A 66-year-old woman from Venezuela with diabetes and without immunodeficiency presented with headache, dizziness, and lower extremity weakness. Hypodense brain lesions on CT raised concern for metastases (Figure, A and E), but full body CTs failed to reveal a primary site. Brain MRI (Figure, B–D, F–I) suggested intracranial cryptococcosus with mass-like cryptococcomas in the cerebelli, left basal ganglia, right temporal lobe, and right occipital lobe and gelatinous pseudocysts manifesting as new dilatation of the perivascular spaces in the left basal ganglia. The diagnosis was confirmed by CSF antigen testing.
Noncontrast CT (A and E), MRI T2 (B and F), postcontrast T1 (C and G), DWI (D and H), and T2 FLAIR (I) images of the brain. Cryptococcoma (solid arrows) are consolidated areas of infection, appearing as heterogeneous hypodense lesions on CT. On MRI, a lobulated “dirty” T2 appearance with internal enhancement is classic. In contrast to a typical abscess, there is no internal restricted diffusion. Pseudocysts (dashed arrows) are poorly seen on CT, appearing as a vague area of hypodensity. On MRI, they appear as newly enlarged perivascular spaces. Patchy enhancement on postcontrast images and surrounding edema on FLAIR distinguish them from normal perivascular spaces if prior imaging is not available. DWI = diffusion-weighted imaging; FLAIR = fluid-attenuated inversion recovery.
While cryptococcosis has been considered a disease of the immunocompromised, rarely immunocompetent individuals can be affected (especially Cryptococcus gattii). On imaging, 3 manifestations may be seen: (1) meningeal disease evidenced by meningeal enhancement, (2) extension of the meningeal disease into the perivascular spaces, giving rise to dilatation and cystic areas (pseudocyst formation), and (3) coalescence of the infectious material into frank parenchymal collections (cryptococcomas).1
Author Contributions
K. Trinh: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. D. Le: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. A. Kuo: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data.
Study Funding
No targeted funding reported.
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was Resident and Fellow Section Editor Whitley Aamodt, MD, MPH.
Teaching slides links.lww.com/WNL/C792
- Received October 30, 2022.
- Accepted in final form March 15, 2023.
- © 2023 American Academy of Neurology
Letters: Rapid online correspondence
- Author Response: Teaching NeuroImage: Cryptococcal Meningoencephalitis With Cryptococcoma and Gelatinous Pseudocysts
- Reader Response: Teaching NeuroImage: Cryptococcal Meningoencephalitis With Cryptococcoma and Gelatinous Pseudocysts
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