Cryptococcal Meningoencephalitis with Possible Clinical-Manometric Intracranial Pressure Dissociation in a Pediatric Patient

A 12-year-old previously healthy girl without an identified immunodeficiency presented with a 25-day history of headache, vomiting, and severe asthenia. Cerebrospinal fluid (CSF) analysis confirmed Cryptococcus gattii meningoencephalitis. Despite consistently normal intracranial pressure (ICP) readings on serial lumbar punctures (all below 20 cm H2O), the patient developed clinical signs suggestive of raised intracranial pressure, progressing to decreased consciousness requiring ICU admission and orotracheal intubation. Brain MRI demonstrated communicating hydrocephalus, leptomeningeal enhancement, and perineural contrast enhancement of the optic nerve sheath and of cranial nerves VII and VIII. Management included an external lumbar subarachnoid drain for CSF drainage and antifungal induction with liposomal Amphotericin B combined with Flucytosine, in accordance with the 2024 ECMM/ISHAM/ASM Global Guideline for non-HIV CNS cryptococcosis. Notwithstanding treatment, the patient developed irreversible amaurosis and bilateral sensorineural hearing loss attributed to perineural leptomeningeal dissemination, confirmed on MRI. This case illustrates a possible clinical-manometric ICP dissociation in pediatric cryptococcal meningoencephalitis—a phenomenon that may reflect adhesive arachnoiditis with spinal CSF compartmentalization rather than true ICP elevation—and underscores the importance of multimodal assessment beyond intermittent manometry in this setting.