Meningeal sporotrichosis in an immunocompetent host: case report

Abstract

Endemic in Brazil, sporotrichosis usually presents in its cutaneous form. Meningeal involvement is rare and generally affects immunocompromised hosts. Here we describe a case of meningeal sporotrichosis in an immunocompetent patient without concurrent skin lesions. A 78-year-old woman, previously healthy, developed cognitive deficits with fluctuating mental confusion over the course of three months, until she went to the emergency department with fatigue and stupor. Laboratory workup showed severe hyponatremia due to inappropriate ADH secretion. She was treated with fluid restriction and discharged. Two months later, she was referred to a neurologist because of persistent mental confusion in spite of controlled sodium. She had no headache, fever, seizures, or focal deficits. Cerebrospinal fluid (CSF) analysis revealed chronic meningitis: 232 cells (95% lymphocytes), elevated protein (3.021 mg/dl) and low glucose; cultures and polymerase chain reaction (PCR) for Mycobacterium were negative. Brain magnetic resonance imaging (MRI) revealed basal meningeal enhancement. She was hospitalized and empirically treated for meningeal tuberculosis, with no clinical nor CSF improvement after one month. In a careful history review, we found out that one year earlier she had been exposed to cats who died from sporotrichosis. One month after that, she had had a single skin lesion which spontaneously disappeared, followed by polyarthritis, which also resolved. At the time of our evaluation, she had no cutaneous lesion nor arthritis; CTs of the chest and abdomen were normal. PCR for Sporothrix in the CSF came out positive. She received liposomal amphotericin for 1 month, followed by a 6-months use of itraconazole. She fully recovered her cognitive capacities; follow-up MRI showed no alterations; her late CSF was nearly normal (5 cells, protein 55 mg/dl, no glucose consumption). Our report draws the attention to atypical neurological presentations of sporotrichosis, a treatable condition that may unrecognized.