In an elderly patient on chronic steroids presenting with a subacute meningitis picture (headache, neck stiffness, photophobia) but afebrile, which diagnosis is most likely?

In an elderly patient on chronic steroids presenting with a subacute meningitis picture (headache, neck stiffness, photophobia) but afebrile, which diagnosis is most likely?

• A. Viral Meningitis
• B. Bacterial Meningitis
• C. Tuberculous Meningitis
• D. Cryptococcal Meningitis

Answer: (D)

Subacute meningitis in someone with chronic steroid use points toward a fungal infection, specifically cryptococcal meningitis. Cryptococcus neoformans tends to affect people with impaired cell-mediated immunity and often causes a gradual illness with headaches, neck stiffness, and photophobia, but little or no fever. The immune suppression blunts the fever response, so afebrile presentations are common. Bacterial meningitis usually presents rapidly with high fever and marked acute illness. Viral meningitis tends to be milder and not as strongly linked to chronic steroid use. Tuberculous meningitis can be subacute as well, but it typically comes with more systemic symptoms (like weight loss, night sweats) and a different CSF profile. Therefore, the pattern described most fits cryptococcal meningitis.

Subacute meningitis in someone with chronic steroid use points toward a fungal infection, specifically cryptococcal meningitis. Cryptococcus neoformans tends to affect people with impaired cell-mediated immunity and often causes a gradual illness with headaches, neck stiffness, and photophobia, but little or no fever. The immune suppression blunts the fever response, so afebrile presentations are common.

Bacterial meningitis usually presents rapidly with high fever and marked acute illness. Viral meningitis tends to be milder and not as strongly linked to chronic steroid use. Tuberculous meningitis can be subacute as well, but it typically comes with more systemic symptoms (like weight loss, night sweats) and a different CSF profile. Therefore, the pattern described most fits cryptococcal meningitis.