BRIEF REPORT • OFID • 1 Open Forum Infectious Diseases BRIEF REPORT Rapid Reversal of Complete Binocular Blindness With High-Dose Corticosteroids and Lumbar Drain in a Solid Organ Transplant Recipient With Cryptococcal Meningitis and Immune Reconstitution Syndrome: First Case Study and Literature Review Zoe Weiss, 1 Nihaal Mehta, 2 Su Nandar Aung, 3 Michael Migliori, 4 and Dimitrios Farmakiotis 5 1 Department of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; 2 Warren Alpert Medical School of Brown University, Providence, Rhode Island; 3 Division of Infectious Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island; 4 Division of Ophthalmology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; 5 Division of Infectious Disease, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island Blindness is a rare, devastating, usually permanent complica- tion of cryptococcal meningitis (CM). We present the frst case of complete vision loss in a solid organ transplant recipient with CM treated with placement of a lumbar drain who had a dra- matic visual recovery that started afer 3 doses of high-dose steroids. Keywords. cryptococcal meningitis; immune reconstitu- tion infammatory syndrome; CM-IRIS; vision loss. CASE PRESENTATION A 62-year-old woman with history of renal transplantation 18 years earlier presented with headache, photophobia, and right facial droop. Her immunosuppressive regimen included mycophenolate, tacrolimus, and prednisone in the setting of chronic rejection. Brain MRI, MRA, and MRV were negative for stroke. Laboratory results on admission are summarized in Table 1. She underwent a lumbar puncture (LP) on day 3 with opening pressure (OP) of 28 cm H 2 O; her cerebrospinal fluid (CSF) had 208 nucleated cells (88% lymphocytes), glucose 51 mg/dL, and protein 222 mg/dL; Gram stain revealed yeast forms, and culture was positive for Cryptococcus neoformans. She was started on liposomal amphotericin-B and renally adjusted flucytosine; mycophenolate was discontinued, and tacrolimus dose decreased, aiming at a trough level of 4 ng/mL. Both blood and CSF cultures were negative by day 6 (day 3 of antifungal treatment). She continued to have elevated OP, receiving sequential LP (Figure 1). All post-LP OP were <20 cm H 2 O. Funduscopic examination did not show papilledema. On hospital day 12 (day 9 of treatment), she developed right-sided vision loss with no light perception, right aferent pupillary defect (APD), decreased lef-sided visual acuity with diminished color percep- tion, and bilateral conjunctival chemosis. Computed tomogra- phy angiography of the brain and contrast magnetic resonance imaging of the orbits were unremarkable. On day 15, despite repeated LP, she had bilateral complete loss of vision with no light perception and grade I papilledema. An epidural drain was placed to allow for continuous CSF drainage without improve- ment. Prednisone 80 mg twice daily was started on day 16 for presumed early immune reconstitution infammatory syn- drome (IRIS). She recovered light perception afer the frst 3 doses. Te lumbar drain was removed the following day. Her vision returned to baseline in both eyes by day 25 (Figure 1). Prednisone was tapered to 10 mg over 4 weeks. She had no further eye complaints. She completed 4 weeks of induction for cryptococcal meningitis, followed by 6 weeks of eradica- tion treatment, and now receives renally adjusted maintenance fuconazole. METHODS We performed a literature search in the National Center for Biotechnology Information’s PubMed database using the term “cryptococcal meningitis,” in conjunction with “immune recon- stitution syndrome,” “immune reconstitution inflammatory syndrome,” “IRIS,” “CM-IRS,” “CM-IRIS”, “ocular,” “optic,” “ophthalmic,” “ophthalmologic,” “blindness,” “visual loss,” and “visual.” After publications were identified, their references were reviewed. For the purposes of this analysis, we included cases of visual impairment independent of suspected etiology (eg, increased intracranial pressure, inflammatory optic neu- ropathy, direct infection of the optic nerve). RESULTS AND DISCUSSION CM is a highly morbid opportunistic fungal infection result- ing in elevated intracranial pressure (ICP) and neurologic symptoms. Though classically described in the setting of HIV infection, CM is nowadays recognized at least as frequently in patients with other forms of immunosuppression, including Open Forum Infectious Diseases ® © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com DOI: 10.1093/ofd/ofy007 Received 12 November 2017; editorial decision 22 December 2017; accepted 5 January 2018. Correspondence: Z. Weiss, MD, 593 Eddy St, Providence, RI 02906 (zoe.weiss@lifespan.org, zoe_weiss@brown.edu).