This report describes an atypical presentation of cryptococcal meningitis (CM) in a 51 year-old HIV-negative male with diabetes, hypertension, and psoriasis. The patient presented with a 10 day history of subacute headache, vomiting, and fever, followed by the abrupt onset of profound bilateral sensorineural hearing loss (SNHL), ataxia, diplopia, anosmia, ageusia, drowsiness, meningismus, absent gag reflex, and bilateral abducens palsy. Brain MRI revealed inflammatory changes involving the sellar diaphragm, thalamus, and pituitary stalk. Cerebrospinal fluid analysis confirmed CM (pleocytosis, elevated protein, hypoglycorrhachia, opening pressure >60 cmH 2 O, positive cryptococcal antigen), with negative HIV and malignancy screens. Audiometry confirmed profound bilateral SNHL. Treatment included intravenous liposomal amphotericin B followed by high-dose oral fluconazole, augmented by serial therapeutic lumbar punctures for intracranial pressure (ICP) control. Partial hearing recovery was observed at 1 month follow-up. This case highlights that sudden bilateral SNHL—rarely the dominant initial manifestation—can herald CM even in hosts without overt immunosuppression, posing significant diagnostic challenges. The constellation of profound SNHL, multiple cranial neuropathies (including VIII), cerebellar signs, and markedly-elevated ICP strongly implicates retrocochlear pathology, likely resulting from meningeal inflammation, direct vestibulocochlear nerve invasion, and/or neural compression. Critically, timely-antifungal therapy combined with aggressive ICP reduction facilitated neurological recovery, demonstrating potential reversibility and avoiding premature cochlear implantation. Clinicians should consider CM in patients presenting with acute bilateral audiovestibular dysfunction accompanied by cranial neuropathies or elevated ICP, particularly with subacute prodromal symptoms. This case underscores the essential role of concurrent ICP-directed management alongside antifungals to optimize neurological outcomes, including hearing recovery.
Alkheder et al. (Tue,) studied this question.