Candida albicans hydrocephalus

Central nervous system (CNS) candida infections are often associated with a poor prognosis. Typically, CNS candidiasis presents as meningitis or microabscesses.

Argersinger et al. report a patient with a challenging presentation of a CNS candidiasis as a discrete, large cauda equina abscess. The patient initially presented with ventriculomegaly due to fourth ventricular outflow obstruction and a cauda equina mass. The patient was treated with a ventriculoperitoneal shunt and underwent a lumbar laminectomy for exploration of the lumbar lesion. An intradural abscess was encountered during surgery. Fungal wet mount revealed fungal elements and polymerase chain reaction confirmed the presence of Candida albicans. The patient did not have any known predisposition to fungal infections; therefore, the authors performed whole-exome sequencing using peripheral blood mononuclear cell DNA. They found heterozygous missense variants in the following genes: colony-stimulating factor 2 (CSF2) and Ras protein-specific guanine nucleotide-releasing factor 1 (RASGRF1)-genes that have been specifically associated with protection from CNS candidiasis via caspase recruitment domain-containing protein 9 (CARD9) signaling, and phospholipase C gamma 2 (PLCG2)-a lectin receptor involved in candidiasis. The authors' experience suggests that C. albicans can present as a cauda equina abscess. Hydrocephalus, a result of diffuse arachnoiditis, is a potential complication from intradural fungal abscesses ¹⁾

a 24 year old man with profound chronic hydrocephalus found to have a cauda equina abscess composed of Candida albicans. Prior literature reveals a paucity of central nervous system candidiasis. In these previously reported cases, there was evidence of local invasion of surrounding structures; however, this case is a sentinel report of a fungal abscess without evidence of local structural invasion. The patient's course was complicated by clinical and radiographic worsening to cauda equina syndrome, requiring emergent surgical decompression, despite appropriate antifungal treatment. This case illustrates the diagnostic challenge of this rare entity and the need for close follow up with this patient population ²⁾.

A unique case of Candida albicans ventriculitis and hydrocephalus in the absence of any evidence of systemic candidiasis or immunosuppression is reported. Initial treatment with CSF shunting and intravenous antimycotic therapy appeared to have eradicated the infection. Recurrence occurred 5 months after discharge and this was treated by intravenous and intrathecal antifungal in addition to removal of the shunt system, external ventricular drainage and then replacement of the shunt. A concomitant pyogenic brain abscess responded to burrhole aspiration and antibiotics. The role of mannan antigen monitoring is discussed. ³⁾.

Cruciani M, Di Perri G, Molesini M, Vento S, Concia E, Bassetti D. Use of fluconazole in the treatment of Candida albicans hydrocephalus shunt infection. Eur J Clin Microbiol Infect Dis. 1992 Oct;11(10):957. doi: 10.1007/BF01962387. PMID: 1486898.

1: Shirvani F, Behzad A, Abdollahi N, Mohkam M, Sharifian M, Esfandiar N, Fallah F. Frequency and co-colonization of vancomycin-resistant <i>Enterococci</i> and <i>Candida</i> in ICU-hospitalized children. New Microbes New Infect. 2021 Apr 14;41:100881. doi: 10.1016/j.nmni.2021.100881. PMID: 34026230; PMCID: PMC8121691.

2: Khurram D, Ali SM, Kozak I. Bilateral acute retinal necrosis in premature newborn with skin, eye, and mouth infection presenting with vitreous and subretinal hemorrhage. Indian J Ophthalmol. 2020 Sep;68(9):2009-2011. doi: 10.4103/ijo.IJO_1038_20. PMID: 32823461; PMCID: PMC7690509.

4: Guner G, Bal ZS, Dogan E, Umit Z, Levent E, Hilmioglu Polat S, Ozkinay F, Kurugol Z. Native valve endocarditis due to Candida albicans in two children: Two new case reports. Echocardiography. 2019 Jul;36(7):1401-1404. doi: 10.1111/echo.14406. Epub 2019 Jun 19. PMID: 31215692.

6: Kormanik K, Praca J, Garton HJ, Sarkar S. Repeated tapping of ventricular reservoir in preterm infants with post-hemorrhagic ventricular dilatation does not increase the risk of reservoir infection. J Perinatol. 2010 Mar;30(3):218-21. doi: 10.1038/jp.2009.154. Epub 2009 Oct 8. PMID: 19812582.

