Cryptococcal meningitis presenting with bilateral complete ophthalmoplegia: a case report

Abstract

BackgroundCryptococcus neoformans is saprophytic encapsulated yeast. Infection is acquired by inhalation of the organism and could be asymptomatic or limited to the lungs, specially in the immunocompetent host. Cryptococcal meningitis is a serious opportunistic infection among post transplant recipients. Cranial nerve palsies and ophthalmoplegia are well known complications of this disease, but bilateral complete ophthalmoplegia is a very rare presentation.Case PresentationA Sri Lankan young male, who is a post kidney transplant recipient, presented with bilateral complete ophthalmoplegia and subsequently was diagnosed to have cryptococcal meningitis based on Indian ink stain and culture of cerebrospinal fluid (CSF). His magnetic resonance imaging (MRI) showed bilateral multiple nodular lesions in both basal ganglia and thalami. Brainstem imaging was normal.ConclusionsCryptococcal meningitis is a serious fungal infection in post transplant patients. It should be suspected in any immunocompromised patient with fever, headache and focal neurological signs. Bilateral thalamic lesions, inflammation and invasion of the cranial nerves and raised intracranial pressure were thought to be possible mechanisms resulting in bilateral complete ophthalmoplegia in this patient.

Cryptococcal meningitis initially presenting with eye symptoms in an immunocompetent patient: A case report

“…Loss of vision, diplopia and ocular motility deficit have been reported previously (5)(6)(7). In the present study, a female immunocompetent patient with CM is reported who initially presented with eye symptoms, and subsequently fully recovered with complete resolution of the initial symptoms following combined treatment with amphotericin B and fluconazole.…”

“…Such impaired patients include those with a malignancy, connective tissue disorder, HIV infection or those who have undergone organ transplantation (2,14). However, previous studies have shown that a number of patients infected with Cryptococcosis are immunocompetent (6,(15)(16)(17). CM causes morbidity and mortality worldwide, particularly in patients with impaired cell-mediated immunity; however, the clinical outcomes in immunocompetent patients are more favorable.…”

“…In non-immunocompromised patients, CM typically presents with signs and symptoms associated with meningitis, such as a fever, headache and neck stiffness (3,18). Additionally, cranial neuropathies and ophthalmoplegia are common complications in patients with CM (5,6,16,19). However, primary bilateral blurred vision without any accompanying symptoms is a rare initial presentation of a cryptococcal infection.…”

Cryptococcus neoformansosteomyelitis and intramuscular abscess in a liver transplant patient

“…Pulmonary involvement is also common 2. Lesions have also been described in the brain, lungs, skin, bloodstream,2 3 kidneys,4 prostate,5 6 eyes,7 sinuses,8 colon,9 liver10 and blood vessels as vasculitis 16…”

“…It is the third leading cause of fungal infection in solid organ transplant recipients, following aspergillosis and candidiasis, with an overall incidence of 2.8% in this population 2 3. Cases most frequently involve the central nervous system or the lungs, but multiple other sites of infection have been documented including the skin, bloodstream,2 3 kidneys,4 prostate,5 6 eyes,7 sinuses,8 colon9 and liver 10. About 5% of all cryptococcal infections present with osteomyelitis 11.…”