Fungal Infection in the Central Nervous System: Two Tertiary Care Centers Experience

Mohammed Reza, MD Laxmi Dhakal, MBBS Grace Gruz, MD Omar Abu Saleh, MD Mark Enzler, MD Lisa Brumble, MD William Freeman, MD


Background. Advancements in transplant procedures and concomitant use of immunosuppressive therapies, as well as the pandemic spread of HIV, have increased the incidence of central nervous system (CNS) fungal infections. We performed a retrospective study of the epidemiological aspects of CNS fungal infection at two tertiary care hospitals.

Methods. A retrospective chart review of patients from Mayo Clinic (Rochester and Jacksonville) with a proven or probable diagnosis of CNS fungal infection was conducted from January 2000 through December 2014. Immunosuppressed states were defined as solid organ or bone marrow transplant, AIDS with CD4 count <200, chemotherapeutic agent use, high dose steroids ≥15 mg daily or immunomodulator use for other indications. Other risk factors including presence of CNS instrumentation were also evaluated.

Results. The 102 patients (96 proven; 6 probable) diagnosed with CNS fungal infection included 78 with cerebrospinal fluid (CSF) antigen or cultures positive for fungal meningitis, 18 with tissue diagnosis, and 6 with CNS imaging indicative of infection with other organ cultures positive for fungal infection (e.g. blood or sputum). Most patients were male (70%) with a median age of 59 years. Sixty-six percent were immunosuppressed; the most common immunosuppressant used was prednisone (27%). Cryptococcal spp., 59% (60 cases) was the most common, followed by Candida spp. 16% (16 cases). Headache 49% (50 patients) was the most common presenting symptom. Thirteen patients (12%) presented with stroke-like symptoms. One-year mortality was highest in CNS aspergillosis (86%). Although cryptococcal CNS infection was the most common, 77% of patients were alive at one year. Use of high dose steroids or immunomodulating medications (41% of cases) were the most common risk factors identified in patients diagnosed with cryptococcal meningitis. Fifty percent of patients diagnosed with CNS Candida spp. infection had a CSF shunt in place prior to the infection.

Conclusion. CNS fungal infections have increased in frequency, particularly in patients requiring immunosuppression. The majority of the CNS fungal infections were due to Cryptococcus spp. CNS infections due to Aspergillus spp. had the highest mortality. CNS infection with Candida spp. was more commonly seen in patients with existing CSF shunts.

Disclosures.All authors: No reported disclosures.


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