What is the most common presentation of cryptococcal meningitis in HIV patients?

• A. Subacute meningitis with headache and fever; elevated opening pressure
• B. Acute bacterial meningitis
• C. Chronic headaches without fever
• D. Stroke with focal deficits

Answer: (A)

The key idea is that cryptococcal meningitis in people with HIV often presents as a subacute meningitis rather than an abrupt, sepsis-like illness. Patients typically have a gradual onset of headache, sometimes with fever, over days to weeks. A distinguishing feature is a raised opening pressure on lumbar puncture, reflecting impaired CSF drainage from the subarachnoid space filled with cryptococcal organisms and their polysaccharide capsule. This combination—indolent meningeal symptoms plus elevated opening pressure—is classic for cryptococcal meningitis in this population.

Why the other patterns fit less well: acute bacterial meningitis tends to come on suddenly with severe fever, rapid deterioration, and marked meningeal signs; chronic headaches without fever lack the infectious meningitis picture; stroke with focal deficits presents with focal neurological weaknesses or speech/motor problems rather than a subacute meningitis with high opening pressure.

In practice, recognizing the subacute course and elevated opening pressure helps distinguish cryptococcal meningitis from other CNS infections in HIV patients.