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Published on: March 18, 2020
Ventriculoperitoneal shunt infection by Cryptococcus neoformans sensu stricto: Case report and literature review
Anil Kumar1, Suhas Udayakumaran2, Arun Sachu3
1Department of Microbiology, Amrita Institute of Medical Sciences & Research Centre, Amrita Vishwa Vidyapeetham, Ponekara, Kochi, Kerala, India.
Background:
Cryptococcal ventriculoperitoneal shunt infection is known to occur due to an underlying infection in the patient rather than by nosocomial transmission of Cryptococcus during shunt placement. A case of chronic hydrocephalus due to cryptococcal meningitis that was misdiagnosed as tuberculous meningitis is described.
Case Report:
Patient details were extracted from charts and laboratory records. The identification of the isolate was confirmed by PCR-restriction fragment length polymorphism of the orotodine monophosphate pyrophosphorylase (URA5) gene. Antifungal susceptibility was determined using the CLSI M27-A3 broth microdilution method. Besides, a Medline search was performed to review all cases of Cryptococcus ventriculoperitoneal shunt infection. Cryptococcus neoformans sensu stricto (formerly Cryptococcus neoformans var. grubii), mating-type MATα was isolated from the cerebrospinal fluid and external ventricular drain tip. The isolate showed low minimum inhibitory concentrations for voriconazole (0.06mg/l), fluconazole (8mg/l), isavuconazole (<0.015mg/l), posaconazole (<0.03mg/l), amphotericin B (<0.06mg/l) and 5-fluorocytosine (1mg/l). The patient was treated with intravenous amphotericin B deoxycholate, but died of cardiopulmonary arrest on the fifteenth postoperative day.
Conclusions:
This report underlines the need to rule out a Cryptococcus infection in those cases of chronic meningitis with hydrocephalus.
Insights
Cryptococcal meningitis can cause chronic hydrocephalus, often misdiagnosed. This case highlights the importance of considering fungal infections in shunt infections, even when initially suspected as bacterial or tuberculous.
Area of Science:
- Infectious Diseases
- Neuroscience
- Medical Mycology
Background:
- Cryptococcal ventriculoperitoneal (VP) shunt infections typically arise from endogenous patient infections, not nosocomial transmission.
- A case of chronic hydrocephalus secondary to cryptococcal meningitis, initially misdiagnosed as tuberculous meningitis, is presented.
Observation:
- Cryptococcus neoformans sensu stricto (MATα) was isolated from cerebrospinal fluid and an external ventricular drain.
- The isolated Cryptococcus strain exhibited high susceptibility to multiple antifungal agents, including amphotericin B and azoles.
- Despite treatment with intravenous amphotericin B deoxycholate, the patient experienced a fatal cardiopulmonary arrest.
Findings:
- The patient's cryptococcal meningitis was misdiagnosed, leading to delayed appropriate treatment.
- The isolated Cryptococcus neoformans strain demonstrated broad antifungal susceptibility.
- The case underscores the challenges in diagnosing and managing cryptococcal meningitis in patients with hydrocephalus.
Implications:
- Clinicians should consider Cryptococcus infection in patients presenting with chronic meningitis and hydrocephalus, especially those with shunts.
- Early and accurate diagnosis of cryptococcal meningitis is crucial for effective management and improved patient outcomes.
- This case emphasizes the need for comprehensive diagnostic workups to rule out fungal etiologies in complex neurological conditions.
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