Cryptococcus meningitis in an immunocompetent teenage boy presented early with diplopia.

AIM: To report a case of cryptococcus meningitis in an immunocompetent teenager that presented early with diplopia and bilateral poor vision.

METHODS: A case report

RESULTS: A 17-year-old boy presented with blurring of vision in both eyes and diplopia for 3 weeks. It was associated with severe throbbing headaches, nausea and vomiting. He was also having low grade fever. On physical examination he was afebrile with no sign of meningism. His vision was 6/15 in both eyes with constricted visual field. Anterior segment was normal in both eyes. Extraocular muscles movement showed bilateral sixth nerve palsies. Fundoscopy revealed bilateral hyperaemic and slightly elevated optic disc. CT scan of the brain was normal with no evidence of intracranial mass or abnormal ventricles. Lumbar puncture revealed high opening pressure >300mmH(2)O. Cerebrospinal fluid (CSF) microscopically and culture showed presence of cryptococcus neoformans. This case was combinedly managed with neuro-medical team. Patient was started on intravenous Amphotericin B and fluconazole. His neurological symptoms recovered after a week. His vision was improved to 6/6 in both eyes with recovery of peripheral visual field. The diplopia improved with recovery of sixth nerve palsies in both eyes. Unfortunately, patient developed nosocomial lower respiratory tract infection and was treated for the problem.

CONCLUSION: This case highlights the indolent nature of cryptococcus meningitis and the fact that the overt signs of meningism may not be present even in immunocompetent person. Diplopia may be one of the early presentations of meningitis patient.