Spectrum of fungal infection in a neurology tertiary care center in India

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.

Preventing Cryptococcosis-Shifting the Paradigm in the Era of Highly Active Antiretroviral Therapy

Cryptococcosis remains a significant cause of morbidity and mortality among HIV-infected patients, especially in sub-Saharan Africa where it causes up to 20 % of AIDS-related deaths in HIV programs. A new, highly sensitive, and affordable point of care diagnostic test for cryptococcal infection, the lateral flow assay, can detect early sub-clinical cryptococcosis especially in areas with limited laboratory infrastructure. With a prevalence of detectable sub-clinical cryptococcal infection averaging 7.2 % (95 % CI 6.8-7.6 %) among 36 cohorts with CD4 <100 cells/μL in Africa, together with data showing that preemptive fluconazole prevents overt cryptococcal disease in this population, implementing a screen and treat strategy as part of HIV care practice among patients with CD4 <100 cells/μL could prevent the incidence of often fatal cryptococcal meningitis in the setting of the HIV pandemic.

Spectrum and outcome predictors of central nervous system infections in a neurological critical care unit in India: a retrospective review

BACKGROUND

There are few published studies on the spectrum and outcome of central nervous system (CNS) infection in the neurology intensive care unit (NICU). We report the spectrum of CNS infections in the NICU and the predictors of outcome.

METHODS

During 2011 to 2012, 235 critically ill neurological patients were admitted to a 12-bed NICU in a tertiary-care teaching hospital in Lucknow, northern India; 76 (32.3%) of them had CNS infections and were included in the present study. The patients' demographic and clinical details were noted, together with the underlying aetiology, Glasgow Coma Scale (GCS) score, Acute Physiology and Chronic Health Evaluation (APACHE II) score, systemic inflammatory response syndrome (SIRS) and complications during mechanical ventilation. Deaths were recorded, and 3-month functional outcome in the surviving patients assessed by the modified Rankin Scale (mRS).

RESULTS

The median age of the patients was 37.5 (4-75) years and 31 were females; 36/76 (47%) patients had tuberculous meningitis, 28/76 (37%) viral encephalitis, 8/76 (11%) pyogenic meningitis and 4/76 (5%) fungal meningitis. Seven of these patients had AIDS. The median duration of mechanical ventilation was 8 (1-121) days and 39/76 patients (51.3%) died. Duration of hospital stay (OR 1.2, 95% CI 1.05-1.37, p=0.006) and duration of mechanical ventilation (OR 0.81, 95% CI 0.68-0.95, p=0.01) were independent predictors of death. At 3-month follow-up, 23/37 patients (62%) had recovered well, 10/37 (27%) were severely disabled and 4/37 (11%) had died.

CONCLUSION

Of patients admitted to the NICU during the study period, one-third had a CNS infection. Half of those with a CNS infection survived, and predictors of death were prolonged mechanical ventilation and prolonged hospital stay.

Fungal central nervous system infections: prevalence and diagnosis

Fungal infections of the central nervous system (CNS) are rare but they pose a significant challenge. Their prevalence spans a wide array of hosts including immunosuppressed and immunocompetent individuals, patients undergoing neurosurgical procedures and those carrying implantable CNS devices. Cryptococcus neoformans and Aspergillus spp. remain the most common pathogens. Magnetic resonance imaging can help localize the lesions, but diagnosis is challenging since invasive procedures may be needed for the retrieval of tissue, especially in cases of fungal abscesses. Antigen and antibody tests are available and approved for use in the cerebrospinal fluid (CSF). PCR-based techniques are promising but they are not validated for use in the CSF. This review provides an overview on the differential diagnosis of the fungal CNS disease based on the host and the clinical syndrome and suggests the optimal use of diagnostic techniques. It also summarizes the emergence of Cryptococcus gatti and an unanticipated outbreak caused by Exserohilum rostratum.

CNS Mold Infections

Mold infections of the central nervous system (CNS) present as abscesses, infarcts, hemorrhages, and, less commonly, meningitis. These invasive infections are difficult both to identify and to eradicate given low-sensitivity diagnostics and high-toxicity, low-efficacy antifungal therapies, hence resulting in high rates of morbidity and mortality. Herein, the recent literature on CNS mold infections is reviewed, and updates in diagnosis and management are discussed.