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Complete Binocular Blindness as the First Manifestation of HIV-Related Cryptococcal Meningitis.
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MedLine Citation:
PMID:  19513136     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Ocular complications of HIV-related cryptococcal meningitis are reasonably common, but complete binocular blindness as the first manifestation of HIV is extremely rare. A 58-year-old man presented with binocular blindness. He experienced blurred vision for 3 days before the blindness. Mild pleocytosis was present in the cerebrospinal fluid, from which Cryptococcus neoformans was cultured. Serology revealed positivity for HIV antibody. He was treated with antifungal and antiretroviral therapy. This case indicates that HIV-related cryptococcal meningitis should be taken into consideration when determining the cause of unexpected sudden binocular blindness.
Authors:
Yun-Jeong Hong; San Jung; Ji-Young Kim; Seok-Beom Kwon; Ki-Bong Song; Sung-Hee Hwang; Yang-Ki Min; Ki-Han Kwon; Byung-Chul Lee
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Publication Detail:
Type:  Journal Article     Date:  2007-12-20
Journal Detail:
Title:  Journal of clinical neurology (Seoul, Korea)     Volume:  3     ISSN:  1738-6586     ISO Abbreviation:  J Clin Neurol     Publication Date:  2007 Dec 
Date Detail:
Created Date:  2009-06-10     Completed Date:  2011-07-14     Revised Date:  2013-05-23    
Medline Journal Info:
Nlm Unique ID:  101252374     Medline TA:  J Clin Neurol     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  212-4     Citation Subset:  -    
Affiliation:
Department of Neurology, Hallym University College of Medicine, Seoul, Korea.
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): J Clin Neurol
Journal ID (publisher-id): JCN
ISSN: 1738-6586
ISSN: 2005-5013
Publisher: Korean Neurological Association
Article Information
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Copyright © 2007 Korean Neurological Association
Received Day: 19 Month: 6 Year: 2007
Accepted Day: 19 Month: 11 Year: 2007
Print publication date: Month: 12 Year: 2007
Electronic publication date: Day: 20 Month: 12 Year: 2007
Volume: 3 Issue: 4
First Page: 212 Last Page: 214
ID: 2686943
PubMed Id: 19513136
DOI: 10.3988/jcn.2007.3.4.212

Complete Binocular Blindness as the First Manifestation of HIV-Related Cryptococcal Meningitis
Yun-Jeong Hong, M.D.A1
San Jung, M.D.A1
Ji-Young Kim, M.D.A1
Seok-Beom Kwon, M.D.A1
Ki-Bong Song, M.D.A1
Sung-Hee Hwang, M.D.A1
Yang-Ki Min, M.D.A1
Ki-Han Kwon, M.D.A1
Byung-Chul Lee, M.D.A1
Department of Neurology, Hallym University College of Medicine, Seoul, Korea.
Correspondence: Address for correspondence : San Jung, M.D. Department of Neurology, Kangnam Sacred Heart Hospital, Daerim-dong 948-1 Yeongdeungpo-gu, Seoul, 150-950, Korea. Tel: +82-2-829-5125, Fax: +82-2-847-1617, neurojs@hallym.ac.kr

Acquired immunodeficiency syndrome (AIDS) has become a worldwide epidemic since its original description as a new disease characterized by opportunistic infections and unusual neoplasm in young adults in 1981.1,3 The number of new cases each year continues to increase, 4,000 people were reported in South Korea, and there are now nearly 40 million people living with HIV infection in the world. Cryptococcal meningitis develops frequently as an opportunistic infection in immunocompromised patients, especially in AIDS. Immunosuppressive drugs (including steroids), liver cirrhosis, diabetes mellitus, cancer, and alcoholism can also induce cryptococcal meningitis.2 Most patients have symptoms of headache, fever, or malaise. Other manifestations include nausea, vomiting, meningeal signs, seizures, and altered mentation. About 50% of the patients have accompanying ocular complications such as papilledema, cranial nerve palsies, and visual loss in the late course of the disease.7 Cryptococcal meningitis is the most common and also most fatal opportunistic infection in HIV infection.5 Whereas 7% of AIDS patients have cryptococcal infection diagnosed during the course of the disease, only 1.9% of cases initially present with cryptococcal infection.1,6 Moreover, complete binocular blindness as the first presentation of HIV-related cryptococcal meningitis is extremely rare. We report a patient with complete binocular blindness who had not been previously diagnosed with HIV infection.