7: Baradkar VP, Mathur M, Sonavane A, Kumar S. Candidal infections of ventriculoperitoneal shunts. J Pediatr Neurosci. 2009 Jul;4(2):73-5. doi: 10.4103/1817-1745.57325. PMID: 21887187; PMCID: PMC3162793.

8: Borha A, Parienti JJ, Emery E, Coskun O, Khouri S, Derlon JM. Granulome cérébral àCandida albicans chez un patient immunocompétent. Cas clinique [Candida albicans cerebral granuloma in an immunocompetent patient. A case report]. Neurochirurgie. 2009 Feb;55(1):57-62. French. doi: 10.1016/j.neuchi.2008.06.001. Epub 2008 Aug 8. PMID: 18692208.

9: Atalay B, Yilmaz C, Cekinmez M, Altinors N, Caner H. Treatment of hydrocephalus with functionally isolated ventricles. Acta Neurochir (Wien). 2006 Dec;148(12):1293-6; discussion 1296. doi: 10.1007/s00701-006-0906-2. Epub 2006 Oct 17. PMID: 17039301.

10: Esposito P, Zerr N, Kehrli P, Pain L, Maitrot D. Complication neuroméningée d'une infection systémique à Candida albicans chez un prématuré [Systemic Candida albicans infection with neuromeningeal complication in a premature infant]. Rev Neurol (Paris). 2005 Sep;161(8-9):832-5. French. doi: 10.1016/s0035-3787(05)85143-4. PMID: 16244566.

11: Moguel MA, Brun FM, Pérez A, Pérez P, Torres LM. Complicaciones infecciosas tras analgesia epidural para control del dolor postoperatorio en cirugía abdominal [Infectious complications after epidural analgesia to control pain after abdominal surgery]. Rev Esp Anestesiol Reanim. 2005 Jan;52(1):44-7. Spanish. PMID: 15747704.

12: Liu KH, Wu CJ, Chou CH, Lee HC, Lee NY, Hung ST, Ko WC. Refractory candidal meningitis in an immunocompromised patient cured by caspofungin. J Clin Microbiol. 2004 Dec;42(12):5950-3. doi: 10.1128/JCM.42.12.5950-5953.2004. PMID: 15583351; PMCID: PMC535248.

13: Koch S, Rudel B, Tietz HJ. Lethal otogenic Candida meningitis. Mycoses. 2004 Oct;47(9-10):450-3. doi: 10.1111/j.1439-0507.2004.01029.x. PMID: 15504133.

14: Soto-Hernández JL, Ramírez-Crescencio MA, Moreno Estrada VM, del Valle Robles R. Candida albicans cerebral granulomas associated with a nonfunctional cerebrospinal fluid shunt: case report. Neurosurgery. 2000 Oct;47(4):973-6; discussion 976-7. doi: 10.1097/00006123-200010000-00037. PMID: 11014440.

15: Murphy K, Bradley J, James HE. The treatment of Candida albicans shunt infections. Childs Nerv Syst. 2000 Jan;16(1):4-7. doi: 10.1007/s003810050002. PMID: 10672422.

16: Sood S, Majumdar T, Chatterjee A, Sethi S, Dutta K, Banerjee U. Disseminated candidosis in premature twins. Mycoses. 1998 Nov;41(9-10):417-9. doi: 10.1111/j.1439-0507.1998.tb00363.x. PMID: 9916466.

17: del Pozo MM, Bermejo F, Molina JA, de la Fuente EC, Martínez-Martín P, Benito-León J. Chronic neutrophilic meningitis caused by Candida albicans. Neurologia. 1998 Aug-Sep;13(7):362-6. PMID: 9810800.

18: Lai PH, Lin SM, Pan HB, Yang CF. Disseminated miliary cerebral candidiasis. AJNR Am J Neuroradiol. 1997 Aug;18(7):1303-6. PMID: 9282859.

19: Duffner F, Brandner S, Opitz H, Klier R, Grote EH. Primary Candida albicans empyema associated with epidural hematomas in craniocervical junction. Clin Neuropathol. 1997 May-Jun;16(3):143-6. PMID: 9197939.

