AN UNUSUAL PRESENTATION OF CNS CANDIDIASIS

Abstract

SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Central nervous system (CNS) candidiasis is uncommon and associated with neonates with low birth weights, neurosurgical patients, and immunocompromised hosts. However, incidence is rising due to increase in intravenous drug abuse (IVDA) and use of corticosteroids, and broad-spectrum antibiotics. We describe a case of CNS candidiasis with fungal endophthalmitis.CASE PRESENTATION: A 29-year-old male with a medical history notable for bilateral posterior uveitis with right eye blindness, IVDA with heroin, and migraines presented with altered mental status, urinary incontinence, and a 6-month duration of progressive blurred vision associated with abnormal gait. His vision was managed by ophthalmology with steroid eye drops for presumed autoimmune uveitis. Vital signs were notable for elevated temperature of 101.2 °F, heart rate of 111 beats per minute, and blood pressure of 185/123 mmHg. He had sluggish left eye pupil constriction and fixed right pupil. Toxicology work-up and ammonia were unremarkable. Non-contrasted brain computed tomography showed acute hydrocephalus and right vitreous hemorrhage. A ventriculostomy catheter was placed with intracranial pressure elevated at 28 mmHg. Serial cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis with low glucose of 40 mg/dL, elevated protein of 75 mg/dL, 405 nucleated cells, and 315 red blood cells. CSF meningitis-encephalitis panel and cultures were negative. Blood cultures and serum testing for tuberculosis, human immunodeficiency virus, cytomegalovirus, Bartonella, syphilis, and toxoplasma were negative. 1-3 B-D- glucan in CSF (>500 pg/mL) and serum (137 pg/mL) were elevated. Brain magnetic resonance imaging (MRI) showed basal meningitis and ventriculitis. B- scan ultrasonography showed fungal endophthalmitis. He underwent vitrectomy and enucleation of the right eye and completed a 6-week induction course of liposomal amphotericin B (L-AmB) 5 mg/kg daily and flucytosine 25 mg/kg Q6H with plans for at least 1 year of oral fluconazole 800 mg daily.DISCUSSION: CNS candidiasis has an incidence rate of 7.6% and mortality rate of 30%. The most common causative fungal organism is Candida albicans. Clinical manifestations are hydrocephalus, basal meningitis, and brainstem infarction. CSF analysis may show low glucose, elevated protein, and neutrophilic or lymphocytic pleocytosis. Our case exemplifies the difficulty in diagnosing CNS candidiasis complicated by hydrocephalus and fungal endophthalmitis, as it was initially missed. Treatment of CNS candidiasis requires induction therapy with L-AmB and flucytosine followed by oral fluconazole. Duration is determined by resolution of symptoms and CSF and radiological abnormalities.CONCLUSIONS: In people who inject drugs presenting with neurological symptoms, CNS candidiasis should be considered. Assessment of risk factors is crucial as failure to diagnose fungal meningitis can lead to death.Reference #1: Charalambous LT, Premji A, Tybout C, et al. Prevalence, healthcare resource utilization and overall burden of fungal meningitis in the United States. J Med Microbiol. 2018;67(2):215-227. doi:10.1099/jmm.0.000656Reference #2: Peter G. Pappas, Carol A. Kauffman, David R. Andes, Cornelius J. Clancy, Kieren A. Marr, Luis Ostrosky-Zeichner, Annette C. Reboli, Mindy G. Schuster, Jose A. Vazquez, Thomas J. Walsh, Theoklis E. Zaoutis, Jack D. Sobel, Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 62, Issue 4, 15 February 2016, Pages e1–e50, https://doi.org/10.1093/cid/civ933Reference #3: Góralska K, Blaszkowska J, Dzikowiec M. Neuroinfections caused by fungi. Infection. 