Abstract Introduction Cryptococcal meningitis is classically associated with immunocompromised states, but cases in immunocompetent individuals are increasingly recognized. Elevated intracranial pressure (ICP) and antifungal toxicities present significant neurocritical care challenges. Case Presentation A 45-year-old previously healthy male presented after an unwitnessed seizure. Neuroimaging revealed communicating hydrocephalus. Lumbar puncture demonstrated markedly elevated opening pressure, and cerebrospinal fluid (CSF) was positive for cryptococcal antigen. Serial LPs were performed for ICP control. The patient was initiated on amphotericin B and flucytosine induction therapy. His course was complicated by amphotericin-induced nephrotoxicity and electrolyte wasting requiring aggressive replacement and dose adjustment. Due to active meningeal inflammation, ventriculoperitoneal (VP) shunting was initially deferred. Immunodeficiency workup was unrevealing. He was discharged after clinical improvement but was readmitted two weeks later with refractory headaches and visual blurring, necessitating VP shunt placement. Discussion Management of elevated ICP in cryptococcal meningitis remains challenging, particularly in immunocompetent hosts. While serial LPs may temporize symptoms, delayed shunting can risk recurrence and neurologic decline. Amphotericin toxicity adds further complexity in the ICU setting, requiring close electrolyte and renal monitoring. Conclusion This case highlights the importance of individualized ICP management and multidisciplinary coordination in cryptococcal meningitis. In immunocompetent patients, refractory ICP may warrant early shunting once infection control is achieved. This abstract is funded by: None
F Sarhan (Fri,) studied this question.