Ophthalmoplegia as a Rare Initial Presentation of Cryptococcal Meningitis: A Case Report and Literature Review

Introduction: Cryptococcal meningitis (CM) frequently associates immunocompromised patients, specifically in HIV infection, and it has high mortality. Neuro-ophthalmic manifestations are rare in patients with CM, especially internuclear ophthalmoplegia (INO) or wall-eyed bilateral internuclear ophthalmoplegia (WEBINO), most of them the result of secondary vasculitis.

Case report: A 53-year-old woman with chronic hepatic failure, had sudden drowsiness, diplopia, fever, and internuclear ophthalmoplegia. MRI showed generalized leptomeningeal enhancement plus infratentorial nodular enhancement type in the midbrain and left cerebellar hemisphere. An India ink test was positive for Cryptococcus neoformans.

Conclusion: Cryptococcal meningitis causes a wide spectrum of neurological manifestations, but neuro-ophthalmological signs are infrequent. Physicians should consider that these meningitis events are capable of generating symptoms due to intra-axial involvement of the Central Nervous System (CNS) due to vasculitis.