Sir,

Cryptococcosis is a common fungal infection in immunocompromized individuals. Frequent sites of involvement include the central nervous system, lung, skin, and eyes. We describe an unusual case of bilateral exudative retinal detachment in a HIV patient with cryptococcal meningitis.

Case report

A 43-year old HIV-positive Chinese man was referred to the ophthalmology department for right-sided blurring of vision for 3 weeks, associated with headache and neck stiffness. He was on HAART (lamivudine, nevirapine, and stavudine), with trimethoprim/sulphamethoxazole, clarithromycin, and ethambutol for Mycobacterium avium complex infection. His CD4 count was 104 cells/mm3. Visual acuity was 6/24 in the right eye and 6/6 in the left, with normal intraocular pressures and no sign of anterior chamber inflammation. Dilated fundal examination revealed bilateral exudative detachments with involvement of the right macula but no vitritis (Figures 1a and b) corroborated on OCT imaging (Figures 2a and b). Systemically, meningitis was suspected and confirmed on MRI imaging of the brain showing increased leptomeningeal enhancement. Lumbar puncture showed opening pressures of 33.5 mm H2O; with CSF stains, cultures, and serology positive for Cryptococcal neoformans. Investigations for other pathogens including CMV, EBV, HSV, VZV, Toxoplasma, and Mycobacterium tuberculosis were negative. He was initiated on amphotericin B and flucytosine, followed by fluconazole. The exudative detachments subsequently resolved with a residual pigment epithelial detachment over the right macula (Figures 3a and b). In view of his systemic findings and response to treatment, a diagnosis of cryptococcal-related exudative retinal detachment was made retrospectively.

Figure 1
figure 1

(a, b) Exudative retinal detachment at presentation.

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Figure 2
figure 2

(a, b) Exudative retinal detachment at presentation with corresponding OCT.

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Figure 3
figure 3

(a, b) Final resolution of exudative retinal detachment with residual pigment epithelial detachment over the right macula.

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Comment

Ocular cryptococcosis often manifests as a consequence of systemic disease. However, isolated ocular involvement may present as choroiditis and endophthalmitis from hematogenous spread, or ophthalmoplegia and papilloedema secondary to raised intracranial pressure or direct infiltration of the optic nerve.1 Cryptococcal endophthalmitis itself is a rare disease; fewer than 20 cases worldwide, including 5 in AIDS-related cases have been reported (none of these patients regained normal vision).

Despite being well documented in animals (especially cats),2 cryptococcal-related exudative detachment has only been reported in cases of endophthalmitis.3 Our case is unique as there was only evidence of cryptococcal meningitis and absence of concomitant endophthalmitis. Exudative retinal detachment in HIV patients are more commonly related to CMV infection,4 immune recovery uveitis, acute retinal necrosis,5 and progressive outer retinal necrosis.6 We report an unusual case of exudative detachment secondary to cryptococcal infection that responded to systemic anti-fungal therapy.