Title : Atypical neurological and ophthalmic debut of AIDS with dual opportunistic infection: Cryptococcal meningitis and cytomegalovirus retinitis
Abstract:
Background: Opportunistic infections of the central nervous system (CNS) and retina are severe complications of advanced HIV/AIDS. However, their simultaneous presentation as the initial manifestation of AIDS is uncommon. The diagnostic challenge increases when the early clinical picture resembles common conditions—viral syndromes, mild respiratory illness, or isolated neurological events—delaying recognition of life-threatening infections such as cryptococcal meningitis and cytomegalovirus (CMV) retinitis. We describe a young patient with an atypical initial presentation who rapidly progressed to dual opportunistic disease.
Case: A previously healthy 24-year-old male presented with severe headache, dizziness, and a syncopal episode two weeks prior to admission. A head CT revealed a left thalamic infarct, initially suggesting a vascular etiology. Concurrently, he developed a one-week history of dry cough, nocturnal diaphoresis, fever up to 39 °C, weakness, asthenia, and fatigue. During this evaluation he received an incidental new diagnosis of HIV.
In the following days, he developed dysarthria and progressive bilateral visual loss. Brain MRI showed a left thalamic ring-enhancing lesion, initially interpreted as cerebral toxoplasmosis or lymphoma. Serologies for Toxoplasma gondii, CSF GeneXpert and culture for tuberculosis, and multiplex meningitis PCR were negative. Empiric trimethoprim–sulfamethoxazole was started, followed by empiric antituberculous therapy due to persistent symptoms.
As his condition worsened, he developed intense headache and rapid progression to bilateral amaurosis. Examination revealed marked bilateral papilledema. A repeat lumbar puncture showed inflammatory CSF with positive India ink staining for Cryptococcus neoformans, confirming cryptococcal meningitis. Amphotericin B plus fluconazole were initiated, along with serial therapeutic lumbar punctures for intracranial pressure management.
Due to persistent vision loss, fluorescein angiography was performed, revealing findings consistent with CMV retinitis. Intravenous ganciclovir was initiated, later transitioned to oral valganciclovir. After two weeks of amphotericin B, the patient experienced significant improvement in headache and partial neurological recovery; however, his bilateral blindness was irreversible. He was discharged hemodynamically stable on fluconazole, valganciclovir, TMP-SMX prophylaxis, and initiated antiretroviral therapy. At one-month follow-up, he remained clinically stable but without visual improvement.
Discussion: This case underscores an atypical and misleading presentation of advanced AIDS. The initial symptoms—headache, syncope, and mild respiratory complaints—suggested common non-opportunistic conditions, diverting attention from early cryptococcal disease, which may present with nearly normal CSF. The coexistence of CMV retinitis reflected profound immunosuppression (CD4 count: 40 cells/µL) and demonstrated the need to consider multiple opportunistic infections in patients with visual disturbances. Management required a multidisciplinary approach due to neurological, ophthalmic, and renal complications associated with disease progression and therapy.
Conclusion: Cryptococcal meningitis and CMV retinitis can present simultaneously as an atypical initial manifestation of AIDS, especially when early symptoms appear benign or non-specific. Persistent headache, papilledema, constitutional symptoms, and visual changes should prompt repeated CSF evaluation and early ophthalmologic assessment, even when initial studies are inconclusive. Timely recognition and appropriate antifungal and antiviral therapy are essential to reduce morbidity, although irreversible visual loss may occur despite adequate treatment.
