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Cryptococcal meningitis presented with irreversible binocular blindness in an HIV infected patient- A case report

Bhattacharjee B, Bhattacharya S, Ghosh M, Raj P, Sardar B, Majumdar D, Naskar A, Ghosh MK, Mallik S, Saha B

Cryptococcal meningitis is a major HIV-related opportunistic infection, occurring when CD4 counts are below 100. Ocular involvement is seen with up to 30% of patients with cryptococcal meningitis. A young HIV infected male was admitted to in patient department of School of Tropical Medicine, Calcutta with complaints of headache for two months with dimness of vision for 10 days. Examination showed decreased visual acuity on both eyes, neck rigidity with right sided extensor plantar reflex, external ophthalmoplegia in the form of left 6th cranial nerve palsy, bilaterally absent light reflex, power 5/5 in all four limbs with normal tone and right eye hypermetropic tilted disc, left eye normal on ophthalmoscopy. India Ink preparation of CSF showed encapsulated budding yeast cells. Fungal culture grows Cryptococcus sp. CSF CRAG (cryptococcal antigen measured by immunochromatographic method) was positive in high titre (1:2560). MRI of brain revealed multiple tiny hypo to isointense lesions on T1 and hyperintense lesions on T2, T2 flair sequences are seen in basal ganglia, peri & paraventricular white matter and centrum semi-ovale on both sides. He was managed with injection amphotericin B deoxycholate along with fluconazole as per WHO recommendations and treatment related complications were managed accordingly. Visual acuity was followed in the entire treatment period but vision did not improve, but GCS improved to 15/15, there was no headache, no neck rigidity. Repeat MRI of brain after three weeks of treatment showed absence of above mentioned lesions. After 12 months of follow up the patient had no perception of light in both eyes and no wave in VEP study of both eyes suggestive of permanent visual loss following cryptococcal meningitis. So, cryptococcal meningitis after completion of treatment may have irreversible visual loss.