Cerebrovascular complications of coccidioidomycosis meningitis: Case report and systematic review.

Coccidioidomycosis exposure is common in the southwest United States and northern Mexico. Dissemination to the meninges is the most severe form of progression. Although ischemic strokes are well-reported in these patients, other cerebrovascular complications of coccidioidomycosis meningitis (CM), as well as their treatment options and outcomes, have not been systematically studied. We present a uniquely severe case of CM with several cerebrovascular complications. We also systematically queried PubMed and EMBASE databases, including articles published before April 2020 reporting human patients with CM-induced cerebrovascular pathology other than ischemic infarcts. Sixteen articles met inclusion criteria, which describe 6 patients with aneurysmal hemorrhage, 10 with non-aneurysmal hemorrhage, one with vasospasm, and one with transient ischemic attacks. CM-associated aneurysms invariably presented with hemorrhage. These were universally fatal until the past decade, when advances in surgical clipping and/or combined surgical and endovascular treatment have improved outcomes. We found that non-aneurysmal intracranial hemorrhages were limited to male patients, involved a diverse set of intracranial vasculature, and had a mortality rate surpassing 80%. Vasospasm was reported once, and was treated with percutaneous transluminal angioplasty. Transient ischemic attacks were reported once, and were successfully treated with fluconazole and dexamethasone. This review suggests that CM can present with a wide array of cerebrovascular complications, including ischemic infarcts, aneurysmogenesis, non-aneurysmal intracranial hemorrhage, vasospasm, and transient ischemic attacks. Mortality has improved over time due to advances in surgical and endovascular treatment modalities. The exception is non-aneurysmal intracranial hemorrhage, which remains associated with high mortality rates and few targeted therapeutic options.

Candida meningitis in neurosurgical patients: a single-institute study of nine cases over 7 years.

Candida meningitis in neurosurgical patients is relatively unusual but is associated with a high mortality rate. We present our experience with this infection and discuss the clinical characteristics, treatment options and outcomes. We retrospectively reviewed neurosurgical patients with multiple positive cerebrospinal fluid (CSF) culture results in our hospital from January 2013 to December 2019. Nine patients were available for review according to our inclusion and exclusion criteria. Four species of Candida were isolated from the CSF samples and Candida albicans accounted for half of all infections. Eight infections were associated with ventricle peritoneal shunt, lumbar cistern peritoneal shunt or external ventricular drain. All of these foreign intracranial materials were removed or changed and all the patients received antifungal treatment, including fluconazole and/or voriconazole. It is associated with severe long-term outcomes in survivors and a mortality rate that reaches 11.1%. Prior treatments with broad-spectrum and high-grade antibiotics and anaemia are possible risk factors for Candida meningitis. We advise that foreign intracranial material should be removed or changed as early as possible and the timing of re-shunt operation can be 1 month after control of Candida meningitis has been achieved, with several negative CSF culture results.

Invasive infections due to filamentous fungi other than Aspergillus: epidemiology and determinants of mortality.

The epidemiology of invasive fungal disease (IFD) due to filamentous fungi other than Aspergillus may be changing. We analysed clinical, microbiological and outcome data in Australian patients to determine the predisposing factors and identify determinants of mortality. Proven and probable non-Aspergillus mould infections (defined according to modified European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria) from 2004 to 2012 were evaluated in a multicentre study. Variables associated with infection and mortality were determined. Of 162 episodes of non-Aspergillus IFD, 145 (89.5%) were proven infections and 17 (10.5%) were probable infections. The pathogens included 29 fungal species/species complexes; mucormycetes (45.7%) and Scedosporium species (33.3%) were most common. The commonest comorbidities were haematological malignancies (HMs) (46.3%) diabetes mellitus (23.5%), and chronic pulmonary disease (16%); antecedent trauma was present in 21% of cases. Twenty-five (15.4%) patients had no immunocompromised status or comorbidity, and were more likely to have acquired infection following major trauma (p <0.01); 61 (37.7%) of cases affected patients without HMs or transplantation. Antifungal therapy was administered to 93.2% of patients (median 68 days, interquartile range 19-275), and adjunctive surgery was performed in 58.6%. The all-cause 90-day mortality was 44.4%; HMs and intensive-care admission were the strongest predictors of death (both p <0.001). Survival varied by fungal group, with the risk of death being significantly lower in patients with dematiaceous mould infections than in patients with other non-Aspergillus mould infections. Non-Aspergillus IFD affected diverse patient groups, including non-immunocompromised hosts and those outside traditional risk groups; therefore, definitions of IFD in these patients are required. Given the high mortality, increased recognition of infections and accurate identification of the causative agent are required.

