Fungal infections of the nervous system: current perspective and controversies in management

In the last two decades, more elaborative use of intensive care units for serious medical disorders, advancements in transplant procedures and concomitant use of immunosuppressive therapies as well as the pandemic spread of HIV, etc. have increased the incidence of systemic fungal infections, especially life threatening central nervous system (CNS) infections. The CNS fungal infections present with various clinical syndromes: meningitis; encephalitis; hydrocephalus/raised intracranial pressure (raised ICP); space occupying lesions; orbito-rhino-cerebral syndromes; acute cerebro-vascular events and spinal infections. However, the common presentations among these ones are basal meningitis, hydrocephalus, space occupying lesions (cerebral abscesses and granulomas) and stroke syndromes. Clinical picture may mimic tubercular meningitis and therefore, needs careful evaluation. The CNS mycoses carry higher risks of morbidities and mortality as compared to other infective processes and therefore promptly require precise diagnosis and appropriate medical and/or surgical management strategies to optimize the outcome. Among the antifungal drugs, the Amphotericin B had remained first line of therapy for many decades in invasive fungal infections but is not effective in many forms of mycoses. Fortunately, many useful antifungal drugs were introduced during the last two decades. Initially, the lipid based formulations of the Amphotericin B, then the new triazoles and most recently, echinocandins. These medications are used more frequently in combinations. Now evidence based data are gathering together in favor of their usefulness in the management of invasive fungal infections. But still, many questions are unanswered and controversies persist relating to their selection and use.