SHM Converge Scientific Abstract ePoster Gallery-When Experts Disagree: The Multidisciplinary Crossroads: To Operate or Not to Operate?

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This case describes a 56-year-old man with HIV, poor antiretroviral adherence, prior cryptococcal meningitis, and remote methamphetamine use who presented with progressive bilateral leg weakness. MRI revealed a 2.1-cm homogeneously enhancing intramedullary mass at T8–T9, raising concern for malignancy, especially lymphoma. Extensive infectious testing was initially negative, and PET imaging showed metabolic activity at the spinal lesion plus multiple lymph nodes. Two lymph-node biopsies showed atypical lymphohistiocytic infiltrates, but flow cytometry was negative. Despite the diagnostic uncertainty, CSF and serum cryptococcal antigen tests were positive, suggesting disseminated cryptococcosis.<br /><br />The patient worsened over the next week, developing paraparesis and urinary retention, and repeat MRI showed lesion expansion. Neurosurgery felt that biopsy or resection carried an unacceptably high risk of neurologic injury, so surgery was deferred even though oncology and infectious disease teams remained concerned about possible cancer.<br /><br />Treatment was started with amphotericin B and flucytosine, followed by corticosteroids. Over the next three weeks, the spinal lesion shrank from 2.1 cm to 1.0 cm, cord edema improved markedly, and the patient’s neurologic function gradually recovered enough to stand with assistance before discharge to rehabilitation.<br /><br />The report highlights that intramedullary spinal cryptococcoma is extremely rare and often mimics neoplasm. While many reported cases have been managed surgically because diagnosis is difficult, this case demonstrates that when surgery is too risky, medical therapy alone can lead to rapid radiologic and clinical improvement. The authors conclude that amphotericin B plus flucytosine may be an effective nonoperative option for selected high-risk spinal cryptococcomas.

Asset Subtitle

Xiaomei Meng

Meta Tag

Author List Xiaomei Meng

Category Clinical Vignettes

Concept Intramedullary Spinal Cryptococcoma

Concept Cryptococcosis

Concept Antifungal Therapy

Concept Amphotericin B

Concept Flucytosine

Distinguished Non-Finalist

Presenter Organization Ohio State University Medical Center

Presenting Author Xiaomei Meng

Track Adult

Keywords

HIV

cryptococcoma

intramedullary spinal mass

thoracic spinal lesion

cryptococcal meningitis

amphotericin B

flucytosine

paraparesis

MRI enhancement

nonoperative treatment

Intramedullary Spinal Cryptococcoma

Cryptococcosis

Antifungal Therapy

Amphotericin B

Flucytosine