Trichosporon asahii infection presenting as chronic meningo-ventriculitis and intra ventricular fungal ball: a case report and literature review.

Central nervous system trichosporonosis is a rare clinical entity and so far only six cases including three each of brain abscess and meningitis has been on record. We report a rare case of chronic meningo-ventriculitis and intraventricular fungal ball due to Trichosporon asahii in an 18-year-old immunocompetent male from Burundi, east Africa. Neuroendoscopy showed multiple nodules and a fungal ball within the ventricle, which on culture grew T. asahii. He was initially empirically treated with liposomal amphotericin B. However, the antifungal susceptibility testing of T. asahii isolate revealed high minimum inhibitory concentration for amphotericin B (2 µg ml⁻¹), flucytosine (16 µg ml⁻¹) and caspofungin (2 µg ml⁻¹) but exhibited potent activity for voriconazole, posaconazole, itraconazole and fluconazole. The patient rapidly succumbed to cardiac arrest before antifungal therapy could be changed. Although disseminated trichosporonosis has been increasingly reported the diagnosis represents a challenge especially in rare clinical settings such as intraventricular fungal ball in the present case, which has not been described previously.

Terminal ventriculostomy as an adjuvant treatment of complex syringomyelia: a case report and review of the literature.

Complex syringomyelia is multifactorial, and treatment strategies are highly individualized. In refractory cases, sectioning of the filum terminale, also known as terminal ventriculostomy, has been described as a potential adjuvant treatment to alleviate syrinx progression. A 10-year-old boy with a history of arachnoiditis presented with complex syringomyelia, progressive lower extremity motor weakness, and spasticity. Previously, he had failed spinal cord detethering and direct syrinx shunting. Imaging studies demonstrated a holocord syrinx extending to the level of his conus medullaris and into the filum terminale. The patient underwent an uncomplicated lumbar laminectomy and transection of the filum terminale. Operative pathologic specimens demonstrated a dilated central canal within the filum. Postoperative imaging demonstrated significant reduction in the diameter of the syrinx. At follow-up, the patient's motor symptoms had improved. Terminal ventriculostomy may be a useful adjuvant in treating caudally placed syringes refractory to other treatments. This procedure carries low neurological risk and involves no hardware implantation. In select cases, terminal ventriculostomy may help preserve neurological function in the face of otherwise progressive syringomyelia.

Rhino-orbital-cerebral mucormycosis: a lethal complication of body dysmorphic disorder.

Young diabetics can sometimes have difficulty with insulin compliance for various reasons. This can be exacerbated if associated with body dysmorphic disorder or other eating disorders. The manipulation of insulin to lose weight can have devastating consequences. The authors describe a fatal case of rhino-orbital-cerebral mucormycosis secondary to insulin manipulation for the purpose of weight loss.

Coccidioidal meningitis and brain abscesses: analysis of 71 cases at a referral center.

