C S Infections are both diagnostic challenges and medical emergencies Delay in diagnosis and initiation of appropriate therapy will

Icad to high mortality rate or in permanent, severe neurological damage Fungal Infections of the CNS are not common However, they are being incrcasmgly diagnosed Or. Ahmed M. At.-Barrag

t9

0SUt'{; G

A,.J-ibioh'

US~

HIV AIDS ~ CA~..L1G-\.s;.s Hematopoicuc stem cell transplant (IISCT) Solid organs transplanrauon Malignancies ~ ~9;1IC::>5,'1~ Neutropenia
Hcreduary immune defects

.~

~:

I. To know the main fungi that affect the central nervous system and the clinical settings or such infections 2 To acquire the basic knowledge about fungal meningnis

Graft versus host disease (GvllD) Chronic granulomatous diserase (CGD)

Immunosuppressive
medications

and

brain abscess. clinical features, etiology, diagnosis. and

treatment

DIabetes mclluus surgery or trauma Indwelling catheters

(e.g candidernia

--7

CNS seeding)

----------~~~~~~-------Several fungal agents can cause C S infections.

nervous system by different spread (common) sinuses, the ear, or

Fungi reach the central mechanisms: l lematogenous

(".IPIOCOC(:Ul

sPP

Candida SPP

Aspergdlns Zygomycetes

.\PP

Fusarnnn .\PP

Esophsata lIuwplasma Blastomyces Coccuhotdes Penunltuvn spp sPP sPP mamettei

.\PP
bQl1/Jol10

Cladopluolophora
Curvntano. Rannchlornhnm

Btpolarts macktnztet

i'amcoccnlundes sPP

Local extension from the paranasal the orbits. Traumatic introduction Surgical procedures Head trauma Injections lumbar punctures

AI D.S IS the leading predisposing

factor

Meningitis
Subacute Chrome and

There are two vonenes OfC!:YPIOCOCClIs l1C!oformaw, Crypsococcvs neofonnons var. neuformance Cryptococcus neofonnons
Capsulated yeast cells y

var, gaui meningitis

I3rain abscess
With

or without vascular invasion

is the

1110S1

cause offungal

( ',.s.pci,s '/Uos ) ~
Certain chntcal syndromes arc specific

Jf)o3h:..of'V>'\of\,.

These cluneal syndromes can occur either alone or

III

combmauon

Naturally
~lallll)

in Pigeon habitats

for ccrtam fungi

menmgms

R. h i";' c.e.r-eb~
TIle rtnnoccrcbral zvgonwcosrs form
IS

r,.'/ nckJ rru:

presenting clinical s~ ndromc
In

the most frequent

Candida SPCCICS are the fourth most common cause ofhospual stream mfecuons Indwelling catheter and a fever unresponsive to anubactenal

acqurred blood

DIllbcllC5 \\llh I..cIQ:lcldosis. In eddrucn 10 other nsk factors

c; ;1'1 VS ," +-1.5agents

The ctuucel manifestations of the rhmoccrcbm! form ':>tort- O'I~t. rapldl~ progress and 111\ 01\ C the orbit. eye and optic nerve and extend 10 the brain

Hematogenously. surgery, c~~

Facral cdcrna. pam. necrosis. 10$s of Angrorropism. As augro-mvcsrou IS

\"iSIOIl.black vco frequent

discharge

CA ; ()~c'l!J( Sy rcJ {'CJ(Y}0

Ccrcbraluucroahsccsscs
Mcninl.lllls Vascular f!C--

jr...,.,;;"d z, '1'3 0""''1

~.st

Monatuv ~

IS

high (RO. 100"/,,)

Progression IS ~ 10 nnprovc R~!,..J Jj;lt".'~I~ Cuu.ml Lh~ ull'krl~ IU!! o,s..:as.;

L.:nh ~ SUf1lK:lld.;hndcm<:JlI AI"""I'Uah::lllllfllll!lllllh':IllI"

the outcome

comphcauon,

(mlill..:h hClllonhagc) C r'

~;II~~~'C(ll/J.

and other "PCr.:lCS mcludmg

C./dlll,rotu.

trap/cfl/n

(.

pflruI'(,lo.ul.

ul/(l

vI)

Ph -(;0 h'jp homyc..-ob;S

Fuugal mfecrions caused by dematiaceous
Nurotropic fungi

hosts

fungi
_ Usually b~.:s (single or multiple) malignancies and cancer --

A severe complication of hcmatolcgical chemotherapy, transplantation

Usually brain abscess, chronic Reponed in immunocompetent

Hematogenousl y but may also occur via direct spread from the anatomically adjacent sinuses, Angiotropism (infraction
IS

and h~ic

necrosis)

r:::----r:l

'/ndopJ/f%phora

b011110J10,-xoplnolo l

I~r<\' i.c restricted

u,...

Curvulono,
from

Fonsecoca ,
Middle East. Mortality A. rate high
ntger.

<> 10

lOci ME)

CFj'"

{Mainly

reported

(y)O\cJ'jen LiJ

filllllj!.aI/I.\",

but also A.

A. flavus. and A. terms

Clinical Samples
Hrstoplasmosrs

(SF
Biopsy

Blastomycosis Coccidiodomycosis Paracocc id] odom ye os I S Caused by primary pathogens

Pus. aspirate Blood

CSI' abncrmahues
Cell count Glucose level (low) Protem level (high) Subacute or chronic Mcning'itis (common). and brain abscess Following a primary infection, e.g, respiratory

t No r s pe. ufiG

D j ~d- M.ic.rv5VO(-l if
Fungal slams
(il<,:ffiSa

GMS, PAS

Irll.h;l

mL. (Cryptococcus

ncoronnansl

Clinical features
Not Specific

(history, risk factors. cte)

Culh>l'e,
I'un~l mcdu ';1).'\. Blll.ol~rnll:J~ rf nccdcd

euro-imaging
Good \ aluc
10

( err sc sri , Ii/ZJ. )

diagnosis and
rhcrnpy

monnonng

Lab lnvestigauons
Hrstopnthologv
Ilhll'pl,hIHJ

('SF

cxnuuunnon (cl..'11count.

chcnustrvt

!ll~'I\ln\\(..:, CllI:l:tJ'''IJ.., I'Jra":I'CcIJII1IJ.:,

Mrcrobrologv

Control of the underlying disease Reduce immunosuppresion, restore immunity ifpossible Start antifungal therapy promptly
Polyenes Azoles Echinocandins

Consider surgery In certain SllU3110ns

Crv ptoccocal mcrunguis Amphotericine

B (combination \\

uh

Fluc)10SIIlC)

CNS Candidiasis
Arnphotcricinc

.
3,Caspofungin. Voriconazolc. Fluconazole

CNS Aspergillosis,
Voriconazole, Caspofungin. Posaconazole (Combt:tion of Vori conazole and Caspofungin) Posaconazolc

C S Zygomycosis :

rAmpholcricinc

13.