Chronic Relapsing Fungal Meningitis in an Immunocompetent Host: A Ten-year Diagnostic and Therapeutic Challenge
Anirudh Rayanki1, Sadat Shamim2
1Texas A&M University College of Medicine, 2Health Texas Provider Network
Background:
Fungal meningitis is a rare but potentially life-threatening infection of the central nervous system (CNS). Diagnosis and management pose challenges due to clinical presentation with nonspecific symptoms, the limited sensitivity of conventional cerebrospinal fluid (CSF) cultures, and the need to balance incomplete data against the risks of delayed therapy. Although most cases occur in immunosuppressed individuals, chronic fungal meningitis can rarely affect immunocompetent hosts.
Design/Methods:
We present the case of a 54 year-old immunocompetent male with a history of epilepsy and legal blindness who developed recurrent seizures, progressive neurologic deficits, and persistent radiographic abnormalities over the course of more than a decade. Early MRI in 2012 demonstrated multifocal FLAIR hyperintensities with gyral mass effect and optic nerve enhancement, while CSF studies showed lymphocytic pleocytosis and elevated protein concerning for meningoencephalitis. Attempts at obtaining a definitive diagnosis were limited by the patient’s refusal of lumbar puncture. In September 2021, serum (1,3)-β-D-glucan (BDG, Fungitell) testing returned positive, providing the first strong evidence of fungal infection and prompting empiric antifungal therapy with isavuconazole, initiated in January 2022. Clinical and radiographic improvements were observed during treatment, but relapse occurred shortly after discontinuation, with subsequent imaging demonstrating progressive right parietal enhancement and BDG levels returning to positive in 2025.
Conclusions:
This case illustrates key challenges in managing chronic fungal meningitis in an immunocompetent host, including the limitations of culture-based diagnostics, the difficulty of determining optimal therapy duration, and the clinical decision-making required to initiate empiric therapy in the absence of definitive microbiologic confirmation. The patient’s decade-long course highlights the evolution of available diagnostics and therapeutics, with newer triazoles such as isavuconazole demonstrating improved safety compared to older agents like voriconazole and amphotericin B. These advances lower the threshold for empiric antifungal therapy, underscoring the value of a clinician’s judgment in guiding treatment decisions.
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