Multifocal Intracranial Cryptococcoma with Treatment Resistance, Recurrence, and Mortality: A Case Report and Literature Review

Intracranial cryptococcoma is an uncommon manifestation of central nervous system cryptococcosis. Imaging commonly shows ring-enhancing lesions that resemble malignant tumors radiologically. Early diagnosis and extended antifungal treatment are crucial for decreasing morbidity and enhancing outcomes. Treatment typically involves a minimum of six weeks of induction therapy, followed by 6-18 months of maintenance therapy. Limited information is available on the complete clinical progression in cases where remission is not attained with initial treatment. A 66-year-old immunocompetent man presented with ten ring-enhancing lesions in the brain parenchyma and an infiltrative lesion in the lungs. Complete resection of the largest lesion in the left frontal lobe confirmed a histopathological diagnosis of cryptococcoma. Despite receiving eight weeks of induction therapy with liposomal amphotericin B and oral flucytosine, exceeding standard recommendations, the lesions only partially regressed, failing to achieve complete remission. Fluconazole maintenance therapy was initiated. At five months, lesion recurrence was observed. Induction therapy was resumed for three weeks, followed by a switch back to fluconazole. However, the patient's level of consciousness deteriorated, making oral medication impossible. The patient died 15 months after the initiation of antifungal treatment. Cryptococcoma is a critical diagnostic complication. When chest imaging findings are not characteristic of a typical malignancy, a biopsy is essential before determining the appropriate treatment strategy. When lesions do not completely resolve after induction therapy, careful clinical and radiological follow-up is crucial because the risk of recurrence remains significant.