# Eyelid Ptosis as an Atypical Manifestation of Meningeal Cryptococcosis: A Case Report

## TL;DR

A man with HIV developed cryptococcal meningitis with unusual eyelid drooping, showing the disease can occur even with moderate immune suppression.

## Contribution

This case report presents an atypical clinical presentation of meningeal cryptococcosis in an HIV patient with a CD4+ count above 100 cells/μL.

## Key findings

- Cryptococcal meningitis presented with ptosis and altered mental status in an HIV patient with a CD4+ count of 218 cells/μL.
- Neurological improvement was observed after treatment with amphotericin B and flucytosine, followed by fluconazole consolidation.
- The case emphasizes the need for prompt evaluation of neurological symptoms in HIV patients, even with moderate CD4+ levels.

## Abstract

Cryptococcal meningitis remains a significant opportunistic infection in people living with human immunodeficiency virus (HIV), occurring with advanced immunosuppression.

We report the case of a 59-year-old HIV-type-1-positive man, previously with an undetectable viral load and a CD4+ count of 504 cells/μL, who presented with altered mental status and right-sided ptosis. He had missed follow-up for one year, and repeat testing showed a CD4+ count of 218 cells/μL and a viral load of 258,000 copies/mL. Brain MRI revealed leptomeningeal enhancement of the basal cisterns. Cerebrospinal fluid analysis confirmed Cryptococcus spp. The patient completed induction therapy with amphotericin B and flucytosine, with marked neurological improvement. Antiretroviral therapy (ART) was resumed after stabilization, and consolidation therapy with fluconazole was initiated.

This case highlights an atypical presentation of cryptococcal meningitis, with CD4+ count above 100 cells/μL, and underscores the importance of ART adherence and prompt investigation of subacute neurological symptoms in HIV-infected individuals.