Supplementary Material for: Longitudinally Extensive Transverse Myelitis and Vasculitis by Cryptococcosis in a Non-HIV patient: A Case Report

Introduction: Cryptococcosis is a fungal infection with frequent involvement of the central nervous system (CNS), particularly in patients immunocompromised by the human immunodeficiency virus (HIV). Its essential neurological presentation is meningoencephalitis, with exceptional spinal cord involvement. We present the case of an immunocompetent patient with myelitis and vasculitis caused by Cryptococcus.

Clinical case: A 59-year-old male patient with diabetes mellitus, presented with two weeks of lower limb weakness, vertigo, and urinary retention with subsequent loss of alertness. Magnetic resonance imaging (MRI) confirmed a longitudinally extensive transverse myelitis (LETM), venous sinus thrombosis, and multiple cerebral infarcts involving the cerebellum, basal ganglia, and corpus callosum. Cerebrospinal fluid (CSF) confirmed Cryptococcus fungal infection. Differential diagnoses (infectious, autoimmune, metabolic, demyelinating, and neoplastic) were excluded. Liposomal amphotericin and flucytosine treatment were started for 6 weeks, with partial improvement. Late primary immunodeficiency was diagnosed based on a low CD4+ count, excluding HIV in multiple instances. The patient continues with motor and sensory sequelae and hypoacusis.

Discussion: Myelitis of infectious origin is predominantly viral and bacterial. Spinal cord involvement by Cryptococcus is extremely unusual, and the literature is limited to case reports. This condition shows high heterogeneity in its presentation, being predominant in patients with immunocompetence. It can be associated with cryptococcomas and transverse or longitudinally extensive myelitis involving any spinal cord segment. The treatment duration and use of corticosteroids are still debatable. Few similar cases have been reported.

Conclusion: Cryptococcus fungal infection should be included in the differential diagnosis of infectious myelopathies, even in patients without HIV infection.