20: Jarløv JO, Born P, Bruun B. Candida albicans meningitis in a 27 weeks premature infant treated with liposomal amphotericin-B (AmBisome). Scand J Infect Dis. 1995;27(4):419-20. doi: 10.3109/00365549509032745. PMID: 8658084.

21: Chiou CC, Wong TT, Lin HH, Hwang B, Tang RB, Wu KG, Lee BH. Fungal infection of ventriculoperitoneal shunts in children. Clin Infect Dis. 1994 Dec;19(6):1049-53. doi: 10.1093/clinids/19.6.1049. PMID: 7888533.

22: Lisch S, Steudel WI. Ungewöhnlicher Verlauf einer Candidiasis des Zentralnervensystems [Unusual course of candidiasis of the central nervous system]. Dtsch Med Wochenschr. 1994 Jan 7;119(1-2):13-8. German. doi: 10.1055/s-2008-1058655. PMID: 8281877.

23: Sánchez-Portocarrero J, Pérez-Cecilia E, Roca V, Rábano J, Martín-Rabadán P, Ramírez C, Varela de Seijas E. Meningitis por Candida albicans en 2 adictos a drogas por vía parenteral. Revisión de la literatura [Candida albicans meningitis in 2 parenteral drug addicts. Review of the literature]. Enferm Infecc Microbiol Clin. 1993 May;11(5):244-9. Spanish. PMID: 8324020.

26: Fukui S, Tabata H, Hayashi H, Matsushima Y. [Successful treatment of Candida meningitis with miconazole]. No To Shinkei. 1990 Sep;42(9):863-6. Japanese. PMID: 2245081.

27: Ikeda K, Yamashita J, Fujisawa H, Fujita S. Cerebral granuloma and meningitis caused by Candida albicans: useful monitoring of mannan antigen in cerebrospinal fluid. Neurosurgery. 1990 May;26(5):860-3. PMID: 2352603.

28: Kacprzak-Bergman I, Szychowska Z, Rudkowski Z. Kandydoza narzadowa z zajeciem opon mózgowo-rdzeniowych u noworodka [Systemic candidiasis with meningeal involvement in a newborn infant]. Pol Tyg Lek. 1989 Apr 24;44(17):394-6. Polish. PMID: 2626360.

29: Papadimitriou JM, Ashman RB. The pathogenesis of acute systemic candidiasis in a susceptible inbred mouse strain. J Pathol. 1986 Dec;150(4):257-65. doi: 10.1002/path.1711500405. PMID: 3806283.

30: Hiruma M, Nitta M, Kagawa S. A case of cerebrospinal fluid shunt colonization and obstruction by Candida albicans. Mykosen. 1986 Oct;29(10):455-60. doi: 10.1111/j.1439-0507.1986.tb03944.x. PMID: 3540663.

31: Eng RH, Chmel H, Buse M. Serum levels of arabinitol in the detection of invasive candidiasis in animals and humans. J Infect Dis. 1981 May;143(5):677-83. doi: 10.1093/infdis/143.5.677. PMID: 7017020.

32: Brill PW, Winchester P, Krauss AN, Symchych P. Osteomyelitis in a neonatal intensive care unit. Radiology. 1979 Apr;131(1):83-7. doi: 10.1148/131.1.83. PMID: 424611.

33: Chesney PJ, Justman RA, Bogdanowicz WM. Candida meningitis in newborn infants: a review and report of combined amphotericin B–flucytosine therapy. Johns Hopkins Med J. 1978 May;142(5):155-60. PMID: 651085.

34: Boe O, Diderichsen J, Matre R. Isolation of Mycoplasma hominis from cerebrospinal fluid. Scand J Infect Dis. 1973;5(4):285-8. doi: 10.3109/inf.1973.5.issue-4.09. PMID: 4592177.

35: INGOMAR CJ, TERSLEV E. CANDIDA ALBICANS-MENINGITIS HOS EN NYFODT. ET TILFAELDE KOMPLICERET MED HYDROCEPHALUS [CANDIDA ALBICANS MENINGITIS IN A NEWBORN INFANT. A CASE COMPLICATED BY HYDROCEPHALUS]. Ugeskr Laeger. 1964 Aug 6;126:1110-2. Danish. PMID: 14178316.