2018;46(4):443-459. doi:10.1007/s15010-018-1152-2DISCLOSURES: No relevant relationships by Shu Xian LeeNo relevant relationships by Kurt SuterNo relevant relationships by Daphne-Dominique VillanuevaNo relevant relationships by Benita Wu SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Central nervous system (CNS) candidiasis is uncommon and associated with neonates with low birth weights, neurosurgical patients, and immunocompromised hosts. However, incidence is rising due to increase in intravenous drug abuse (IVDA) and use of corticosteroids, and broad-spectrum antibiotics. We describe a case of CNS candidiasis with fungal endophthalmitis. CASE PRESENTATION: A 29-year-old male with a medical history notable for bilateral posterior uveitis with right eye blindness, IVDA with heroin, and migraines presented with altered mental status, urinary incontinence, and a 6-month duration of progressive blurred vision associated with abnormal gait. His vision was managed by ophthalmology with steroid eye drops for presumed autoimmune uveitis. Vital signs were notable for elevated temperature of 101.2 °F, heart rate of 111 beats per minute, and blood pressure of 185/123 mmHg. He had sluggish left eye pupil constriction and fixed right pupil. Toxicology work-up and ammonia were unremarkable. Non-contrasted brain computed tomography showed acute hydrocephalus and right vitreous hemorrhage. A ventriculostomy catheter was placed with intracranial pressure elevated at 28 mmHg. Serial cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis with low glucose of 40 mg/dL, elevated protein of 75 mg/dL, 405 nucleated cells, and 315 red blood cells. CSF meningitis-encephalitis panel and cultures were negative. Blood cultures and serum testing for tuberculosis, human immunodeficiency virus, cytomegalovirus, Bartonella, syphilis, and toxoplasma were negative. 1-3 B-D- glucan in CSF (>500 pg/mL) and serum (137 pg/mL) were elevated. Brain magnetic resonance imaging (MRI) showed basal meningitis and ventriculitis. B- scan ultrasonography showed fungal endophthalmitis. He underwent vitrectomy and enucleation of the right eye and completed a 6-week induction course of liposomal amphotericin B (L-AmB) 5 mg/kg daily and flucytosine 25 mg/kg Q6H with plans for at least 1 year of oral fluconazole 800 mg daily. DISCUSSION: CNS candidiasis has an incidence rate of 7.6% and mortality rate of 30%. The most common causative fungal organism is Candida albicans. Clinical manifestations are hydrocephalus, basal meningitis, and brainstem infarction. CSF analysis may show low glucose, elevated protein, and neutrophilic or lymphocytic pleocytosis. Our case exemplifies the difficulty in diagnosing CNS candidiasis complicated by hydrocephalus and fungal endophthalmitis, as it was initially missed. Treatment of CNS candidiasis requires induction therapy with L-AmB and flucytosine followed by oral fluconazole. Duration is determined by resolution of symptoms and CSF and radiological abnormalities. CONCLUSIONS: In people who inject drugs presenting with neurological symptoms, CNS candidiasis should be considered. Assessment of risk factors is crucial as failure to diagnose fungal meningitis can lead to death. Reference #1: Charalambous LT, Premji A, Tybout C, et al. Prevalence, healthcare resource utilization and overall burden of fungal meningitis in the United States. J Med Microbiol. 2018;67(2):215-227. doi:10.1099/jmm.0.000656 Reference #2: Peter G. Pappas, Carol A. Kauffman, David R. Andes, Cornelius J. Clancy, Kieren A. Marr, Luis Ostrosky-Zeichner, Annette C. Reboli, Mindy G. Schuster, Jose A. Vazquez, Thomas J. Walsh, Theoklis E. Zaoutis, Jack D. Sobel, Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 62, Issue 4, 15 February 2016, Pages e1–e50, https://doi.org/10.1093/cid/civ933 Reference #3: Góralska K, Blaszkowska J, Dzikowiec M. Neuroinfections caused by fungi. Infection. 2018;46(4):443-459. doi:10.1007/s15010-018-1152-2 DISCLOSURES: No relevant relationships by Shu Xian Lee No relevant relationships by Kurt Suter No relevant relationships by Daphne-Dominique Villanueva No relevant relationships by Benita Wu