Cerebral Cryptococcoma Masquerading as High-Grade Glioma in an Immunocompetent Traveler from South America: A Diagnostic Challenge and Systematic Review

Abstract

INTRODUCTION: Cerebral cryptococcoma is a rare focal form of central nervous system (CNS) cryptococcosis, typically described in immunocompromised hosts. In immunocompetent individuals, it may present as a solitary mass lesion, closely mimicking a high-grade glioma and posing a significant diagnostic challenge, especially in returning travelers from endemic regions. CASE PRESENTATION: A 36-year-old previously healthy man from a rural region of South America presented with progressive left hemiparesis, headache, behavioral changes, and a generalized tonic-clonic seizure. Neuroimaging revealed a large, enhancing right parietal lobe lesion with extensive perilesional edema, mass effect, and midline shift-features highly suggestive of glioblastoma. The patient underwent emergency craniotomy with macroscopic complete resection. Histopathological examination, however, demonstrated a cryptococcoma with characteristic mucopolysaccharide capsules and budding yeasts, confirmed by special stains. Serum and cerebrospinal fluid cryptococcal antigen were positive. HIV serology was negative, and CD4 count was normal. He was treated with liposomal amphotericin B and flucytosine, followed by fluconazole, with good neurological recovery. SYSTEMATIC LITERATURE REVIEW: A systematic PubMed search identified 13 previously reported cases of cerebral cryptococcoma in immunocompetent patients. The mean age was 56.1 years (range 40-64 years), with a male predominance (69.2%, 9/13). The most common locations were cerebral parenchyma (38.5%, 5/13) and intraventricular (23.1%, 3/13). Surgical intervention was performed in 84.6% (11/13) of cases. Outcomes were favorable in 84.6% (11/13), with one fatal outcome (7.7%) and one patient surviving with persistent sequelae (7.7%). CONCLUSION: Cerebral cryptococcoma should be considered in the differential diagnosis of ring-enhancing CNS mass lesions, even in immunocompetent travelers or migrants from endemic areas. Preoperative serum cryptococcal antigen testing may aid diagnosis and help avoid unnecessary surgical resection. Histopathology remains the diagnostic gold standard.