Disclosures: Max H. Epstein, MD: Nothing to disclose

Case Description: A 48-year-old woman with a history of multiple sclerosis (MS) on Gilenya and rheumatoid arthritis (RA) on Plaquenil (hydroxychloroquine) presented with new onset seizures to an acute care hospital. She was found to have Cryptococcal meningitis on lumbar puncture (LP) and MRI brain with contrast enhancement subsequently treated with fluconazole. During inpatient rehabilitation, the participant demonstrated marginal improvement in activities of daily living (ADLs), ambulation, and transfers as well as in speech therapy given her significant cognitive deficits in memory and attention. While physical exam remained unchanged, she regressed in therapy by requiring increased verbal cues to perform ADLs and displaying a new gait imbalance.

Setting: Inpatient Rehabilitation Unit.

Patient: A 48-year-old woman with a history of MS on Gilenya and RA on Plaquenil.

Assessment/Results: This comprehensive regression in therapy prompted further medical workup including repeat LP and MRI brain imaging. She was found to have a positive Cryptococcus antigen titer and new lesions with worsening edema. She was promptly treated with amphotericin B and progressed quickly with modified independent transfers and bed mobility along with stand by assist ambulation using an assistive device. Weeks later, LP sensitivities revealed resistance to fluconazole.

Discussion: Drug-induced cryptococcal meningitis is a rare fatal side effect of Gilenya with recently strengthened warnings in certain patient populations. While fluconazole-resistant cryptococcal meningitis has been reported in multiple cases over the past 20 years, the majority of these patients have had AIDS or prior exposure to fluconazole. Given this patient’s Plaquenil use for RA, it is possible that she was more susceptible to developing an underlying infection.

Conclusion: This presents a unique case regarding drug-resistant cryptococcal meningitis in an otherwise healthy patient with no prior fluconazole exposure. Therapy regression proved as useful indicator for further work-up in patients with otherwise unchanged physical exam findings.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/drug-induced-and-drug-resistant-cryptococcus-meningitis-in-an-ms-patient-on-gilenya-fingolimod/