Acute ischemic stroke revealing cryptococcal meningitis in an HIV-infected patient with a relatively preserved CD4 count: a case report.
Ahmad M, Umair M, Akram M • Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology • 2026
This case demonstrates that cryptococcal meningitis may present as acute ischemic stroke in HIV-infected patients despite a relatively preserved CD4 count and the absence of classical meningeal manifestations.
Key Findings
Background
Cryptococcal meningitis presented as acute ischemic stroke in an HIV-infected patient with a relatively preserved CD4 count of 302 cells/mm³.
The patient was a 28-year-old man with an 11-year history of HIV infection.
CD4 count was 302 cells/mm³, which is above the threshold of advanced immunosuppression typically associated with cryptococcal meningitis.
The initial presentation was acute right-sided hemiparesis, without classical meningeal manifestations.
This represents an uncommon presentation, as ischemic stroke rarely serves as the initial manifestation of cryptococcal meningitis.
Results
Brain MRI demonstrated an acute infarction of the left internal capsule with communicating hydrocephalus.
Imaging modality used was brain magnetic resonance imaging (MRI).
Infarction was localized to the left internal capsule, consistent with the patient's right-sided hemiparesis.
Communicating hydrocephalus was also identified on imaging.
These findings were the neurological manifestations prompting further diagnostic workup.
CSF analysis revealed lymphocytic pleocytosis, elevated protein, and low glucose.
Cryptococcal antigen was positive in the CSF.
Culture confirmed the organism as Cryptococcus neoformans.
CSF findings were consistent with cryptococcal meningitis despite absence of classical meningeal symptoms.
Results
Treatment with amphotericin B and fluconazole resulted in marked clinical improvement.
The antifungal regimen consisted of amphotericin B combined with fluconazole.
The patient achieved marked clinical improvement following initiation of antifungal therapy.
Prompt antifungal therapy is identified as essential to improve neurological outcomes.
Early CSF evaluation is highlighted as critical to avoid delayed diagnosis in similar presentations.
Discussion
Cryptococcal meningitis should be considered as a cause of acute ischemic stroke in HIV-infected patients even without advanced immunosuppression or classical meningeal signs.
Classical meningeal manifestations were absent in this patient at presentation.
The case challenges the assumption that CM-related stroke occurs only in severely immunocompromised patients.
The authors emphasize that early cerebrospinal fluid evaluation is essential to avoid delayed diagnosis.
Ischemic stroke is described as an 'uncommon manifestation' that 'rarely represents the initial presentation' of cryptococcal meningitis.
What This Means
This research describes a case of a 28-year-old man living with HIV for 11 years who arrived at the hospital with sudden weakness on his right side. Rather than the typical symptoms of meningitis — such as severe headache or neck stiffness — his main symptom was stroke-like. Brain scans confirmed he had suffered a stroke in a key area of the brain called the internal capsule, along with a buildup of fluid in the brain. Despite having a relatively healthy immune system by HIV standards (a CD4 count of 302 cells/mm³), spinal fluid testing revealed he had a serious fungal brain infection called cryptococcal meningitis, caused by the fungus Cryptococcus neoformans.
This research suggests that cryptococcal meningitis — an infection usually seen in people with severely weakened immune systems — can cause stroke even when a patient's immune system appears relatively intact. It also suggests that this infection can occur without the classic warning signs of meningitis, making it easy to miss or misattribute to other causes. The patient improved significantly after being treated with antifungal medications (amphotericin B and fluconazole).
The practical implication of this case is that doctors evaluating HIV-positive patients who present with a stroke should consider testing spinal fluid for fungal infections, even if the patient does not appear severely immunocompromised and does not have typical meningitis symptoms. Early diagnosis and prompt antifungal treatment appear critical for achieving better neurological outcomes in such patients.
Ahmad M, Umair M, Akram M. (2026). Acute ischemic stroke revealing cryptococcal meningitis in an HIV-infected patient with a relatively preserved CD4 count: a case report.. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. https://doi.org/10.1007/s10072-026-09360-2