OBJECTIVE: Coccidioides species are the most common etiologic agents of chronic meningitis in regions endemic for coccidioidomycosis. Occasionally, even short-term travel to endemic regions results in the acquisition of meningeal disease, so awareness of this complication of coccidioidomycosis is important even in nonendemic areas. The prognosis depends on the early recognition and treatment of the disease, so it is important to be familiar with the varied clinical manifestations, risk factors associated with meningeal involvement, diagnostic challenges, and therapeutic modalities. METHODS: We performed a retrospective analysis of 71 cases with coccidioidomycosis involving the CNS seen from 1996 to 2007 at a referral medical center in southern Arizona. RESULTS: The only presenting symptom found in the majority of patients was headache. Those who were immunocompromised (most commonly HIV/AIDS and chronic steroid therapy) were at increased risk, but diabetics were not at increased risk. There was a preponderance of males (2:1) and people of Hispanic, African, and Asian (especially Pacific Isles) background. CSF anticoccidioidal antibody and culture were frequently negative on presentation, but in these cases, the serum antibody test was usually positive. Imaging studies were helpful in two thirds of cases, most commonly demonstrating basilar meningitis or hydrocephalus, which frequently required ventriculoperitoneal shunting. Most were treated with fluconazole, and prognosis was good for most of those who remained on treatment. CONCLUSIONS: Coccidioidal meningitis remains a diagnostic challenge, but the diagnosis can usually be made successfully when coccidioidal serum and CSF antibodies and cultures are combined with appropriate imaging studies.

Fungal meningitic hydrocephalus with repeated shunt malfunction.

A 33-year-old female presented with a rare case of fungal meningitis caused by Aspergillus detected for the first time at 15 years after onset. The meningitis repeatedly occurred over a period of 15 years. On admission, cerebrospinal fluid examination found cell count 1340/high-power field, protein 158 mg/dl, and sugar 8 mg/dl, indicating meningitis, although no bacterial or fungal species were detected. Cerebral computed tomography demonstrated hydrocephalus and cervical computed tomography demonstrated a mass lesion on the ventral side of the spinal cord from C4 to C6. Fungal meningitis was suspected and treated with amphotericin B. Her symptoms improved and she was eventually discharged. She was readmitted for recurrence of meningitis and hydrocephalus 2 months later. Amphotericin B was administered and a ventriculoperitoneal (VP) shunt was placed. Shunt malfunction recurred seven times. Aspergillus was detected for the first time from the atrium side of the ventriculoatrial shunt tube at 15 years after onset. Fluconazole was administered. She had narrowing of the cisterna magna, and underwent foramen magnum decompression. The VP shunt was finally reconstructed. Fluconazole administration was continued. Combination of foramen magnum decompression and long-term administration of fluconazole was effective in this case.

Coccidioidal meningitis.

Coccidioidal meningitis affects between 200 to 300 persons annually within the endemic area of the United States, with much larger numbers expected in epidemic years. Because this represents a chronic disease for survivors, several thousand patients may be under treatment at any given time. Epidemiology, background, and diagnosis are reviewed. Azole therapy has replaced intrathecal amphotericin B for induction and maintenance therapy for this disease, given its ease of administration and equivalent efficacy in controlling infection even at the cost of losing the opportunity for cure. Both itraconazole and fluconazole have demonstrated efficacy, but have not been compared in randomized human studies. One of the uses of intrathecal amphotericin B is as "add on" therapy in failing azole regimens without evidence of antagonism. Details of therapeutic approach are reviewed. Approach to diagnosis and management of the two principal potentially life threatening complications, hydrocephalus and vasculitis, is also discussed.

Cure of ventriculitis and central nervous system shunt infection by Staphylococcus epidermidis with vancomycin by intraventricular injection in a liver transplant recipient.

A 19-year-old female underwent orthotopic liver transplantation for acute hepatic failure because of fulminant Wilson's disease. Three months post transplantation she developed systemic fungal meningoencephalitis and obstructive hydrocephalus that required cerebrospinal fluid (CSF) shunting by a ventriculo-atrial shunt. Subsequently, she contracted Staphylococcus epidermidis bacteremia, ventriculitis, and shunt infection. Treatment with vancomycin either by conventional intravenous (i.v.) or continuous i.v. injection proved ineffective because of insufficient drug concentrations in the CSF. Eradication of S. epidermidis from CSF and cure of chronic ventriculitis and shunt infection was readily achieved by delivering vancomycin by intraventricular injection (5 mg/24 h) via an extraventricular drain together with continuous i.v. infusion (4 g/24 h) over a period of 18 days. This treatment was well tolerated and free of untoward side effects despite the patient's chronic immunosuppression subsequent to liver transplantation. Intraventricular injection of vancomycin is an effective and safe procedure to eradicate S. epidermidis from the central nervous system when i.v. vancomycin treatment fails.

