Fungal meningitis

Last reviewed: 26 Aug 2022
Last updated: 05 Aug 2020

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • progressive headache
  • severe headache
  • meningismus
  • symptoms of hydrocephalus (impaired cognitive function, confusion, coordination and gait disturbances, and urinary incontinence)
  • behavioural or personality change
  • reduced visual acuity and papilloedema
More key diagnostic factors

Other diagnostic factors

  • nausea or vomiting
  • fever
  • reduced conscious level
  • cranial nerve palsies
  • seizures
  • weight loss
  • mouth ulcers
  • focal neurological signs
  • lymphadenopathy, hepatosplenomegaly
  • dyspnoea
  • papular umbilicated skin lesions
  • retinal defects
  • nasal or palatal eschar
Other diagnostic factors

Risk factors

  • HIV infection
  • corticosteroid use
  • underlying chronic disease (e.g., malignancy, organ failure, autoimmune disease, organ transplant)
  • residing in or visiting northern Australia, Papua New Guinea, or Vancouver Island, Canada
  • exposure to disturbed soil, chicken guano, or bat caves
  • impaired cell-mediated immunity
  • Filipinos and African Americans
  • neutropenia or impaired phagocytic function
  • neurosurgery
  • infants and neonates
  • central vascular catheters
  • sinonasal disease
  • antibacterial usage
  • prior surgery
  • hyperalimentation
  • intravenous drug use
More risk factors

Diagnostic investigations

1st investigations to order

  • CT and/or MRI head scan
  • fungal blood cultures (3 sets)
  • serum cryptococcal antigen test
  • serum + urine Histoplasma antigen
  • immunodiffusion tests (IgM and IgG) and complement fixation test (IgG) for coccidioidomycosis
  • cerebrospinal fluid opening pressure
  • cerebrospinal fluid (CSF) WBC and differential
  • cerebrospinal fluid (CSF) protein
  • cerebrospinal fluid (CSF) glucose
  • cerebrospinal fluid India ink stain
  • cerebrospinal fluid (CSF) culture
  • cerebrospinal fluid cryptococcal polysaccharide antigen test
  • cerebrospinal fluid Histoplasma antigen
  • cerebrospinal fluid Histoplasma antibodies
  • cerebrospinal fluid coccidioidal IgG antibodies
  • cerebrospinal fluid (CSF) galactomannan antigen test
More 1st investigations to order

Investigations to consider

  • histopathology and culture of biopsies: meningeal, brain, extraneural sites of involvement
  • polymerase chain reaction (PCR)
More investigations to consider

Emerging tests

  • 18F-fluorodeoxyglucose (FDG) PET/CT
  • cerebrospinal fluid (CSF) (1-3)-beta-D-glucan

Treatment algorithm

ACUTE

cryptococcal

histoplasmal

coccidioidal

candidal

Exserohilum rostratum

Aspergillus

mucormycosal

Contributors

Authors

Abhijit Chaudhuri, DM, MD, PhD, FACP, FRCP (Glasg), FRCP (Lond)

Consultant Neurologist

Clinical Lead of Neuroinflammation

Department of Neurology

Queen's Hospital

Romford

UK

Disclosures

AC declares that he has no competing interests.

Acknowledgements

Dr Abhijit Chaudhuri would like to gratefully acknowledge Dr Thomas S. Harrison and Dr Angela Loyse, previous contributors to this topic.

Disclosures

TSH and AL declare that they have no competing interests.

Peer reviewers

Robert A. Larsen, MD

Associate Professor of Medicine

University of Southern California

Keck School of Medicine

Los Angeles

CA

Disclosures

RAL declares that he has no competing interests.

  • Fungal meningitis images
  • Differentials

    • Tuberculous meningitis
    • Bacterial meningitis
    • Viral meningitis
    More Differentials
  • Guidelines

    • Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV
    • Guidelines for the diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children: supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection
    More Guidelines
  • Patient leaflets

    Meningitis and septicaemia

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer