Case Presentation: A 27-year-old woman with no significant medical history presented with a two-month history of headache, neck stiffness, nausea, vomiting, photophobia, back pain, and fever. Two months prior, she underwent liposuction and a Brazilian Butt Lift. Examination showed nuchal rigidity and lumbar tenderness. Labs revealed elevated ESR (24 mm/hr) and CRP (31.9 mg/dL), with negative blood cultures, an HIV test, and a normal brain MRI. Spine MRI demonstrated post-surgical changes and leptomeningeal enhancement at T11/12, raising suspicion for infection or neoplastic process. CSF analysis showed pleocytosis (380 WBCs/mm³), elevated protein (51.1 mg/dL), and low glucose (43 mg/dL) with negative cultures and viral/fungal tests. She was started on ceftriaxone, vancomycin, and dexamethasone for suspected meningitis. Despite treatment, CSF pleocytosis worsened. After a CDC fungal meningitis alert, antifungal therapy with IV Voriconazole and Amphotericin-B was initiated, supported by a positive BDG. A ventricular access device for intrathecal Amphotericin-B was placed after persistent pleocytosis. Therapy resulted in gradual improvement. The patient, ambulant with physiotherapy support, was discharged on day 72 on oral Voriconazole and intrathecal Amphotericin-B. Follow-up showed full recovery.
Discussion: The above is part of an ongoing outbreak of nosocomial fungal meningitis. As of 6/23/2023, 169 patients were under investigation, with 16 suspected, 10 probable, 9 confirmed cases, and 6 deaths. Five deaths occurred in patients with confirmed F. solani infections.⁷Fungal CNS infections predominantly affect developing countries, especially individuals with HIV.⁸ A 2022 outbreak of F. solani aseptic meningitis in Mexico was linked to contaminated bupivacaine. Fungi can thrive in poorly sterilized drugs, such as steroids and bupivacaine.⁶Fungal meningitis is challenging to diagnose and manage due to subacute or chronic presentations like headache, nuchal rigidity, photophobia, and altered mentation. CNS infection usually occurs via hematogenous spread from a pulmonary focus, but in this case, inoculation following epidural was suspected. The diagnosis was complicated by the low yield of detecting fungal meningitis in immunocompetent patients. Empirical antifungal therapy was delayed until day 11 when a third lumbar puncture revealed positive BDG.For suspected fungal meningitis, CSF analysis should include opening pressure, cell count, glucose, protein levels, and BDG, alongside Gram stain, India ink, and culture tests. Leukocyte counts typically range from 20–1000 cells/mm³ with lymphocyte predominance, low glucose (10–39 mg/dL), and elevated protein levels (50–700 mg/dL).⁹ This case underscores the need for coordinated public health responses. Early antifungal treatment was initiated based on outbreak alerts and CDC/ESCMID guidance.⁷,¹⁰ Treatment of invasive Fusariosis is challenging due to drug resistance.¹⁰ As systemic Amphotericin B failed to achieve sufficient CSF levels, intraventricular therapy was employed. Intrathecal Amphotericin B has shown promise in small studies, though larger trials are needed to confirm efficacy and safety.¹¹-¹⁴
Conclusions: Managing fungal meningitis in immunocompetent patients is complex. Persistent meningitis after procedures warrants considering fungal causes, as seen in the F. solani outbreak, highlighting diagnostic and treatment challenges.