A Case of Concomitant Cryptococcal Meningitis and Anti-NMDA Receptor Encephalitis in a Patient with Myelofibrosis on Ruxolitinib Therapy

Background The following case presentation describes a rare association between two concomitant neurological diseases (cryptococcal meningitis and anti-NMDA receptor encephalitis) and ruxolitinib-treated myelofibrosis. The case also delves into the potential role immune reconstitution inflammatory syndrome (from ruxolitinib withdrawal) may have played in exacerbating the neurological conditions. Case Presentation A 66-year-old man, Mr. Evans (pseudonym), with a background of myelofibrosis on ruxolitinib therapy, presented to a rural emergency department, with one month of constitutional symptoms, and an associated mild headache. Mr. Evans appeared very fit and well, with no focal neurological signs or symptoms. He was discharged without a lumbar puncture, with his symptoms attributed to progression of his myelofibrosis. He re-presented nine days later with altered mental status and was diagnosed with cryptococcal meningitis, along with anti-NMDA receptor encephalitis. Conclusions This case will focus predominantly on that first presentation, and how Mr. Evan's care and risk stratification could have been optimised, to avoid progression to the second presentation. The case will highlight a lack of general awareness for the immunosuppressive potency of myelofibrosis and ruxolitinib and will push for change to current clinical guidelines to incorporate more infective screening, specifically for cryptococcus, to help avoid putting the next patient through what Mr. Evan's and his family endured.