3093 Management of active multiple sclerosis after fingolimod cessation in the context of cryptococcal meningitis

Background There are at least 15 case reports published about cryptococcal meningitis (CM) in multiple sclerosis (MS) patients treated with fingolimod. The risk of CM associated with the use of fingolimod appears to increase with more than two years of therapy, lymphopenia, low CD4 counts and older age.¹ It is generally recommended to avoid corticosteroid use during the induction phase of CM treatment due to associations with adverse outcomes.² However, fingolimod cessation can be associated with rebound activity of MS.¹

Methods We describe a case of a 35 year old female diagnosed with CM after 12 years of treatment with fingolimod for relapsing-remitting MS.

Results In this case corticosteroids were used to manage MS disease activity after induction treatment for CM with amphotericin B and flucytosine for two weeks. One week after stopping induction treatment, she developed severe headaches and repeat cerebrospinal fluid examination confirmed recurrent CM. She was given a further four weeks of induction treatment before corticosteroids were used again, due to the development of new active MS lesions on imaging.

Conclusion This case demonstrates the difficulties of rationalising corticosteroid use in a patient with MS and CM the context of fingolimod cessation.

References

1. Cuascut F, Alkabie S, Hutton GJ. Fingolimod-related cryptococcal meningoencephalitis and immune reconstitution inflammatory syndrome in a patient with multiple sclerosis. Mult Scler Relat Disord 2021;53:103072. doi:10.1016/j.msard.2021.103072.

2. Liu J, Liu J, Yang L, et al. Review: the application of corticosteroids in cryptococcal meningitis. J Mycol Med 2023;33(2):101364. doi:10.1016/j.mycmed.2023.101364.