Fungal Meningoencephalitis Morning Report July 13, 2017

Fungal Meningoencephalitis Fulminant among the immunocompromised Indolent and insidious among the relatively immunocompetent   Broad symptom presentation, but most commonly reported included mental status changes (confusion, dementia), seizures, basilar meningeal signs/cranioneuropathies. Absense or presence of fever Gram stains and cultures are frequently negative Although rare: reported stroke syndromes from fungal infection–related vasculitis and thrombosis from angioinvasive molds, including Aspergillus and Mucor, more commonly than yeasts like Candida and Cryptococcus

Common Species Cryptoccocus Aspergillus Candida Mucormycosis Exserohilum rostratum Endemic Fungi: Histoplasma, Coccidiomycosis, Blastomycosis

Mucormycosis Genera: Rhizopus, Mucor, Route of infection: inhalation of fungal sporangiospores have been released in the air or direct inoculation of organisms into disrupted skin or mucosa Location: predisposition to invade nasal mucosa Risk factor: Diabetes, immunocompromised states, iron overload states diabetes mellitus as a predisposing factor for mucormycosis in 36%–88% of cases Biopsy: non-septal hyphae on GMS silver stain Lack of septal results in leakage of cellular material and rapid death follow biopsy - poor growth in culture 6 major clinical forms: (1) rhinocerebral, (2) pulmonary, (3) cutaneous, (4) gastrointestinal, (5) disseminated, and (6) uncommon rare forms, such as endocarditis, osteomyelitis, peritonitis, and renal infection Black necrotis eschar – present <50% Courtesy of www.doctorfungus.org. Copyright ©2007 and UptoDate Mucormycosis (zygomycosis). sinuses (39%), lungs (24%), and skin (19%) rhinoorbital disease, with or without cerebral invasion, accompanied by bony destruction CUTANEOUS: black necrotic eschar is the hallmark of mucormycosis Experimental studies suggest that iron increases the susceptibility of the host to mucormycosis.

Mucormycosis – Rhinocerebral Characteristics: vasotropic Invade the endothelium causing thrombotic arteritis, infarct, hemorrhage and tissue necrosis Involvement of the internal carotid artery, cavernous sinus, and ophthalmic artery is common. Treatment: antifungals (amphotericin B) + surgical debridement Mortality average 60% with poorer prognosis leading to fatality with delayed diagnosis and brain, cavernous sinus, or carotid involvement They then germinate, forming angioinvasive hyphae that cause infarction of the involved tissue, giving in a “dry” gangrene appearance fungus proliferates within the internal elastic lamina, dissecting it away from the media The predisposition of patients with diabetes to acquire the disease may be partially related to hyperglycemia, and the presence of ketoacidosis is presumed to induce a neutrophil defect, resulting in reduced phagocytosis and chemotaxis. amphotericin B and either posaconazole or

References Petrikkos G, Skiada A, Lortholary O, et al. Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis 2012 Weprin. Long-term survival in rhinocerebral mucormycosis. Case report. J Neurosurg. 1998 Mar;88(3):570-5. Panackal, A. Fungal Infections of the Central Nervous System. g Learning in Neurology: December 2015 - Volume 21 - Issue 6, Neuroinfectious Disease - p 1662–1678 Chayakulkeeree, M M. Zygomycosis: the re-emerging fungal infection. European journal of clinical microbiology & infectious diseases. 2006