First report of concomitant cryptococcal meningitis and anti-NMDAR encephalitis

Abstract

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder, seen most often in young adults and children, triggered by tumors or infections. We report a case of cryptococcal meningitis in a patient with sarcoidosis, presenting prominent neuropsychiatric symptoms, electroencephalographic features of autoimmune encephalitis and positive anti-NMDAR antibodies in the cerebrospinal fluid, raising the hypothesis of an infectious immune-mediated mechanism triggering the production of anti-NMDAR antibodies. Since anti-NMDAR encephalitis is potentially fatal and has significant morbidity, further descriptions of its etiological associations are essential to early identification and prompt treatment.

Clinical Characteristics of Patients with Cryptococcal Meningitis in Hokkaido: A Case Series

“…In contrast, in patient 9, who showed delayed exacerbation, anti-NMDAR antibodies were detected before antifungal treatment. The coexistence of cryptococcal meningitis and anti-NMDAR antibody encephalitis has been reported previously (18)(19)(20); however, the pathogenesis of autoim-mune encephalitis remains unclear. Taken together, these reports suggest that autoantibodies may be one mechanism underlying the delayed exacerbation of cryptococcal meningitis.…”

Molecularly targeted immunotherapy used to treat a novel overlap syndrome of pediatric N‐methyl‐d‐aspartate receptor encephalitis (NMDARE) and possible neurosarcoidosis

“…One report describes a 22-yearold woman with encephalitis and diabetes insipidus, and another reports a 39-year-old man with pulmonary sarcoidosis who had cryptococcal meningitis and positive NMDAR-IgG. 3,4 In NMDARE, MRI is normal in greater than 50% of patients and is often used to rule out other conditions. 11 The prevalence of abnormal MRI in NMDARE in pediatric patients is 30%-40%.…”

“…2 There are few reports of overlap syndromes between NMDARE and sarcoidosis, and none previously reported in children. 3,4 Treatment of neuroinflammatory overlap syndromes is challenging due to differing mechanisms, complications, and time courses of disease. Targeted immunotherapy using cytokine testing is emerging as a treatment strategy for neuroinflammatory conditions and has been trialed in neuroinflammatory diseases such as febrile infection-related epilepsy syndrome (FIRES).…”

“…In children, the most often reported overlap syndrome is between NMDARE and myelin oligodendrocyte glycoprotein antibody‐associated disease 2 . There are few reports of overlap syndromes between NMDARE and sarcoidosis, and none previously reported in children 3,4 …”

Cryptococcus Meningitis Can Co-occur with Anti-NMDA Receptor Encephalitis

“…The balance of Th1-Th2 cytokines has been reported as the immunologic mechanism underlying cryptococcal infection ( 2 ). Recently, a case of concomitant CM and anti-N-methyl-D-aspartate (NMDA) receptor encephalitis was reported ( 3 ); however, whether or not cryptococcal infection is related to brain auto-immunity is unclear.…”