Cryptococcal meningitis with cerebrospinal fluid human immunodeficiency virus escape presenting as transient diplopia and areflexia.

We report a case of a man in his early 40s living with stable HIV and receiving continuous antiretroviral therapy (ART) who presented with transient binocular diplopia and areflexia. Neuroimaging was unrevealing, but lumbar puncture demonstrated elevated opening pressure, lymphocytic pleocytosis, the presence of cryptococcal antigen and growth of Cryptococcus neoformans Additional testing disclosed detectable cerebrospinal fluid (CSF) HIV RNA despite serum viral suppression. He was diagnosed with cryptococcal meningitis; CSF revealed HIV escape. He was treated with amphotericin B and flucytosine followed by fluconazole with parallel intensification of ART to improve central nervous system (CNS) penetration. Neurological symptoms, including diplopia and areflexia, resolved with this combined therapy. This case highlights that subtle transient visual symptoms may herald cryptococcal meningitis, perhaps from sequelae of elevated intracranial pressure. CSF HIV escape should be considered in patients with progressive CNS disease despite control of HIV viral load and CD4 cell counts over 400 cells/µL.