Diagnostic MR imaging features of craniocerebral Aspergillosis of sino-nasal origin in immunocompetent patients.

BACKGROUND: Craniocerebral invasive Aspergillosis of sino-nasal origin has been reported with a very high mortality due to a peculiarly fulminant clinical course. Early diagnosis based on clinical radiological imaging may have an impact on final clinical outcome. This retrospective study focuses on characteristic MR imaging features of Aspergillosis (of sinonasal origin) in immunocompetent patients. METHODS: Medical records of patients were reviewed retrospectively during the period from 1991 to 2003 in the two tertiary care hospitals. All the patients had radiological evidence of disease in the paranasal sinuses with or without intracranial extension. Immunocompetence of patients was assessed on clinical and radiological data. MRI scans (n=20) were reviewed by both clinical neurosurgeons and neuroradiologists separately. MRI was done on 1.5 tesla scanners and both T2-weighted and T1 weighted sequences were obtained followed gadolinium enhanced images. Patients were categorized into three types based on their anatomical location on MRI scans; type-1 being intracerebral, type-2 as intracranial extradural and type-3 invading orbit and/or skull base only. All these patient had the epicenter of disease in the nose and/or paranasal sinuses as evident on MR imaging. All patients underwent standard surgical intervention followed by antifungal therapy. Clinical outcome was assessed on Glasgow outcome scale with mean duration of clinical follow up of 13.9 months. FINDINGS: Mean age of patents (n=20) was 31.1 years with male preponderance (3:1). MRI scans showed evidence of disease in paranasal sinuses including mucosal thickening (n=11) and complete filling of sinuses (n=9). T2-weighted images showed extremely hypo-intense fungal mass (n=19) while T1-weighted images had iso-intense signals (n=18). Gadolinium-enhanced images showed bright homogenous contrast enhancement (n=18) and peripheral ring enhancement pattern (n=2). All patients underwent appropriated surgical procedures depending upon anatomical location followed by standard antifungal therapy. Tissue diagnoses were established by histopathology (n=20) and culture growth (n=5). Overall mortality remained 15 percent. INTERPRETATION: Craniocerebral Aspergillosis of sinonasal origin has typical MR imaging features. These features include a mass lesion producing hypo-to-iso-intense signals on T1-weighted, extremely low signals (hypo-intense) on T2-weighted images, with bright homogenous enhancement on post-gadolinium T1-weighted imaging. These features in the clinical background may be helpful in early diagnosis and management of Aspergillosis of sino-nasal origin in immunocompetent hosts. Prospective clinical study is required to make firm clinical therapeutic recommendations.

Coccidioidal meningitis presenting as memory loss.

PURPOSE: This case study is designed to help the nurse practitioner recognize atypical symptoms of coccidioidal meningitis, particularly in high-risk groups that require further diagnostic treatment. DATA SOURCES: Selected research, clinical articles, and case studies. CONCLUSIONS: Coccidioidal meningitis is a potentially lethal infection unless recognized and treated. Unlike other infectious meningitides that present with more acute meningeal symptoms, disseminated coccidioidomycosis can present insidiously. When it presents as cognitive dysfunction, it may be mistaken for early dementia and if undiagnosed can result in death. While it is an infectious disease that is endemic to a small number of southwestern states, these areas see a high volume of tourists who can unwittingly become infected. Knowledge of this infectious disease and the many ways it can imitate other diseases is critical to its early recognition and treatment. IMPLICATIONS FOR PRACTICE: Failure to recognize this reemerging, endemic fungal infection in high-risk groups can result in death.

