Episodic motor posturing and unilateral oval pupil from cryptococcal meningitis

Motor posturing in acutely comatose patient is suggestive of an evolving brain herniation. In the presence of a unilateral pupillary abnormality, a metabolic or drug induced coma can be excluded. Neuroimaging studies in such cases will likely reveal underlying mass or acute ventricular obstruction. We recently encountered a patient who presented in stupor with repetitive motor posturing and a transient right oval pupil to light stimulus. Surprisingly, an urgent brain CT revealed only mild global atrophy for age. Further evaluation disclosed cryptococcus meningitis as the underlying cause.