Cryptococcal meningitis in an immunocompetent host: acute bilateral sensorineural hearing loss with normal intracranial pressure.

BACKGROUND AND PURPOSE: Cryptococcal meningitis typically affects immunocompromised hosts and presents with headache and fever. Sensorineural hearing loss (SNHL) occurs in up to 30% of cases but is traditionally associated with elevated intracranial pressure. CASE PRESENTATION: A 59-year-old immunocompetent man presented with rapidly progressive bilateral SNHL, dizziness, and gait instability over three weeks. Initial brain MRI was unremarkable, leading to a preliminary diagnosis of idiopathic sudden sensorineural hearing loss. Despite steroid treatment, he deteriorated. Repeat MRI revealed symmetric T2/FLAIR hyperintense lesions involving the hypothalamus, cerebral aqueduct, corpora quadrigemina, and cerebellar regions adjacent to the fourth ventricle. CSF analysis demonstrated lymphocytic pleocytosis, elevated protein, hypoglycorrhachia, and positive cryptococcal antigen confirmed by India ink staining and culture. Notably, serial lumbar punctures revealed normal opening pressures despite profound hearing loss. Treatment with liposomal amphotericin B and flucytosine, followed by fluconazole, led to significant clinical and radiological improvement despite persistent hearing impairment. CONCLUSIONS: This case expands the clinical spectrum of cryptococcal meningitis by demonstrating that acute bilateral deafness can occur without elevated intracranial pressure, potentially through direct involvement of central auditory pathways, particularly the inferior colliculi. Clinicians should consider cryptococcal infection in the differential diagnosis of acute bilateral hearing loss with CNS lesions, even in immunocompetent hosts, despite normal initial imaging and intracranial pressure.