We described a 61-year-old man who was diagnosed as having chronic
cryptococcal meningitis, while he was hospitalized with
Claude syndrome. The patient was admitted because of acute onset of gait disturbance. He had a tendency to fall down to his left side since he awoke in the morning of August 12, 1995. On admission, he was mentally alert, showing a right
oculomotor nerve palsy, gaze-evoked
horizontal nystagmus in the left eye on the left lateral gaze, and
incoordination of the left upper and lower extremities. In addition, he fell to the left side on standing up with feet together and with eyes closed. He had mild wild-based gait with a tendency to fall down to the left on tandem gait. Babinski sign was present on the left side. He did not have
fever, nor meningeal signs, nor sensory abnormalities.
X-ray films of the chest showed multiple nodular shadows consistent with
pneumoconiosis. Cranial X-ray computed tomography and magnetic resonance imaging revealed a small lesion in the paramedian area of the midbrain on the right, consistent with an
infarct. Cerebral arteriography revealed a
stenosis in the proximal portion of the right posterior cerebral artery. Cerebrospinal fluid (CSF) showed a moderate mononuclear cell predominant
pleocytosis, a moderate elevation of total
protein, slightly reduced
glucose values. Although the culture and
India ink preparation of CSF were negative for cryptococcus in repeated studies, its
antigen was positive both in the serum and CSF. In addition, the CSF showed an
oligoclonal IgG band which was predominantly K type. After the
antigen of Cryptococcus neoformans was added to the CSF in vitro, the
oligoclonal IgG band was absorbed completely. The patient was treated with
fluconazole (FLCZ), which did not cause any improvement of the CSF abnormalities, so that FLCZ was replaced by 5-flucytosine (5-FC). Since the CSF abnormalities moderately improved with 5-FC, he was discharged on December 21, 1995. After the 5-FC was discontinued, the CSF results slowly worsened over several months without any signs and symptoms of
meningitis. He was hospitalized again on October 28, 1996 for treatment with both 5-FC and
amphotericin B. Although the CSF abnormalities improved markedly, the
meningitis was not cured. After he was discharged on February 1, 1997, he was treated with both 5-FC and FLCZ. Although his CSF abnormalities worsened mildly, he remained afebrile without meningeal signs and symptoms and led an ordinary life. In our patient it remained undetermined whether the
Claude syndrome was caused by arteriosclerotic
infarction, or
vasculitis due to
cryptococcal meningitis, or both. Asymptomatic chronic
cryptococcal meningitis as observed in our patients is unusual. In addition, this is the second case after Porter et al (1977) that the
oligoclonal IgG band in CSF proved to be related to cryptococcal
infection.