Contributing factors to the development of

a fungal infection

• Increased exposure to air, water and food

contaminated with fungal spores
• Virulence of the fungus

•Host immune status

– Underlying disease
– Immunosuppressive therapy
Fungal infections of the CNS – clinical
syndromes
Fungal infections of the CNS – skull-base
syndromes
Diagnosis of fungal infections of the CNS –
red flags
Predisposing risk factors for invasive
aspergillosis
• Neutropenia • Glucocorticoid use
• lymphoma • Burns
• Leukemia • Alcoholism
• transplantation • Major trauma
• Chronic granulomatous • Liver failure
disease • Intravenous drug abuse
• Diabetes mellitus
Aspergilloma
 Cryptococcosis with dilated Virchow-Robin spaces in an immunocompromised patient. T2WI (A) shows multiple bilateral basal ganglia
hyperintensities, which do not reveal any enhancement on postcontrast T1WI (B). Lesions show no restriction on DWI (C). CSF culture showed
Cryptococcus neoformans
Alternative Pharmacological Treatment

• Induction Phase
– Fluconazole 400 mg daily PO x 8–10 weeks +
Flucytosine 100 mg/kg daily PO x 6–10 weeks
• Consolidation Phase
– Itraconazole 200 mg twice-daily PO
• Fluconazole 800 mg PO daily x 8 weeks also
used in some resource-limited settings for
induction and consolidation phases
 Treatment of Increased Intracranial Pressure

• CSF drainage for opening pressure >250

mmH2O
• Treatment involves serial LPs,
ventriculoperitoneal shunts or lumbar drain
aimed at reducing opening pressure to <200
mmH2O
• Repeat lumbar drainage as needed until
achieving stable opening pressure
 Toxicities Related to Drugs
Flucytosine
• Bone marrow suppression

Fluconazole
• GI and hepatotoxicity

Amphotericin B
• Renal toxicity and electrolyte abnormalities
 Treatment Failure
• Repeat lumbar puncture if no improvement or
worsening of symptoms
• Consider alternative diagnosis
• Fluconazole and amphotericin resistance
(rare)
• Consider immune reconstitution syndrome
(IRIS)
 Prognostic Indicators
Poor Prognosis
• Increased intracranial pressure
• Altered mental status
• Low white blood cell count on CSF
• Positive India ink
 Summary
• Cryptococcus meningitis is fatal if untreated
• Elevated intracranial pressure is associated
with a poor prognosis and must be managed
promptly
• Obtain brain image prior to lumbar puncture
in patients with focal neurological deficits,
papilledema and/or obtundation