Typically presents as a progressive, life-threatening, chronic or subacute meningitis.
Occurs most commonly in immunosuppressed individuals and is often accompanied by systemic involvement.
Cerebrospinal fluid (CSF) typically shows lymphocytic pleocytosis, elevated protein, and low glucose.
The most common type of fungal meningitis is caused by Cryptococcus neoformans.
A rapid aetiological diagnosis is required to guide antifungal therapy.
Complications include seizures, cerebral infarction, hydrocephalus, and elevated CSF pressure without hydrocephalus.
Meningitis is an inflammatory disease of the leptomeninges. All major fungal pathogens have the capacity to cause meningitis. The incidence of fungal meningitis is increasing worldwide due to the increasing number of patients immunosuppressed by pharmacological agents and HIV infection. Cryptococcal, histoplasmal, coccidioidal, and candidal meningitis will be discussed specifically in this monograph.
History and exam
- presence of risk factors
- progressive headache
- severe headache
- symptoms of hydrocephalus (impaired cognitive function, confusion, coordination and gait disturbances, and urinary incontinence)
- behavioural or personality change
- reduced visual acuity and papilloedema
- 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
- infants and neonates
- central vascular catheters
- sinonasal disease
- antibacterial usage
- prior surgery
- intravenous drug abuse
- 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
- CSF opening pressure
- CSF WBC and differential
- CSF protein
- CSF glucose
- CSF India ink stain
- CSF culture
- CSF cryptococcal polysaccharide antigen test
- CSF Histoplasma antigen
- CSF Histoplasma antibodies
- CSF coccidioidal IgG antibodies
- CSF galactomannan antigen test
Clinical Lead of Neuroinflammation
Department of Neurology
AC has received honoraria, speaker fees, and travel or international meeting sponsorship from Biogen, Genzyme, Merck, Novartis and Teva; he may receive travel and/or meeting sponsorship from Bial and Genzyme in 2018-2019. AC has attended or may attend the Advisory Board meetings for product development and/or marketing with Bial, Merck, Novartis, and Teva. AC declares that these posts and payments do not constitute any competing interest in relation to the topic of fungal meningitis.
Dr Abhijit Chaudhuri would like to gratefully acknowledge Dr Thomas S. Harrison and Dr Angela Loyse, previous contributors to this monograph. TSH and AL declare that they have no competing interests.
Associate Professor of Medicine
University of Southern California
Keck School of Medicine
RAL declares that he has no competing interests.
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