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Update on diagnosis and treatment of fungal meningitis: lessons from recent outbreaks
Paula Beltran-Reyes1, Luis Ostrosky-Zeichner2, Maria F Gonzalez-Lara1
1Clinical Microbiology Department, Infectious Diseases Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico.
Purpose Of Review:
Recently, fungal meningitis outbreaks have occurred in association with neuraxial and epidural anesthesia in immunocompetent patients. Herein, we describe the course of those outbreaks, their diagnosis, treatment, prognosis, and lessons learned.
Recent Findings:
Two outbreaks of Fusarium solani meningitis during 2022-2023 were associated with epidural anesthesia in two distant cities in Mexico (Durango and Matamoros). The initial etiological agent identification was delayed due to insensitivity of cultures. A Fusarium solani qPCR was validated and positive in 38% cerebrospinal fluid (CSF) samples from Durango, while BD-Glucan allowed early diagnosis of the index case in Matamoros. Antifungal treatment with voriconazole and liposomal amphotericin B (L-AmB) was recommended. Overall mortality was 51%. Once the cause was confirmed, some patients received fosmanogepix.
Summary:
Fungal meningitis outbreaks due to filamentous fungi are usually associated with direct epidural inoculation. They result in severe presentations and high mortality. Early diagnosis should be suspected, BD-Glucan CSF testing screening is recommended. Aggressive antifungal treatment based on antifungal susceptibility testing should be administered as early as possible. The advent of molecular diagnostic methods and new antifungal drugs may allow for timely diagnosis and treatment, increasing the chances of survival.
Insights
Two Fusarium solani meningitis outbreaks linked to epidural anesthesia caused high mortality. Early diagnosis via BD-Glucan and molecular methods, along with aggressive antifungal treatment, is crucial for survival.
Area of Science:
- Infectious Diseases
- Neurology
- Mycology
Background:
- Fungal meningitis outbreaks have emerged in immunocompetent patients following neuraxial and epidural anesthesia.
- These events pose significant diagnostic and therapeutic challenges.
Purpose of the Study:
- To describe the course, diagnosis, treatment, prognosis, and lessons learned from recent fungal meningitis outbreaks.
- To highlight the importance of early detection and aggressive management.
Main Methods:
- Retrospective analysis of two Fusarium solani meningitis outbreaks in Mexico (2022-2023).
- Validation of Fusarium solani quantitative PCR (qPCR) for cerebrospinal fluid (CSF) samples.
- Utilized BD-Glucan assay for early diagnosis.
Main Results:
- Outbreaks linked to epidural anesthesia in Durango and Matamoros.
- Initial diagnosis delayed by culture insensitivity; qPCR confirmed Fusarium solani in 38% of CSF samples.
- BD-Glucan facilitated early diagnosis in one outbreak.
- Overall mortality reached 51%, with treatment including voriconazole, liposomal amphotericin B (L-AmB), and fosmanogepix.
Conclusions:
- Filamentous fungal meningitis outbreaks often result from direct epidural inoculation, leading to severe illness and high mortality.
- Early suspicion, CSF BD-Glucan screening, and molecular diagnostics are recommended for timely diagnosis.
- Aggressive, susceptibility-guided antifungal therapy is essential for improving survival rates.