CASE REPORT

A 58-year-old man presented with acute visual disturbance. He had been treated for hypertension for 2 years. He was divorced 30 years ago and was living alone. He had suffered from intermittent headache for 2 months and had taken benzodiazepines and analgesics under the diagnosis of somatoform disorder at a local clinic. Brain MRI with gadolinium enhancement performed at that time produced normal findings. He had a 5-day history of diplopia and a 3-day history of blurred vision that progressed to blindness during the preceding 24 hours. On admission his blood pressure was 130/70 mmHg, pulse rate was 82/min, respiratory rate was 20/min, and body temperature was 36.3℃. On neurologic examination the patient was alert and exhibited no meningeal signs. Both of his pupils were slightly dilated and reactive to light. Only light perception was possible in both eyes, but no other neurological abnormality was noted. Lumbar puncture showed the opening pressure of 160 mm H2O with clear cerebrospinal (CSF) fluid. CSF evaluation showed 30 red blood cells/mm3, 80 white blood cells/mm3, 80% lymphocytes, 41 mg/dl glucose, and 114 mg/dl protein. His body temperature increased to 38.8℃ 1 day after admission, but CBC revealed no leukocytosis. Brain MRI showed no meningeal enhancement, parenchymal lesion, or intracranial vascular abnormality supplying the optic nerve, optic chiasm, or optic tract. He exhibited intermittent confusion on the third day after admission. The results of fundoscopic examinations were unremarkable, and visual evoked potential showed no wave formation on bilateral pathways (Fig. 1). An India ink smear of the CSF demonstrated encapsulated yeast, and Cryptococcus neoformans was cultured (Fig. 2). We started intravenous amphotericin B treatment. He was found to be seropositive for HIV with a high antibody titer (53.87 S/CO). CD4 cells comprised 10% of the total T lymphocytes. He was treated with both antiretroviraland antifungal agents, and his visual acuity had improved upon discharge.


DISCUSSION

Neuro-ophthalmic lesions are present in 6% of patients with HIV infection during the course of the disease, with most of them being are attributable to cryptococcal meningitis.3Cryptococcus neoformans, the cause of cryptococcal meningitis, is the fourth most common source of life-threatening infection in AIDS patients after infections of cytomegalovirus, Pneumocystis carinii, and Mycobacterium avium intracellulare.1 It is present in pigeon droppings and infects by inhalation of contaminated soil. Cryptococcal meningitis is fatal in HIV-infected patients if not treated, and hence early diagnosis is very important. The signs and symptoms of cryptococcal meningitis include headache (80~92% of cases), meningeal signs (50~80%), nausea/vomiting (40~80%), fever (36~67%), and visual disturbances (33~47%).1 Our patient presented with acute blindness without other definite clinical symptoms at the time of admission.

Possible mechanisms for binocular blindness due to cryptococcal meningitis include direct fungal infiltration of the optic nerve, optic chiasm, or optic tracts, adhesive arachnoiditis, cerebral vasculitis, and intracranial hypertension.4 It has been suggested that rapid-onset visual loss is caused by infiltration of the optic nerve or optic chiasm, while slow-onset visual loss is due to increased CSF pressure.4 A CSF opening pressure exceeding 200 mmH2O and papilledema reflect intracranial hypertension, but our patient showed a normal CSF opening pressure and unremarkable fundoscopic examination findings. Moreover, his visual symptoms developed very early in the course of the disease. Thus, the sudden visual loss might have been due to retrobulbar fungal infiltration.

Whereas the prevalence of cryptococcosis is decreasing because of the widespread availability of antiretroviral therapy, cryptococcal meningitis is still a fatal complication of HIV infection. Thus, both early diagnosis of cryptococcal meningitis and detection of the underlying causes are important. In our opinion, unexpected sudden binocular blindness should be considered as a possible initial manifestation of cryptococcal meningitis related to HIV infection.


Notes

Supported by a grant of the Korea Health 21 R&D Project, Ministry of Health and Welfare, Republic of Korea (no. A060171).

References
1. Giberson TP,Kalyan-Raman K. Cryptococcal meningitis: initial presentation of acquired immunodeficiency syndromeAnn Emerg Med 1987;16:802–804. [pmid: 3592336]
2. Kim SW,Jung SI,Kim YS,Ki HK,Kim CK,Kim SM,et al. Cryptococcal meningitis in 25 non-AIDS patientsJ Korean Infect 1999;31:467–473.
3. Jabs DA. Ocular manifestations of HIV infectionTrans Am Ophthalmol Soc 1995;93:623–683. [pmid: 8719695]
4. Claus JJ,Portegies P. Reversible blindness in AIDS-related cryptococcal meningitisClin Neurol Neurosurg 1998;100:51–52. [pmid: 9637206]
5. Mirza SA,Phelan M,Rimland D,Graviss E,Hamill R,Brandt ME,et al. The changing epidemiology of cryptococcosis: an update from population-based active surveillance in 2 large metropolitan areas, 1992-2000Clin Infect Dis 2003;36:789–794. [pmid: 12627365]
6. Johnston SR,Corbett EL,Foster O,Ash S,Cohen J. Raised intracranial pressure and visualcomplications in AIDS patients with cryptococcal meningitisJ Infect 1992;24:185–189. [pmid: 1569310]
7. Kestelyn PG,Cunningham ET Jr. HIV/AIDS and blindnessBull World Health Organ 2001;79:208–213. [pmid: 11285664]

Article Categories:
  • Case Report

Keywords: HIV-related cryptococcal meningitis, Complete binocular blindness.

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