This case illustrates the importance of considering Cryptococcal meningitis in patients presenting with cranial nerve palsies, despite apparent normal immune function.

Cranial nerve palsies typically involving a single nerve, most commonly the abducens nerve, are seen in about 25% of patients with cryptococcal meningitis. Involvement of multiple cranial nerves is very unusual, especially when unliteral.

A 69-year-old male physician with no previous history of headaches presented to the hospital with 2-months of worsening headaches associated with binocular diplopia. CT head, CTA head and neck did not reveal any pathology. MRI of the brain with and without contrast revealed patchy acute infarcts within the bilateral cerebellar hemispheres with contrast enhancement. Due to unclear etiology and unusual pattern of the stroke, a conventional cerebral angiogram was conducted with unremarkable findings. The next day, the patient developed third and sixth cranial nerve palsies in the right eye with loss of vision. Fundoscopic examination revealed significant optic disk edema and microhemorrhages. Lumbar puncture with CSF analysis demonstrated an opening pressure of 28 mm H2O, 96 WBCs/mm3, Protein of 83 mg/dl, and cryptococcal antigen positive. The patient was started on amphotericin B and Flucytosine. Detailed work up for possible immunosuppression or malignancy was negative. By 6 month follow up, third and sixth cranial nerve palsies resolved, but vision continued to be impaired.

Cryptococcal meningitis is a relatively rare condition among apparently immunocompetent individuals. When frank immunosuppression is not evident, less-considered sources of minor immunosuppression should be explored. Cryptococcal meningitis should be considered in patients with headache and unilateral, multiple cranial nerve palsies with noncontributory imaging in relation to present neurological deficits.