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Fungal meningitis

  • Overview
  • Theory
  • Diagnosis
  • Management
  • Follow up
  • Resources
Last reviewed: 5 Apr 2025
Last updated: 13 Jun 2023

Summary

Definition

History and exam

Key diagnostic factors

  • progressive headache
  • severe headache
  • meningismus
  • symptoms of hydrocephalus (impaired cognitive function, confusion, coordination and gait disturbances, and urinary incontinence)
  • behavioral or personality change
  • reduced visual acuity and papilledema
Full details

Other diagnostic factors

  • nausea or vomiting
  • fever
  • reduced conscious level
  • cranial nerve palsies
  • seizures
  • weight loss
  • mouth ulcers
  • focal neurologic signs
  • lymphadenopathy, hepatosplenomegaly
  • dyspnea
  • papular umbilicated skin lesions
  • retinal defects
  • nasal or palatal eschar
Full details

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
Full details

Diagnostic tests

1st tests 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
Full details

Tests to consider

  • histopathology and culture of biopsies: meningeal, brain, extraneural sites of involvement
  • polymerase chain reaction (PCR)
Full details

Emerging tests

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

Treatment algorithm

ACUTE

cryptococcal meningitis

histoplasmal meningitis

coccidioidal meningitis

candidal meningitis

Exserohilum rostratum meningitis

Aspergillus meningitis

mucormycosal meningitis

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.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Johnson RH, Einstein HE. Coccidioidal meningitis. Clin Infect Dis. 2006 Jan 1;42(1):103-7.Full text  Abstract

World Health Organization. Guidelines for diagnosing, preventing and managing cryptococcal disease among adults, adolescents and children living with HIV. June 2022 [internet publication].Full text  Abstract

National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Disease Society of America. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. September 2022 [internet publication].Full text

Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis. Clin Infect Dis. 2016 Sep 15;63(6):e112-46.Full text  Abstract

Pappas PG, Kauffman CA, Andes DR, et al. Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-50.Full text  Abstract

Johnson RH, Einstein HE. Coccidioidal meningitis. Clin Infect Dis. 2006 Jan 1;42(1):103-7.Full text  Abstract

Patterson TF, Thompson GR 3rd, Denning DW, et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Aug 15;63(4):e1-60.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Fungal meningitis images

  • Differentials

    • Tuberculous meningitis
    • Bacterial meningitis
    • Viral meningitis
    More Differentials

  • Guidelines

    • Guidelines for diagnosing, preventing, and managing cryptococcal disease among adults, adolescents and children living with HIV
    • Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV
    More Guidelines

  • Patient information

    Lumbar puncture

    More Patient information
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