Coccidioidomycosis meningitis and syndrome of inappropriate antidiuretic hormone.

The syndrome of inappropriate antidiuretic hormone (SIADH) secretion has been well described in patients with meningeal spread from metastatic carcinomatosis and bacterial or mycobacterial infections. We describe a 39-year-old white man who was diagnosed with coccidioidomycosis pneumonia 7 years before presentation. He displayed evidence for meningitis with the onset of SIADH. We reviewed the diagnosis of coccidioidomycosis and radiological findings in the central nervous system. Last, we discussed the findings that led to the diagnosis of SIADH.

Rhino-orbital and rhino-orbito-cerebral mucormycosis.

BACKGROUND: Rhino-orbito-cerebral mucormycosis (ROCM) is a devastating infection of immunocompromised hosts. We present our experience with 19 ROCM cases and attempt to define preferred diagnostic and treatment protocols. METHODS: All had tissue biopsies obtained studied by direct smear, histologic studies, and cultures. Imaging was obtained in 14 cases. RESULTS: Sixteen patients presented between August and November. Six had mixed fungal infections. Seven patients had end-stage underlying disease or infection and did not undergo surgery and 4 had an indolent form of disease. Patients were treated by surgery and by amphotericin B. The overall survival was 47%. CONCLUSIONS: ROCM may have seasonal incidence peaking in the fall and early winter. The therapeutic approach should be unchanged in cases of mixed fungal infections. Amphotericin B with aggressive debridement remains the mainstay of treatment. Early recognition and treatment are essential. A presentation and survival-dependent classification of ROCM are offered.

Vasculitic complications associated with coccidioidal meningitis.

Vasculitis complicating coccidioidal meningitis is becoming increasingly recognized. At this time, predisposing clinical features have not been elucidated. Histologically, 2 types of vascular inflammation have been described. The first is a transmural inflammatory process of the intracranial blood vessels that occurs early in the course of disease. Encroachment of the vessel lumen may result in thrombosis. The second process occurs with chronic disease and is associated with intimal thickening and luminal occlusion with little inflammation. Numerous substances, including metalloproteinases, cytokines such as tumor necrosis factor (TNF)-alpha, and an elastase, have been postulated as putative virulence factors. Recently, a rabbit model has been developed that appears to closely mimic human disease. By using this model, a parallel between coccidioidal vasculitis and temporal arteritis has been developed. Currently, there are no established therapies for coccidioidal vasculitis. The use of corticosteroids is controversial. Of interest are agents that may block the pathologic process, such as omega-3 oils, and pentoxyfylline.

Cryptococcal meningitis in human immunodeficiency virus-infected patients in Harare, Zimbabwe.

A prospective observational study was conducted over a 10-month period to determine the clinical and laboratory manifestations of cryptococcal meningitis in Zimbabwe, a country where antifungal agents are not widely available. Eighty-nine patients with cryptococcal meningitis (median age, 34 years; range, 11-63 years; 56 males) were identified from 406 patients for whom a clinical diagnosis of meningitis had been made. All patients tested were positive for antibody to human immunodeficiency virus. Cryptococcal meningitis was the first AIDS-defining illness in 88% of patients. Typical presentations were headache, mental impairment, and meningism (median duration, 14 days; range, 1-180 days). The median CD4+ cell count was 70/microL (range, 0-651/microL). The cumulative median survival from the time of diagnosis was 14 days (range, 0-233 days); 22% of patients survived for >30 days. Independent indicators of a good prognosis were not identified. This study provides a unique basis for the development of novel management strategies for patients with cryptococcal meningitis who reside in resource-poor countries.

Disseminated miliary cerebral candidiasis.

We present a case of disseminated intracranial infection by Candida albicans in a 5-year-old girl who had fever and a change of consciousness after surgery for complex congenital heart malformation. MR imaging revealed multiple small ring-enhancing hemorrhagic abscesses. One year after antifungal treatment, the abscesses and ventriculomegaly were almost completely resolved. The patient was discharged in a stable but vegetative condition.