerosis patient treated with Fingolimod: A case report

Abstract

Multiple sclerosis (MS) is one of the most common diseases of the human central nervous system, causing significant neurological disability. Fingolimod, a sphingosine-1-phosphate receptor modulator, is an approved oral therapy for relapsing-remitting multiple sclerosis (RRMS) that works by decreasing the egress of lymphocytes from lymph nodes to the central nervous system. Despite its effectiveness in treating MS, Fingolimod can increase the risk of opportunistic infections due to its immunosuppressive effects. A 34-year-old male was diagnosed with MS in 2017, presenting with spastic gait, paraparesis, and a history of left homonymous hemianopia. He was prescribed Fingolimod in September 2019 following a relapse. About four years after starting Fingolimod, he developed severe headaches and visual impairment. Initially treated for an MS relapse with methylprednisolone, he returned two weeks later with progressive loss of consciousness and confusion, and was subsequently diagnosed with disseminated cryptococcosis. Hemoculture and cerebrospinal fluid culture confirmed the presence of Cryptococcus neoformans. Due to clinical worsening and acute renal injury, the patient was treated with liposomal amphotericin B and fluconazole, after receiving routine induction therapy with amphotericin B and flucytosine. The patient underwent serial lumbar punctures every other day for intracranial pressure management. After two weeks of treatment, he was discharged with significant improvement and no major complaints.