A 55-year-old farmer, male, was admitted to the Intensive Care Unit of the Befelatanana University Hospital in Antananarivo with an altered consciousness. One month prior to his admission, he complained of a moderate and diffuse headache associated with blurred vision. His general condition worsened quickly during the 3 days prior to admission with the onset of fever and confusion. At admission, physical examination revealed a mild fever (38.6 C), but most of the other physiological parameters were within normal limits. Glasgow Coma Scale (GCS) was 4/15; the patient presented unresponsive bilateral tight myosis and signs of meningeal irritation, that is, neck rigidity, Kernig, and Brudzinski signs. No focal neurological signs were observed. Chest auscultation revealed crackles of the lower zones on both sides and diffuse rhonchi. A lumbar puncture showed a high opening pressure (35 cm H2O) of cerebrospinal fluid (CSF), which was macroscopically limpid. Examination of other systems revealed no apparent abnormalities, and there was no history of long-term medication with corticosteroids, solid organ or stem transplantation, hematologic malignancies, or chronic disease conditions, such as tuberculosis or kidney/hepatic failure.
Initial laboratory investigations of the CSF showed normal white count and glucose and an increased concentration of protein at 288 mg/dL (normal: <40 mg/dL). Blood count showed elevated white cells at 14 x 103/muL (normal: 4.4 to 10.5 x 103/muL) with 91% neutrophils (normal: 42 to 77%) and 7% lymphocytes (normal: 17 to 49%). Other biological parameters were within normal ranges. A rapid HIV serological test (Alere Determine  HIV-1/2, Alere Inc, USA) was negative; RNA HIV-1 viral load (Generic HIV Charge Virale, Biocentric, Bandol, France) was undetectable, and CD4 count (Alere Pima  CD4, Ireland) was 126 cells/mm3. The brain Computerized Tomography scan and chest radiography were normal.
Direct microscopic examination of CSF with India ink showed the presence of a large number of spherical yeasts surrounded by a clear haloed zone consistent with Cryptococcus spp. (Figure 1). A lateral-flow immunochromatographic assay for the rapid and semiquantitative detection of Cryptococcus antigen (CrAg  LFA Immuno-Mycologics, Inc., OK, USA) revealed a low titre (1 : 40) in the CSF and a higher titre (1 : 160) in the serum. Subsequently, the CSF, inoculated onto Sabouraud-chloramphenicol media without cycloheximide, incubated at 30 C, yielded smooth yeast colonies later confirmed as Cryptococcus neoformans var. grubii by matrix-assisted laser desorption ionization time-of-flight (MALDI-ToF) mass spectrometry using Bruker BioTyper instrument. The isolate was correctly identified at the species and varietal level with a log (score) value of spectra of 2.12. The antifungal susceptibility of the isolate was tested retrospectively by using Etest (BioMerieux, La Balme les Grottes, France). The Minimum Inhibitory Concentration (MIC) was determined as the lowest concentration that inhibited 100% and 80% of the fungal growth for amphotericin B and azoles, respectively. The MIC value for amphotericin B was 0.25 mug/mL, for voriconazole 0.38 mug/mL, and for fluconazole 48 mug/mL. The high MIC value of fluconazole was confirmed at 32 mug/mL by the EUCAST reference method (EDef 7.2 Revision). Following antigen detection and direct examination of CSF, the patient was treated immediately with fluconazole (1200 mg/day) via nasogastric tube, but the outcome was fatal after 7 days of treatment with acute respiratory distress and worsening of the neurological status with transition to unresponsive coma.