Post-influenza meningitis in an immunosuppressed man

Abstract

Background: We report a case of post-influenza invasive aspergillosis causing ventriculitis in a patient immunosuppressed on methotrexate for rheumatoid arthritis. Summary: A 63-year-old male with a positive H1N1 throat swab presented with increasing dyspnoea and pyrexia that failed to improve despite broad-spectrum antibiotics and zanamivir. Imaging of his chest showed cavitating lung disease and a possible post influenza fungal infection. He was initiated on antifungal treatment that was stopped after 10 days following a negative bronchoalveolar lavage and serum galactomann test. Respiratory symptoms and inflammatory markers improved but he developed confusion and falls. Computed tomography of the head showed hydrocephalus but there was no papilloedema. Examination of the cerebrospinal fluid (CSF) showed lymphocytosis with elevated proteins but negative initial investigations. Subsequent magnetic resonance imaging of the head with contrast showed obstructing hydrocephalus with ventriculitis. He underwent an urgent ventriculostomy by the neurosurgeons which demonstrated purulent CSF. CSF testing was strongly positive for beta-D glucan, a positive PCR result for aspergillus in CSF was received from the initial lumbar puncture and histology from operative samples showed fungal hyphae. Dual antifungal treatment was recommenced but the patient’s conditioned worsened, and he died on ITU. Conclusion: Whilst invasive pulmonary aspergillosis is a recognised complication of influenza, extrapulmonary infection is less well documented. This is the first case in the literature in which ventriculitis due to aspergillus is described as a sequel to infection with influenza. Clinicians should remain vigilant for fungal infection in patients with influenza who are immunosuppressed.