A 55-year-old African-American woman with sarcoidosis treated with double lung transplant on immunosuppression and T2DM presented with 1-year history of headaches, and 3 months of left lower extremity (LLE) weakness and sensory loss. Exam showed 1+ left patellar reflex, provoked sustained clonus in the left ankle, 3+ bilateral upper extremity and RLE reflexes, decreased vibration sense in bilateral feet and decreased pinprick sensation to the knee in the LLE. She was weak in left hip and knee flexion, extension, dorsiflexion, and plantarflexion.

MRI brain showed punctate strokes in the left superior cerebellar hemisphere and left caudate. Spinal imaging showed minimal multilevel degenerative disease with mild left L3-L4 neural foraminal narrowing due to disc protrusion. These were done without contrast due to patient’s poor renal function. EMG/NCS showed severely decreased left fibular motor amplitude at the EDB but not at the TA and loss of sensory responses in the legs. This indicates a lumbosacral plexopathy vs. L3-L4 polyradiculopathy and a length-dependent axonal sensorimotor polyneuropathy, respectively. CSF showed glucose 12, protein 274, 34 WBCs (60% lymphocytes), and cytology negative for malignant cells but with positive cryptococcal antigen (titer >1:2560). CSF and blood cultures grew Cryptococcus neoformans.

The patient was diagnosed with cryptococcal meningitis which likely contributed to the patient’s upper motor neuron symptoms. Cryptococcal infection causing plexus/nerve root inflammation and possibly contributing to polyradiculopathy along with known disc protrusion likely contributed to the symmetric lower extremity weakness and patellar hyporeflexia. Likewise, cryptococcus can contribute to length-dependent polyneuropathy but is confounded by the patient’s T2DM. The strokes had no clear source on workup and likely did not contribute to patient’s presentation but can be seen with Cryptococcal infections. While MRI with contrast may have better delineated these processes, this is nevertheless a unique case of Cryptococcus contributing to multiple neurological complications.