Fingolimod-associated cryptococcal choroiditis and osseous cryptococcosis in a case of relapsing–remitting multiple sclerosis

A man in his 20s with a background of relapsing–remitting multiple sclerosis developed spinal cryptococcosis and choroiditis after 8 years of therapy with the oral immunomodulator fingolimod. The osseous cryptococcosis was diagnosed with a vertebral biopsy, after radiological changes in the C5 vertebra were incidentally identified during routine biannual neuroimaging. He was subsequently admitted for intravenous antifungal therapy. During admission, the patient reported bilateral floaters and was subsequently found to have bilateral choroidal lesions suggestive of a partially treated cryptococcal choroiditis with normal vision. This case is, to our knowledge, the first report of cryptococcal choroiditis secondary to fingolimod therapy and reaffirms the importance of a high index of clinical suspicion of ocular infections in the setting of chronic immunosuppression.