Cryptococcal meningitis complicated with a large abdominal cyst mimicking acute pancreatitis.

Cryptococcal meningitis usually occurs in immunocompromised patients, and shows central nervous symptoms. Here, we report an unusual case of a patient with cryptococcal meningitis, who presented himself with mimicking acute pancreatitis, complicated with a large abdominal cyst at the tip of the ventriculoperitoneal (V-P) shunt. Finally, the abdominal cyst fluid was aspirated and confirmed as Cryptococcus neoformans. This 80-year-old male patient had a history of normal pressure hydrocephalus, status post V-P shunt insertion for more than 10 years, and he underwent V-P shunt revision due to malfunction 3 years ago. This time, he presented himself to our emergency department with abdominal pain, diarrhea, cold sweating, and chills for 1 day. The laboratory data showed leukocytosis and elevated lipase (149 U/L) and amylase (848 U/L). Abdominal computed tomography revealed swelling of the pancreas, a large abdominal cyst of the upper left abdominal cavity, and a V-P shunt inside the abdominal cyst (Fig. 1). He was admitted to a ward and received antibiotic treatment with intravenous cefmetazole 1 g every 6 hours for 14 days. He was discharged after fever subsided and relief of gastrointestinal symptoms. The patient started to have altered consciousness, neck stiffness, and fever on the 2 day after discharge. He also had abdominal pain and tenderness over the abdominal cyst. Cerebrospinal fluid (CSF) obtained through shunt reservoir of the skull showed elevated protein (304 mg/dL), decreased glucose level (22 mg/dL), normal cell counts (white blood cells, 3 cells/mL and red blood cells, 9 cells/ mL). Gram stain, tuberculosis polymerase chain reaction, and India ink stain of CSF all showed negative findings, but cryptococcal antigen showed a titer of 1:256, and the CSF culture yielded C. neoformans 2 weeks later. The V-P shunt externalization was performed and shifted to CSF diversion drainage. Specimens from the V-P shunting catheter and