When stroke is not stroke: cryptococcal meningitis presenting as progressive cerebral infarction in a patient with rheumatoid arthritis – a case report and literature review

Background Cryptococcal meningitis (CM) is a prevalent fungal infection of the central nervous system, particularly in immunocompromised hosts. Cerebral infarction, a well-recognized yet underappreciated severe complication, occurs in approximately 13% of CM cases, with a notably higher incidence observed in non-HIV populations than in those with HIV infection. Due to its frequently nonspecific clinical features, diagnosis and treatment are often delayed. Herein, we report a case of CM in which multiple cerebral infarctions constituted the predominant clinical manifestation, aiming to enhance clinicians' recognition of this atypical presentation. Case presentation A 66-year-old male with a history of rheumatoid arthritis(RA) presented with dizziness and headache initially diagnosed as "cerebral infarction" at another hospital. Despite standard secondary stroke prevention, his condition progressively worsened to gait instability, bilateral limb weakness, and neuropsychiatric abnormalities. Brain magnetic resonance imaging revealed newly developed infarctions in the bilateral basal ganglia, temporo-occipital lobes, and pons with meningeal enhancement. Cerebrospinal fluid analysis detected Cryptococcus neoforman s by culture, next-generation sequencing, and positive cryptococcal antigen. The patient showed clinical improvement following antifungal therapy with amphotericin B, flucytosine, and fluconazole, though treatment was complicated by nephrotoxicity requiring regimen adjustment. Conclusion This case highlights that CM should be considered in immunocompromised patients presenting with cryptogenic multiple deep cerebral infarctions, particularly those involving the basal ganglia and posterior circulation with concomitant meningeal enhancement. Early cerebrospinal fluid examination is crucial for timely diagnosis and intervention.