Abstract
Purpose: Fungal infections of the central nervous system (CNS) are potentially lethal conditions with high morbidity and mortality. In this review, we summarise the most common clinical manifestations, diagnostic methods, and treatment strategies for intracranial fungal infection at two tertiary care teaching hospitals. Material and methods: Prospective hospital study is carried out at Department of Neurosurgery; Assiut and Suhaj University Hospitals between January2010 to January 2018 (Minimum 12-months follow-up). Radiographs and hospital data of 74 patients with proven intracranial fungal infections were gathered and analyzed. There were no exclusion criteria: age, gender, clinical presentations, immunity status, radiological findings, laboratory, and microbiological data, types of management and outcome. In surgically treated patients, diagnosis was confirmed by pathologic evaluation. Gathered data were coded and entered into a computer and analyzed using SPSS version 22. Results: The greatest number of the patients had 40 to 60 years old (49; 66%) and the mean age was 44 years. There was an overwhelming male patient’s ranged preponderance 66%; 49 cases. Sixty-three patients (85%) were immunosuppressed; 11 cases (15%) were immunocompetent. The most common causes of immunosuppression were diabetes 27 patients; 43%, on chemotherapeutic agents 19 patients; 31%, on corticosteroid 16 patients; 25% and AIDS in one patient; 1%. Five different fungal types were identified but Cryptococcus spp. was the most common cause of CNS fungal infection, occurring in 39 patients (53%). This was followed by Candida spp. in 14 patients (19%), Aspergillus in 11 patients (15%), Blastomyces in 7 patients (9%) and Coccidiosis in 3 patients (4%). Headache was the most common presenting symptom, occurring in 33 patients (45%). Other relatively common symptoms were nausea or vomiting 11 patients (15%), fever 10 patients; (13%), seizures 9 patients (12%), acute mental status changes 8 patients; (11%) and stroke like Symptoms 3patients (4%). Different surgical procedures were done. Stereotactic biopsy is in 19 patients (deep; located in an eloquent region of the brain or multiple small lesion) or excision in 38 patients (cortical, relatively accessible regions of the brain), and CSF shunting in 17 patients. All patients received parenteral and, in some cases, oral antifungal chemotherapy in addition to surgical therapy. Overall mortality was 52.7% (39 deaths). An additional 8 surviving patients exhibited permanent morbidity due to neurological deficits and seizure disorders. Conclusion: This prospective population study demonstrates an insight into the intracranial fungal infection and management. CNS fungal infections have increased in frequency, particularly in immunocompromised patients; most infections are caused by Cryptococcus spp. Diabetes was the most common cause of immunosuppression and headache was the most common symptom at presentation. CNS fungal infection is still associated with a high mortality and morbidity. Prompt diagnosis; early and appropriate medical and surgical management are fundamental to optimize the outcome.
Highlights
Fungal infections of the central nervous system (CNS) are rare clinical entities presenting with protean clinical manifestations, difficult diagnostic dilemmas and special therapeutic challenges
We summarise the most common clinical manifestations, diagnostic methods, and treatment strategies for intracranial fungal infection at two tertiary care teaching hospitals
We summarise the most common clinical manifestations, diagnostic methods, and treatment strategies for intracranial fungal infection at two tertiary care teaching hospitals as such data base is helpful to clinicians and may spur additional efforts to systematically study these uncommon infections
Summary
Fungal infections of the central nervous system (CNS) are rare clinical entities presenting with protean clinical manifestations, difficult diagnostic dilemmas and special therapeutic challenges. There appears to be an increasing incidence of invasive fungal infections from 6.6% from 1993 to 1996 to 10.4% from 2001 to 2005 [3]. This increase in frequency is likely attributed to multiple factors including an aging population, increased use of disease-modifying drugs for treatment of autoimmune disorders, malignancies requiring use of cytotoxic drugs, increased number of bone marrow and solid-organ transplantations requiring long-term use of immunosuppressive agents, and the pandemic spread of HIV/AIDS [4]. Intracranial fungal masses were rarely seen even in major neurosurgical centers in Egypt. No multicenter epidemiology studies have been reported, but the incidence of some fungal diseases in Egyptian population at risk has been reported previously from single centers;
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