Fungal meningitis

Incidence has increased because of an increasing number of immunosuppressed patients which includes those on immunosuppressive drugs, malignancies, AIDS and premature neonates.

May occur in the absence of immunosuppression.

Results from hematogenous spread from fungi inspired into the lungs.

Can result from direct spread from infected sinuses or following surgical or other trauma.

Because of nonspecific symptoms and subacute onset the diagnosis is often delayed weeks to months.

Fever and headache are common but may be absent.

May be associated with a slow deterioration in mental status, confusion with dementia in the elderly.

Nuchal rigidity and photophobia seen less often than in bacterial meningitis.

May be associated with cranial nerve abnormalities.

Findings and symptoms of increased intracranial pressure may be seen, particularly in cryptococcal meningitis.

Diagnostic studies include brain imaging and analysis of the CSF.

All patients with suspected disease should undergo a lumbar puncture.

CSF evaluation includes opening pressure, cell count with differential, protein, levels glucose levels, India ink stain and or Cryptococcus antigen testing, Gram stain and cultures.

Fungal media is required to recover fungi, although Candida and Aspergillus species will grow on standard bacterial culture media.

Utilizing increased volumes of CSF of 5-10 mL will improve culture sensitivities.

Serologic tests for Histoplasma antigen, Coccidioides complement fixation antibody, Aspergillus antigen performed on serum or CSF can be helpful in diagnosis.

Coccidioides can cause a lethal meningitis that develops within weeks to months after and often unrecognized primary infection.

CSF analyses usually show moderate pleocytosis, low glucose levels, and mild increase in protein levels.

CSF differential cont typically has a predominance of mononuclear cells, but may show an increased percentage of polymorphonuclear cells.

Increased eosinophils in the CSF may be seen with coccidioidomycosis and increased neutrophils are seen with blastomycosis.

Enhanced CT or MRI of the brain may reveal meningeal enhancement or hydrocephalus and imaging must be done to rule out parenchymal changes and edema.

Outcome commonly related to the underlying immune status of the patient.

More successfully treated in patients who have a reversible immunosuppressed state.

In HIV patients with cryptococcal disease, results are more successful in those with a CD4+ count greater than 100/┬ÁL.

Amphotericin B historically the mainstay of treatment, but better tolerated lipid formulations frequently substituted.

Azoles commonly used for follow-up treatment or secondary prophylaxis.

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