32 years old man with history of intravenous drug use (IVDU) presented with seizures, nuchal rigidity, and papilledema. Head CT showed communicating hydrocephalus and brain and spine MR showed diffuse leptomeningeal enhancement extending to the cauda equina. HIV, syphilis, and quantiferon-gold tests were negative but his CD4 count was 203 (430 - 1185 /mm3). Lumbar puncture showed opening pressure of 45 mmH2O, CSF protein > 392 mg/dl (15-45), glucose 5 mg/dL (40-70), nucleated cells 246 (0-5), 83% lymphocytes, red blood cells 1 (0-1). CSF meningitis panel was negative, but encephalitis panel showed NMDA receptor antibody. 1,3- Beta-D-glucan was 79 (<60 pg/mL) in the serum and 295 in the CSF and CSF cultures grew Candida dublinensis.

Chronic base of the skull meningitis has many causes including inflammatory conditions, malignancies, and infections.

Invasive C. dublinensis infection is very rare and usually associated with immunodeficiency (HIV or post-transplant). This is the fourth case of C.  dublinensis in an immunocompetent host described in the literature. Like our case, in two of those three reports the infection was associated with IVDU, and this information is not available for the third case. This corroborates the hypothesis that IVDU could be a risk factor for this infection.

Regarding his CSF NMDA receptor antibody, he did not have limbic encephalitis, dysautonomia, seizures or psychiatric symptoms. There is a known association of this antibody and ovarian teratomas and herpes simplex encephalitis but no association with Candida sp. is known.

Despite his low CD4 count he did not have other opportunistic infections. No etiology was identified for this finding.