Medical Mycology Case Reports

Cryptococcal meningitis, caused typically by Cryptococcus neoformans, is a severe fungal infection with high morbidity and mortality, particularly common in severely immunosuppressed patients, such as those with advanced HIV disease in sub-Saharan Africa. High intracranial pressure (ICP) is a frequent and devastating complication, often leading to symptoms like headache, fever, and confusion, with vision loss being a fairly frequent and severe complication attributed to papilledema or optic nerve infiltration. Prompt diagnosis and control of high ICP are crucial for improved outcomes.

This is a case report detailing the management of a 26-year-old woman with newly diagnosed HIV and cryptococcal meningitis presenting with acute, bilateral vision loss. Diagnosis was confirmed by a positive CrAg LFA (lateral flow assay) in blood and CSF, and a lumbar puncture (LP) showing high opening pressure (>400 mm H$_{2}$O). Treatment involved multi-agent antifungal induction therapy (liposomal amphotericin B, flucytosine, and fluconazole) and serial therapeutic LPs to manage ICP. The role of a handheld, non-mydriatic fundus imaging device (Phelcom Eyer fundus camera) was highlighted for monitoring disease progression and the efficacy of therapeutic interventions, with images adjudicated by local and remote ophthalmologists.

The patient experienced severe symptoms, including vision loss that progressed to minimal perception. The initial therapeutic LP led to a rapid, but temporary, improvement in headache and vision (from minimal perception to identification of shapes and colors, approx. 20/800). Her clinical course was marked by a cycle of worsening headaches and vision, followed by improvement after therapeutic LPs, even when opening pressures normalized later in the illness. Fundus imaging using the handheld device established a baseline, demonstrated low-grade papilledema that resolved by day 4 after LPs, and ruled out other causes of vision loss like CMV retinitis. Vision and neurological deficits, including cranial nerve impairments, improved as she continued antifungal therapy and ICP was managed.

This case report highlights an unusual presentation of abrupt, reversible vision loss in an advanced HIV patient with cryptococcal meningitis, potentially unmasked by recent ART initiation. Crucially, it demonstrates the utility of a handheld, non-mydriatic fundus imaging device (Phelcom Eyer) in a low-resource setting. This device allowed general medicine practitioners to monitor papilledema, guide the decision for therapeutic lumbar punctures, and utilize tele-ophthalmology to rule out other ocular pathologies, thus aiding in the prompt diagnosis and management that was associated with the reversal of the patient's severe vision loss.