Case Presentation: Patient is a 41-year-old male with past medical history of alcohol use disorder, traumatic brain injury, and schizoaffective disorder who presented with progressive confusion and agitation. Patient experienced traumatic brain injury five months prior to admission when imaging showing communicating hydrocephalus of unclear etiology. One month later, he presented to the ED with symptoms concerning for meningitis and new basilar leptomeningeal enhancement. Ultimately, the team ruled out bacterial, viral, fungal, and autoimmune encephalitis and he was discharged without further treatment. Over the course of three months, he was brought to the emergency room for agitation, confusion, and worsening ability to take care of himself. Despite imaging showing worsening hydrocephalus, he was discharged without intervention. His symptoms deteriorated on his final emergency room visit leading to intubation and emergent external ventricular device (EVD) placement for hydrocephalus. Imaging showed worsening leptomeningeal enhancement and cerebral spinal fluids studies eventually grew candida albicans. However, work up including biopsy and CSF Beta-D-glucan helped confirm the diagnosis. The patient was treated with amphotericin B and flucytosine. His EVD was exchanged for a ventriculoperitoneal shunt. His course was complicated by ongoing hydrocephalus and abscess formation unresponsive to antifungals requiring extended treatment and ongoing hospitalization.
Discussion: Candida is rare cause of fungal meningitis, particularly in adults without central nervous system instrumentation. While acute candida meningitis can present similar to acute bacterial meningitis with a fever, headache, and stiff neck, chronic candida meningitis can be more difficult to diagnose with subtle symptoms including worsening encephalopathy. Given the patient’s history, his symptoms were likely attributed to his co-morbidities including his traumatic brain injury. It was not until his mental status declined and he had life-threatening symptoms such as a blown pupil, that an additional in-depth workup was done. Candida meningitis is difficult to diagnose. Diagnosis can be done by isolating Candida in the CSF, often requiring large volume samples. Additionally, patient can have CSF studies with high beta-D-glucan, high protein, low glucose, and pleocytosis. Treatment for candida meningitis consists of amphotericin B with flucytosine. Duration ranges from weeks to months pending improvement in abscesses, CSF studies, and resolution of associated symptoms. The overall mortality associated with candida meningitis was 53%, 33% in adequately treated patients.
Conclusions: Although rare, chronic candida meningitis can exist in a patient without neurosurgical interventions. Therefore, it should remain on the differential in a patient with progressive encephalopathy, particularly in those with hydrocephalus.