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Candida albicans and Stenotrophomonas maltophilia: atypical cases of meningitis in a Neurointensive Unit

RESUMO

Case report: 1. Female, 85 years old, previously hypertensive and diabetic, presented, on July 15, 2021, HSA-fisher 3, being admitted to the Neurointensive Unit. He evolved with hydrocephalus and intracranial hypertension. On July 16, an external ventricular shunt was placed with an intracranial pressure monitor. On the third postoperative day, he showed fever and worsening inflammatory patterns. In the CSF study, it had an opening pressure of 20cmH2O, with 18773/mm 3 cells (75% neutrophils), 181 mg/dL protein, 20 mg/dL glucose. CSF culture, with growth of Gram negative Stenotrophomonas malthopilia sensitive to levofloxacin and tigecycline. After one month of treatment, he died, despite the medication; 2. A 34-year-old male with no previous comorbidities is admitted to the Neurointensive Unit to investigate a seizure. The patient had no history of epilepsy. It was reported that, a week ago, he had started with a mild headache and tremors of the extremities, which was followed by a fever measured between 38-39°C and blurred vision. In emergence, kernig and brudzinski signs are present. Laboratory tests and magnetic resonance imaging of the skull were performed, without alterations. In neurointensive care, liquor was collected, which showed PCR detecting Candida albicans. He was then treated with liposomal amphotericin B and fluconazole. About two weeks later, the patient's symptoms improved significantly and he was discharged from the hospital. Discussion: Meningitis caused by S. maltophilia is rare, with only 18 cases reported so far. Populations at risk for S. maltophilia meningitis are typically immunocompromised patients, those who have had neurosurgical procedures, premature infants, and patients requiring prolonged hospitalization. Multi-agent resistance is a hallmark of S. maltophilia. Regarding the fungal meningitis described, its prevalence began to decrease in the last decade, while the frequency of detection of C. albicans species gradually increased. It presents manifestations similar to those of bacterial meningitis, making the initial use of antibacterials not uncommon. It has a good prognosis after the institution of the correct therapy. Final comments: Although these atypical meningitis remain rare in the population, physicians should be aware of them as possible meningitis-causing organisms for better therapeutic follow-up, even in the absence of their known risk factors.