Undiagnosed Cryptococcus gattii meningitis leading to subsequent ventriculoperitoneal shunt infection in a patient with symptoms of normal pressure hydrocephalus: case report and literature review

Cryptococcal meningitis in apparently immunocompetent patients

Cryptococcal meningitis (CM) is an invasive fungal disease that currently poses a threat to human health worldwide, with high morbidity and mortality, particularly in immunocompromised patients. Although CM mainly occurs in HIV-positive patients and other immunocompromised patients, it is also increasingly seen in seemingly immunocompetent hosts. The clinical characteristics of CM between immunocompromised and immunocompetent populations are different. However, few studies have focussed on CM in immunocompetent individuals. This review summarizes the clinical characteristics of apparently immunocompetent CM patients in terms of aetiology, immune pathogenesis, clinical presentation, laboratory data, imaging findings, treatment strategies and prognosis. It is of great significance to further understand the disease characteristics of CM, explore new treatment strategies and improve the prognosis of CM in immunocompetent individuals.

Comparison of shunt outcomes for non-bacterial infectious hydrocephalus with common hydrocephalus etiologies: a retrospective case-control study

BACKGROUND

Shunting is an established treatment for hydrocephalus, yet reports on shunt outcomes for non-bacterial infectious (NBI) hydrocephalus are limited. Furthermore, comparison of mechanisms and rates of failure for shunted NBI hydrocephalus versus more typical etiologies remains undetermined.

METHODS

Patients who underwent shunting for hydrocephalus at two centers (1995-2020) were included. Indications for shunting were grouped as "typical" (congenital, post-hemorrhagic, normal pressure hydrocephalus, malignancy-related, trauma, and idiopathic) and NBI hydrocephalus (coccidioidomycosis, cryptococcus, and neurocysticercosis). Rates of shunt malfunction were compared.

RESULTS

There were 261 patients shunted for typical hydrocephalus (48.7% male; age 50.7±21.7) and 93 NBI hydrocephalus (72.0% male; age 41.8±13.2). For patients with typical hydrocephalus, 29.5% required ≥1 shunt revision, compared with 64.5% with NBI hydrocephalus (p<1E-5). Of those with malfunction, NBI shunts required more revision operations (median 3.0; max 21) compared with typical shunts (median 2.0; max 6; p<0.05). Censored median time to shunt failure for NBI hydrocephalus was 26.9 months and not reached for typical etiologies by 180 months. Multivariate analysis showed shunts for NBI hydrocephalus were significantly more likely to fail (HR 2.25; 95% CI 1.58-3.19). A distal pseudocyst was implicated in 30.0% and 2.6% of shunt failures for NBI and typical hydrocephalus, respectively (p<1E-5). Sixteen (26.7%) NBI shunt failures required revision to lower resistance systems compared to six (7.8%) typical failures (p<0.05).

CONCLUSIONS

Shunts placed for hydrocephalus secondary to non-bacterial infections are complicated by significantly higher rates of malfunction. These patients are prone to develop distal abdominal pseudocysts and often require revision to low-resistance systems.

Ventriculoperitoneal shunt infection by Cryptococcus neoformans sensu stricto: Case report and literature review

BACKGROUND

Cryptococcal ventriculoperitoneal shunt infection is known to occur due to an underlying infection in the patient rather than by nosocomial transmission of Cryptococcus during shunt placement. A case of chronic hydrocephalus due to cryptococcal meningitis that was misdiagnosed as tuberculous meningitis is described.

CASE REPORT

Patient details were extracted from charts and laboratory records. The identification of the isolate was confirmed by PCR-restriction fragment length polymorphism of the orotodine monophosphate pyrophosphorylase (URA5) gene. Antifungal susceptibility was determined using the CLSI M27-A3 broth microdilution method. Besides, a Medline search was performed to review all cases of Cryptococcus ventriculoperitoneal shunt infection. Cryptococcus neoformans sensu stricto (formerly Cryptococcus neoformans var. grubii), mating-type MATα was isolated from the cerebrospinal fluid and external ventricular drain tip. The isolate showed low minimum inhibitory concentrations for voriconazole (0.06mg/l), fluconazole (8mg/l), isavuconazole (<0.015mg/l), posaconazole (<0.03mg/l), amphotericin B (<0.06mg/l) and 5-fluorocytosine (1mg/l). The patient was treated with intravenous amphotericin B deoxycholate, but died of cardiopulmonary arrest on the fifteenth postoperative day.

CONCLUSIONS

This report underlines the need to rule out a Cryptococcus infection in those cases of chronic meningitis with hydrocephalus.

Cryptococcal meningitis: a review for emergency clinicians

INTRODUCTION

Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization.

OBJECTIVE

This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM.

DISCUSSION

This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS).

CONCLUSIONS

CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.

Cryptococcosis caused by cryptococcus gattii: 2 case reports and literature review

Cryptococcosis caused by Cryptococcus gattii, is a life threatening fungal infection with recently increasing prevalence. C. gattii is a species complex comprising multiple independent species. However, many biological characteristics and clinical features of cryptococcosis due to C. gattii are relatively less well defined. In this paper, we identify two cases of C. gattii infection, and laboratory findings of genotype VGI and VGII in two groups of apparently immunocompetent Chinese individuals respectively. Upon detailed review of all 35 cases of C. gattii infections, it was observed that C. gattii can cause debilitating illness in both immunocompetent and immunocompromised individuals. Cryptococcosis due to C. gattii is a serious systemic fungal infection, with pulmonary central nervous system tropism. Epidemiologically, C. gattii infection is not only restricted in tropical and subtropical regions, but also in other geographical settings.

Normal pressure hydrocephalus secondary to Lyme disease, a case report and review of seven reported cases

BACKGROUND

Infection with tick borne Borrelia Burgdorferi (Lyme disease) can without treatment rarely develop into a chronic phase. Secondary Normal Pressure Hydrocephalus (sNPH) based on chronic infection with Borrelia Burgdorferi (Bb) is an even rarer entity, that with the right treatment is potentially curable.

CASE PRESENTATION

A 67-year-old male with a slow onset of progressive balance problems, also presented unspecified dizziness, urge feeling, neck soreness and discrete cognitive complaints. An MRI scan revealed an enlarged ventricular system compatible with NPH. After further liquor dynamic procedures, cerebrospinal fluid (CSF) was analysed with the surprising results of lymphocytic pleocytosis, and signs of increased antibody production. Microbiology revealed chronic neuroborreliosis and the patient was treated with antibiotics accordingly. At the one-year follow-up no symptoms remained and the ventricular system almost normalized.

CONCLUSIONS

We describe the 7th published case of sNPH secondary to chronic Borreliosis in a previous healthy adult. Existing published literature has been reviewed and previous cases showed similarly nearly full clinical recovery. Primary/idiopathic NPH (iNPH) is treated with the surgical intervention of ventriculoperitoneal shunt and can be mistaken for a sNPH. The awareness of rare causes of sNPH like chronic Borreliosis is important as it is easily treated non surgically.