Open Peer Review Any reports and responses or comments on the article can be found at the end of the article. CASE REPORT Case Report: Cryptococcal meningitis in an apparently immunocompetent patient in Nepal - challenges in diagnosis and treatment [version 2; peer review: 2 approved with reservations] Ashish Jha , Sudeep Adhikari , Keshav Raj Sigdel , Buddhi Paudyal , Buddha Basnyat , Gyan Kayastha , Sumita Pradhan , Ujjwol Risal , Jiwan Poudel 1 Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal Oxford University Clinical Research Unit, Patan Hospital, Lalitpur, Nepal General Surgery, Patan Academy of Health Sciences, Lalitpur, Nepal Abstract A 50 year old woman from Nepal had clinical features suggestive of meningitis. Cerebrospinal fluid (CSF) analysis was normal except for the presence of cryptococcal antigen. The inclusion of test for in Cryptococcus the CSF helped in making the diagnosis of cryptococcal meningitis in our patient who was apparently immunocompetent. Treatment with liposomal amphotericin B could not be started on time due to financial constraints. The patient had a stroke and further deteriorated. Liposomal amphotericin B is stocked by the government of Nepal for free supply to patients with visceral leishmaniasis, but the policy does not allow the drug to be dispensed for other infections. The family members of our patient acquired the drug within a few days from a government center using their political connections and following administering the treatment the patient improved. This case demonstrates the utility of considering cryptococcal meningitis as a differential diagnosis, and including tests for Cryptococcus when dealing with immunocompetent patients presenting with meningitis. It also demonstrates the effects of the sociopolitical situation on health care delivery in low- and middle-income countries (LMICs) such as Nepal. Keywords cryptococcal meningitis, immunocompetent patient, liposomal amphotericin B This article is included in the Oxford University gateway. Clinical Research Unit (OUCRU) 1 1 1 1 1,2 1 3 1 1 1 2 3 Reviewer Status Invited Reviewers version 2 published 17 Jun 2019 version 1 published 26 Mar 2019 1 2 report report , B.P. Koirala Institute of Health Lila B. Basnet Sciences, Dharan, Nepal , B.P. Koirala Institute of Paras K. Pokharel Health Sciences, Dharan, Nepal 1 , London School of Fiona Cresswell Hygiene and Tropical Medicine, London, UK 2 26 Mar 2019, :55 ( First published: 4 ) https://doi.org/10.12688/wellcomeopenres.15187.1 17 Jun 2019, :55 ( Latest published: 4 ) https://doi.org/10.12688/wellcomeopenres.15187.2 v2 Page 1 of 15 Wellcome Open Research 2019, 4:55 Last updated: 17 JUN 2019