Idiopathic Intracranial Hypertension (IIH) is characterized by increased intracranial pressure, which most frequently occurs in childbearing-age obese women. Scarce reports of COVID-19 infection associated IIH exist and have only described this in women and children. “Fulminant IIH” is defined as intracranial hypertension without secondary cause, with severe vision loss within 4 weeks of onset, and progressive vision loss over days.

A 36-year-old man with obesity came to the Ophthalmology clinic for evaluation of vision loss and headache, the patient tested positive for SARS-CoV-2 one month before this. He was identified to have bilateral grade V papilledema, confirmed with optical coherence tomography (OCT), and admitted to Neurology for IIH management. The patient was started intravenous therapy with high-dose steroids and acetazolamide without relief of headache or vision improvement (20/100). Lumbar puncture was performed, revealing an opening pressure of ≥55 cm H20. The MRI only showed findings of increased intracranial hypertension, and the MRV ruled out thrombosis. The lack of improvement in his headaches and vision loss ultimately required ventriculoperitoneal shunt placement. The patient had immediate subjective visual improvement after this, with unchanged visual acuity. On follow-up 4 weeks later, the patient continued to have headaches and the opening pressure was 30 cm H20. Lumboperitoneal shunt was placed. Both optic nerves became completely atrophic. Despite finally reaching an opening pressure of 15 cm H20, headaches did not resolve, and the patient currently only perceives light.

This case represents, to our best knowledge, the first description of fulminant IIH associated with SARS-CoV-2. The previous reports described mild to moderate cases in women and children with response to treatment. This occurred to an adult male who despite receiving promptly treatment, had a poor response. Further studies are needed to determine if atypical clinical phenotypes are associated with refractory forms.