Atypical Presentation of Pediatric Systemic Lupus Erythematosus Complicated by Cryptococcal Meningitis

BACKGROUND: Cryptococcus is an opportunistic fungal pathogen that leads to life-threatening infections. Cryptococcal infections are mainly reported in HIV patients and less commonly encountered in non-HIV immunocompromised host. Cryptococcus neoformans (C. neoformans) is the most common Cryptococcus species causing diseases in humans which can be presented as pulmonary, meningitis, cutaneous, and/or disseminated cryptococcosis. Case Presentation. A 12-year-old female girl from Cairo, Egypt, presented to the pediatric hospital with signs of systemic lupus erythematosus (SLE). She had an aggressive lupus nephritis course for which corticosteroids, mycophenolate mofetil, and cyclophosphamide were prescribed, and the child gradually improved and was discharged. Two months later, the patient exhibited skin lesions involved both in her legs, massive ulcers were developed and extended rapidly through the entire legs followed by deterioration in her conscious level, and signs of meningitis were documented. Cerebrospinal fluid (CSF) examination and microbiological workup were confirmatory for C. neoformans infection, and mental and motor functions were rapidly deteriorated. Treatment with amphotericin B in addition to supportive treatment and close follow-up of the patient's medical condition result in obvious clinical improvement and patient discharge with minimal residual weakness in her legs after almost a one-month duration. After six months, the patient was brought to the emergency department complaining of repeated attacks of seizures, a lumbar puncture was performed, and culture results were again confirmatory for C. neoformans. An intensive course of antifungal therapy was prescribed which was successful, evident by resolution of the signs and symptoms of infection in addition to negative culture results and negative sepsis biomarkers. The child clinically improved, but unfortunately, gradual optic nerve degeneration and brain cell atrophy as a sequel of severe and longstanding cryptococcal infection resulted in her death after almost one year from her first attack. CONCLUSION: Cryptococcal infection among non-HIV patients is a rare disease but can result in advanced medical complications which may be fatal. The disease should be suspected to be reliably diagnosed. Cryptococcus infection can be presented as a skin lesion which, if not treated properly at an earlier time, can result in dissemination and life-threatening consequences. Amphotericin B can be used effectively in cryptococcosis management in the settings where flucytosine is not available. Signs of cryptococcal meningitis can be manifested again after a period of remission and clinical cure which signifies the latency of Cryptococcus in the central nervous system. The second activation of Cryptococcus after its latency is usually life-threatening and mostly fatal.