Aspergillus meningitis: a rare clinical manifestation of central nervous system aspergillosis. Case report and review of 92 cases

Abstract

Objectives: To describe the pathogenesis, clinical presentation, cerebrospinal fluid findings and outcome of Aspergillus meningitis, meningoencephalitis and arachnoiditis.

Methods: A case of Aspergillus meningitis is described. A comprehensive review of the English-language literature was conducted to identify all reported cases of Aspergillus meningitis described between January 1973 and December 2011.

Results: Ninety-three cases (including the one described herein) of Aspergillus meningitis were identified. Fifty-two (55.9%) were in individuals without any predisposing factor or known causes of immunosuppression. Acute and chronic meningitis was diagnosed in 65.6% of patients and meningoencephalitis in 24.7% of them with the remaining presenting with spinal arachnoiditis and ventriculitis. Cerebrospinal fluid cultures for Aspergillus spp. were positive in about 31% of cases and the galactomannan antigen test in 87%. Diagnosis during life was achieved in 52 patients (55.9%) with a case fatality rate of 50%. The overall case fatality rate was 72.1%.

Conclusions: Aspergillus meningitis may occur in both immunocompetent and immunocompromised patients and run an acute or chronic course. The findings of this systematic review extend the information on this life-threatening infection and could assist physicians in achieving an improved outcome.

Figure 1

Medication history, clinical course and kinetic of Aspergillus antigen in CSF of our case of Aspergillus flavus meningitis. The dotted line represents the cut-off value of GM. The light blue line is the index on CSF and the red line on plasma. The blue circle represents the CSF levels of voriconazole. The purple diamond and the yellow triangle are respectively the down and peak plasma levels of voriconazole. The blue rectangle denotes the range of expected therapeutic levels of voriconazole.

Figure 2

Sagittal and coronal T1-weighted gadolinium-enhanced magnetic resonance scan of the brain of our patient with Aspergillus flavus meningitis showing contrast impregnation along the basilar artery in the prepontine cistern.

Figure 3

Sagittal T2 (a) and gadolinium enhanced T1-weighted (T1W) (b) MRI demonstrate pathologic enhancement and endocanalar pathologic tissue of the L4-S2 tract.